viewpoints TO SLEEP, PERCHANCE TO DREAM . ..

Do sleeping pills help when sleep does not come~easily? An article summarising the findings of a special study of the uses of hypnotic drugs in ambulatory medicine carried out by the Institute of Medicine of the National Academy of Sciences in the US makes a strong plea for more and better research into sleep problems and the drugs used to alleviate them. The adverse effects and public health problems of principal concern in the report include suicide attempts, drug/ alcohol interactions, residual effects on daytime performance and 'dependence' (only as nightly reliance on drugs for sleep). The numbers of hypnotic prescriptions have declined appreciably in the last 7 years - from 41.7 million in 1971 (47% for barbituratesho 25.6 million in 1977 (17 % for barbiturates and 53 % for flurazepam, 'Dalmane'). 39 % of hypnotics prescribed in 1977 were for persons over 60 years old. Insomnia is a subjective complaint and the benefit, if any, of hypnotic drugs is typically to reduce the time needed to fall asleep by 10-20 minutes and to lengthen the night's total sleep time by 20-40 minutes.

'As a class of drugs, hypnotics should have only a limited place in contemporary medical practice . .. the committee favors the prescription of only very limited numbers of sleeping pills for use for a few nights at a time, to aid in specific situa­tions such as travel or transient psychosocial stress.'

They should not be given to patients with respiratory impairment, mental depression or substance abuse problems, and should be

used very selectively and cautiously (if at all) for patients who are or may become pregnant, who operate machinery, who have kidney or liver disease or who are old. Most specialists in sleep disturbances seem to think that hypnotic drugs should not be the primary form of treatment for most patients with persistent insomnia. Patients on these drugs should be closely monitored and not given automatic repeat prescriptions. Patients should be given clear directions and warnings about the use of hypnotic drugs. Benzodiazepines are now used as hypnotics far more than any other drugs, but the committee believes their hazards have been insufficiently appreciated. The most frequently prescribed benzodiazepines (fiurazepam, nitrazepam) have important psychoactive metabolites with long half-lives, which can accumulate with long term use. This poses the risk of impaired visual-motor coordination skills in the daytime and interactions with other drugs such as alcohol the day after night-time use. Benzodiazepines and barbiturates are probably equally effective in the short term, but long term the side effects and risks of benzodiazepine hypnotics are likely to increase, and tolerance to the sleep promoting properties of barbiturates is likely to develop. The advertising and labelling of benzodiazepines should carry clearer warnings about their risks. The Committee finds no justification for more restrictive scheduling of barbiturate hypnotics. The 'ideal' hypnotic has not been found. There is a need for better efficacy studies of present hypnotics and for research to find better ones. Promising drugs include shorter acting benzodiazepines such as oxazepam ('Serax') and lorazepam ('Ativan'), methylprylon ('Noludar'), chloral hydrate, diphenhydramine ('Benadryl'), L­tryptophan and antidepressants such as amitriptyline ('Elavil') and doxepin ('Sinequan'). Solomon. F. et al.: New England Journal of Medicine 300: 803 (5 Apr 1979)

2 INPHARMA 14 Apr 1979 0156~2703/79/0414-0002 $00.50/0 © ADIS Press