The Slippery Slope of Sleep Meds

How many times have you seen increasing doses of sleep medications prescribed to your patients?

As my technician was processing a prescription the other day, she received an error message that indicated the patient she was typing the prescription for had recently filled a similar medication. This particular patient had been taking a sleep medication, and then had a new prescription for a different sleep medication from another physician. The patient was not available in the store at the time to consult with, so I put in a phone call to the new physician. I explained the situation: the patient had picked up a different sleep medication from a primary care physician only 5 days prior. The new physician was unaware of this.

Evidently, the patient had gone to the new physician specifically for his sleep issue. The new physician thanked me for the call and asked me to put a hold on the new medication until I heard back from him. He stated that he would call the patient and discuss the process. The doctor let me know he’d be happy to handle the patient’s sleep medication therapy, but only if he received all of his sleep medications from one doctor and one pharmacy. He asked if I’d take the time to call the patient’s primary care physician and explain the situation. By the end of the day, it was all worked out, and we were all on the same page.

I don’t believe the patient was attempting to withhold any information from the pharmacy or the physician; the problem is that the patient wasn’t sleeping well. This particular patient had been receiving one particular sleep medication for some time, and it had been progressively becoming less and less effective. He then had an appointment with a sleep specialist who prescribed another medication to help him sleep. At that point, it didn’t occur to the patient to let the physician know that he’d just picked up the other sleep medication 5 days prior and had a full bottle of it at home.

I appreciate an opportunity to have a counseling session with a patient when it’s their first time ever receiving a sleep medication. We’re able to discuss the concept that most sleep medications are indicated for short-term treatment of insomnia and not indicated for daily dosing. We discuss that most of the medications used for sleep, with 1 or 2 exceptions, are used to help an individual fall asleep more quickly, not necessarily keep them asleep longer. We also talk about the fact that if someone takes a sleep medication on a nightly basis, the body becomes conditioned to the medication, making it difficult to fall asleep without a sleep medication.

Most prescriptions for sleep medications are written to be taken “as needed” for sleep. The “as needed” portion of the directions is where some reasonable pharmacist counseling should come in. It’s important for a patient to understand that if they want their medication to continue to work for them when they need it, it’s a good idea to not take their sleep medication every night. It’s reasonable to use an “as needed” dose for a couple nights to get some good rest, and then try a night or 2 without the medication. This “as needed” process helps keep the body from developing a tolerance to the sleep medication.

There are indications where the physician will have their patient take a sleep medication on a nightly basis; however, when taken on a nightly basis, it’s likely that the patient will develop a tolerance to the medication over time. As tolerance develops, it will appear that the medication isn’t working as well, and the patient may ask the doctor to increase the dosage. An increased dosage may then be effective for some length of time, but again, tolerance may build up, and once again it’ll seem that the medication isn’t working as well.

At this point, the patient might ask the physician if there’s any other medication to try for sleep, or perhaps the patient may need to be referred to a sleep specialist.