Council | How to wean yourself safely off sleeping pills

Most start using over-the-counter or prescription pills to counteract sleep disturbances caused by short-term disturbances such as travel, unusual stress and hospitalization, or long-term conditions such as chronic insomnia (or another sleep disorder), depression , anxiety and hyperthyroidism.

Most of my patients want to stop taking sleeping pills, but many have been reluctant to try. They have different reasons for wanting to quit, such as:

• Their or their doctors’ concerns about over-dependence on medications.
• Side effects.
• Declining effectiveness.
• Individual health considerations such as pregnancy, upcoming surgery, or drug interactions.

They also have several reasons for continuing to take the pills, including:

• Relief in the certainty of a good night’s sleep and doubt about their ability to sleep without medication.
• High anxiety about poor sleep.
• Failed tapering attempts during which they experienced difficulty sleeping, anxiety or other withdrawal symptoms.

If, like my patients, you want to reduce or stop your medications, but feel discouraged, resigned, anxious, and doubtful, I want to assure you there is hope.

No single approach to reducing sleep aids

Sleeping pills are not a unitary category. Hypnotic and sedative drugs include different types of drugs with different modes, durations of action, and discontinuation issues. There is no one-size-fits-all approach to reducing or stopping such varied agents.

Practical considerations also vary from drug to drug. Some pills are not meant to be cut. Others can be trimmed, but some are too small to do so precisely. Some people need to substitute another drug to help them get off the first one, or need to figure out which of the two or more drugs to cut back on first.

There are many other considerations. For example, if you have only been on a medication for a month, the tapering approach will likely be faster (to avoid extended use) than the gradual approach described below for those who have been on medications long-term.

Ways to prepare to reduce or stop sleeping pills

There are a few general principles to help you be successful at tapering:

• Work closely with your doctor to determine a safe rate and method.
• Pharmacists can help, by dividing pills or assisting with liquid or compound formulations to create fractional doses.
• Go slowly. The biggest mistake my patients make is going too fast. They end up returning to their full fix, chastised and disheartened by the experience.

Before you start decreasing, though, know what you’re healing. It’s not okay to remove a pill if you don’t have proper treatment for the below sleep condition. There are many cases of undiagnosed restless legs syndrome, sleep apnea, depression, or other conditions that result in poor sleep. Sleep doctors are excellent at sorting out diagnoses.

I have a patient who has tried many times over several years to cut down on benzodiazepines. Each time, however, she experienced unmanageable insomnia. I used this metaphor to explain why going slow was important:

Imagine a pool with shallow and deep ends. Imagine a ramp that connects the two, and it’s not a steep drop but a gradual descent. You are safe in the shallow end not out of your depth if you sleep well with the help of medication. Your goal, however, is to be a competent and confident swimmer to the core so that you can sleep well without (or on less) medication.

There are three reasons for slow decline:

1. Going slowly minimizes withdrawal, or insomnia, anxiety, and other symptoms that can result from dosage reductions. If you’re cutting small amounts very gradually, your system will barely register the change. You are taking one small step at a time down the ramp.
2. The slow approach is a form of graded exposure therapy. Each new step down the ramp, each new dose reduction allows you to minimize and perhaps even overcome your anxiety before proceeding to a more difficult step, which may not seem more difficult because you have mastered the previous step. It also feels relatively non-threatening to take baby steps.
3. Slow taper provides time to develop sleep skills to replace the medication. I have written about some of these skills. You may not have needed it because you were on medication. Going slowly, you master swimming skills at each new depth. When you progress to the end, you will be an excellent swimmer.

Over the course of about a year, with support from her doctor, my patient reduced her dose to a quarter of what it was.

Steps to stop using or cut down on sleeping pills

Here’s a way to taper off if your doctor approves. My patients tend to find it easy and non-threatening. For simplicity, I’ll assume you’re taking an entire pill and don’t want to go down to anything.

1. Establish step sizes and milestones. Decide whether you want to cut down by an eighth of a pill at a time or a quarter or some other fraction. Let’s say it’s an eighth. Your first milestone is seven-eighths of a pill. You work towards that milestone and only that milestone at the start.
2. Gradually increase the number of nights per week you take the milestone dose (for example, seven eighths) versus the full dose (one pill). You might start with once a week at the lowest dose and gradually work your way up to seven times a week, always taking the highest dose on the nights you don’t take the lowest. You don’t have to hit all of your travel numbers from zero to seven nights a week at the lowest dose.
3. Distribute the lowest doses for example, every four nights if you take the smaller dose twice a week.
4. You can repeat weeks. For example, if you take the lower dose every other night and the higher dose the other nights, you can repeat the pattern for another week or two.
5. Once you reach the first milestone (e.g., seven-eighths of a pill each night), that dose becomes your new high dose, and one more drop (e.g., three-quarters of a pill) becomes your new low dose. You have finished taking a complete pill. Flexibly repeat the pattern that led you to the first milestone to reach the second and subsequent milestones.
6. Slow down the cone towards the end. Reducing by an eighth of a pill is only a 12.5% ​​reduction to start with, but it’s a 50% reduction once you’re down to a quarter of a pill.
7. Try not to go up the rampbut if necessary, go back to the rung where you were last sleeping well and stabilize there before resuming the tapering more slowly.
8. Map out what you’re going to to take each night on an editable calendar to track where you are and to keep your resolve.

You should feel in control. The goal isn’t perfect sleep or zero anxiety; it’s confidence in your ability to get through difficult times. You set the pace.

We welcome your comments on this column a OnYourMind@washpost.com.

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