Confessions of a GP

Sleep

Is not being able to sleep a medical problem? I’m not sure it is. I see lots of people telling me that they can’t sleep and they want me to give them a cure. Usually, they ask for a sleeping pill and are then surprised by my reluctance to prescribe them one. We all have nights lying awake and watching the clock slowly tick by. It’s not much fun but it strikes me as part of being human. Some people struggle more than others but usually we can find a reason for not sleeping. Causes can be divided into extrinsic and intrinsic. Extrinsic factors include having a crying baby or noisy neighbours keeping you awake. I can’t do much about those, but intrinsic factors such as stress, anxiety, excitement and pain are probably more common causes of insomnia. There is usually something keeping us awake and I always feel that there are plenty of routes to explore before we make the knee-jerk reaction of reaching for the sleeping pills.

The problem with sleeping pills is that they are addictive and stop working after a short period. The manufacturers advise that they should not be taken for more than a month, but despite this I have literally hundreds of patients who have been taking sleeping pills for up to 40 years! Benzodiazepines (benzos) are still the most commonly prescribed sleeping tablet (aka Valium, diazepam, temazepam, etc.). For those patients on these medications, stopping them is extremely difficult. My patients on Valium are like any addicts. They crave their drug and will often lie, cheat and steal to make sure they don’t miss their next dose. In the rougher parts of this country, Valium has a street value and is sold by drug-pushers along with heroin and crack cocaine. If it is viewed by dealers and junkies as an illicit drug, maybe it is time that doctors saw it in the same way.

Diazepam is a type of tranquilliser and works on specific receptors in the brain to relax muscles, relieve anxiety and cause sedation. In the short term it can seem like a wonder drug for all those angst-ridden insomniacs. The problem is the side effects. The body gradually gets accustomed to the sedative effect of the medicine and after a short period of time the drugs are no longer effective. Users start needing higher doses to have the same effect. They find that without the drug they feel increasingly anxious and unwell and can have quite severe physical side effects such as abdominal cramps, vomiting and even seizures. Taking sleeping pills at night often makes them feel slow and sluggish during the following day. I’ve had to sign people off work who were addicted to sleeping pills when they were too tired to work safely as a truck driver or machine operator during the day.

I’m not suggesting that we stop prescribing these medications altogether, as benzos do have their uses. They are valuable in calming and relaxing people prior to operations and if it wasn’t for benzos, B. A. Baracas would never have got on a plane! They can also be used to bring epileptics out of a fit and I often prescribe them when someone is under acute stress. For example, in the immediate period after a bereavement or a when a relationship has ended, a short course of diazepam can help someone to get through the first few terrible days. They are also good for patients with severe muscle spasm such as a slipped disc in the back.

I fully accept that there are drug and alcohol addicts out there. To add to those numbers many more addicts created by doctors and, principally GPs, seems such a shame. There is still a strong culture of prescribing sleeping tablets among some GPs. It is the quick fix for both patient and doctor. The patient gets a pill that makes them feel relaxed and able to sleep and the doctor gets the patient out of the room quickly. It is much tougher for both patient and doctor to try to identify the underlying cause of the sleeping problem. Depression, pain and anxiety are all difficult issues and ten minutes isn’t nearly enough time to handle them. For my patients who can’t sleep, I usually ask why they think they can’t sleep. I then move on to something called ‘sleep hygiene’ and offer advice about exercise during the day and having a hot bath and cocoa just before bedtime. I even add in a bit of feng shui and advise never to use the bedroom for anything other than as a place to sleep so that the bedroom tunes the brain into sleeping rather than thinking. Some patients like all this holistic stuff, others just want a magic pill and are disappointed when I say no.