Guidance for the Management of Insomnia
POLICY DOCUMENTDocument Title Guidance for the Management of InsomniaPolicy Type Prescribing and Treatment GuidelineElectronic File/Location N:\Pharmacy\Policies, procedures, PGDs, guidancesIntranet LocationClinical resources > Pharmacy > Prescribing and treatment guidelinesStatus FinalVersion No/Date Version 2 – August 2016Author(s) Responsible forWriting and Monitoring Lead Pharmacist MidApproved By and Date Medicines Management Group September 2016Implementation Date September 2016Review Date September 2019Copyright? North Essex Partnership University NHSFoundation Trust (2016). All rights reserved. Not tobe reproduced in whole or in part without the permission of the copyright owner.All matters or concerns regarding fraud or corruption should be reported to: Chris Rising, Senior Manager (Chris.Rising@bakertilly.co.uk 07768 873701), Mark Kidd LCFS Lead (Mark.Kidd@bakertilly.co.uk ) Mark Trevallion, LCFS Lead (Mark.Trevallion@bakertilly.co.uk 07800 718680) OR the National Fraud and Corruption Line 0800 028 40 60 Number1Introduction32Aim33Scope34Reference to other standards, policies or procedures35 Guidance45.1Management strategies45.2Sleep hygiene (non-pharmacological interventions)45.3Pharmacological intervention (use of hypnotic agents)55.4Prescribing for inpatients65.5Prescribing for patients in the community75.6Prescribing in the elderly85.7Long term hypnotic use and stopping hypnotics86 References9Appendices1Patient information leaflet – stopping hypnotics10Summary of ChangesDatePage numberSummary of changesAugust 2016All5577 & 8Reformatted to new templateReference added to choice and medication leafletPrescriptions for inpatients can be regular or when required and pharmacy will label accordingly but with a note for short term useTable 1 updated to include onset of actionPrescribing in community and elderly patients addedGUIDANCE FOR THE MANAGEMENT OF INSOMNIAINTRODUCTIONInsomnia is a disturbance of normal sleep patterns commonly characterised by difficulty in initiating sleep (sleep onset latency) and/or difficulty maintaining sleep (sleep maintenance). Insomnia can have a number of different causes:Primary Insomnia is insomnia that can be differentiated from other factors or identifiable causes of sleep disturbanceSecondary insomnia is insomnia due to an identifiable cause such as personal circumstances, physical or psychiatric co-morbidity, drug therapy or substance misuseSleep disturbance and the resulting daytime fatigue cause distress and impairment of daytime functioning, both social and occupational, which have been associated with reduced quality of life.Sleep disturbances occur in up to 50% of hospitalised patients and can be attributed to both pathophysiological and environmental factors.Drugs used to induce sleep will be referred to as ‘hypnotics’. AIMThe aim of this guidance is to provide prescribing and management advice to staff treating patients with insomnia. It also provides advice on transfer of care in the community.SCOPEThis guidance applies to all North Essex Partnership University NHS Foundation Trust (NEP) staff treating/caring for patients with insomnia as an inpatient or in the community.REFERENCE TO OTHER STANDARDS, POLICIES OR PROCEDURESNEP Traffic Lights for the Prescribing of Psychotropic MedicinesNEP Medicines Policies – Tab 5, PrescribingNEP Medicines Policies – Tab 12, Community Medicines PolicyGUIDANCEManagement StrategiesThe choice of management strategy for insomnia is dependent upon both the duration and nature of the presenting symptoms. The options for managing insomnia are as follows:Identify potential causes of insomnia such as: underlying illness, drugs (prescribed or bought over the counter) and substance misuseSleep hygienePharmacological interventionAll patients with sleep disturbance should have a documented assessment for potential causes of insomnia and outcomes/actions from this assessment.Sleep hygiene should be considered the first lane management strategy after ruling out other potential causes and managing those.Sleep Hygiene (non-pharmacological interventions)There is a lack of high quality studies to confirm the effectiveness of non-pharmacological interventions for insomnia. However the use of sleep hygiene as a management strategy is widely supported and recommended.All patients should be offered an information leaflet from the Choice and Medication website on insomnia and sleep hygiene available here: . This leaflet highlights sleep hygiene options and provides general self-help advice to patients.The following sleep hygiene approaches should be considered:Increase daily exercise (not in the evening)Do not nap in the daytimeReduce caffeine, nicotine and alcohol intake, especially before bedtime and avoid caffeine after middayDon’t stay in bed for a significant amount of time if you are not sleepingUse anxiety management and relaxation techniquesDevelop a regular routine of sleeping and waking at the same time each dayAvoid looking at screens (phone, computer, television) before going to sleepMake sure the bedroom environment is quiet and dark and at the right temperatureDo not have heavy meals late at nightPharmacological Intervention (use of hypnotic agents)When sleep hygiene and non-pharmacological interventions have not provided satisfactory improvement in sleep, pharmacological intervention should be considered.Hypnotics can provide relief from the symptoms of insomnia but do not treat the underlying cause. They should be considered somewhat effective for treating sleep onset insomnia but they are ineffective for maintaining sleep. Hypnotics can be considered for the following patients/scenarios:Short term use following an emotional problem (for example bereavement) or serious medical illnessShort term use during hospital stay where the environment may affect sleepShort term use while waiting for treatment of underlying cause to take effectThe following are general guidelines for the prescribing of hypnotics to treat insomnia:Use the lowest effective doseUse intermittent (alternate nights) or ‘when required’ dosing where possiblePrescriptions should be for short term (maximum 4 weeks) use in the majority of casesDiscontinue slowly after medium to long term use (see below for further information)Be alert for rebound insomnia/withdrawal symptomsAdvise patients on the interaction with alcohol and other sedating drugsAvoid the use of hypnotics in patients with respiratory disease, severe hepatic impairment and in addition-prone individualsThe risks of prescribing hypnotics in the elderly may outweigh the benefit (see below for further information)Short acting hypnotics are better for sleep onset insomnia but tolerance and dependence develop more quicklyLong acting hypnotics are more suitable for patients with frequent or early morning wakening but next day sedation is more likely to occurTolerance to the effects of hypnotics can develop within 3-14 days of continuous use and long term efficacy cannot be assuredZopiclone, Zolpidem and Zaleplon should be considered equally effective and patients not responding to one, should not be prescribed another unless the patient is suffering from a drug-specific adverse effectIf insomnia is associated with daytime anxiety then the use of a long acting drug should be considered as a single dose at night may treat both insomnia and anxietyPrescribing for inpatientsInpatients should not be routinely prescribed hypnotics on admission without a full assessment for underlying causes of insomnia and the use of sleep hygiene.If patients are admitted already prescribed a hypnotic, they should be asked how often they use the hypnotic and how long they have taken it for. If the prescriber is satisfied the patient will continue to require the hypnotic as an inpatient it can be prescribed on the drug chart (PMAC) unless it is not recommended (for example nitrazepam could be changed to zopiclone. The prescription and use of the hypnotic should be reviewed after one week.If the decision is taken not to prescribe the hypnotic, consideration should be given to withdrawal effects. Hypnotics should not be discontinued abruptly and should be gradually reduced. Hypnotics can be prescribed as regular or ‘when required’ but should state the indication, maximum dose and a weekly review date. If a patient newly admitted is assessed as needing a hypnotic, the choice of hypnotic should be based on the individual patient, patient preference, local formulary guidance and the advice in Table 1 below and the guidance above. A ‘when required’ prescription is preferred to allow the patient and nursing staff the option of not administering to minimise tolerance and dependence and the prescription should be reviewed weekly.Named-patient supplies from Pharmacy will be labelled as per the prescription but with an additional label to highlight the recommendation of short term use only.During their admission and in the build-up to discharge, all patients prescribed hypnotics should have their use reviewed with a view to reducing or stopping.At the point of discharge, any patients still prescribed a hypnotic should have a clear plan documented in the discharge summary to the GP which states the reason for prescribing, the expected duration of treatment and a plan to reduce and stop the hypnotic. DrugUsual doseMaximum dose*Time until onset (min)NotesVery short actingZaleplon10mg10mg30Patients should be advised not to take a second dose during the nightControlled drug schedule 4.1Melatonin2mg-6mg in children10mg day in childrenUnclearPharmacy stock 2mg MR capsulesNEP have approved the off-label use of melatonin in childrenNon-formulary for adults – Form B requiredShort actingZolpidem5-10mg10mg7 - 27Drowsiness can persist next dayControlled drug schedule 4.1Temazepam10-20mg40mg (exceptional circumstances)30 - 60Controlled drug schedule 3Liquid availableMedium actingZopiclone3.75mg7.5mg15 - 30May have next day drowsinessControlled drug schedule 4.1Oxazepam15-25mg50mg20 - 50Licensed for insomnia associated with anxietySuitable in mild-moderate hepatic impairmentControlled drug schedule 4.1Long actingNitrazepam5-10mg10mg20 – 50Not recommendedControlled drug schedule 4.1Promethazine20-50mg100mg / 24 hours60 - 120Antihistamine with multiple indicationsRisk of antimuscarinic adverse effectsAvailable over the counterTable 1. Choice of hypnotic agents and prescribing guidance* Reduce doses by half to a quarter in the elderlyPrescribing for patients in the communityWhen a patient is reviewed in the community, either at a team base as an outpatient or at home or A&E, and it is felt a hypnotic is required, a prescription should be given if needed immediately.If the hypnotic is not needed immediately, a recommendation for prescribing should be made to the GP. This should include the choice of hypnotic, dosage instructions, aim of treatment, expected duration and suggested review date with a discontinuation plan if possible. Patients should be counselled to include the information above, particularly the recommended short term, intermittent use and managing treatment expectations.Prescribing in the elderlyAs stated above, the risks of treating patients over 60 years of age may outweigh the benefits. Older adults are at greater risk of becoming ataxic and confused which may lead to falls and injury. When a hypnotic is used to treat an elderly patient, the dose should be reduced to half to a quarter that of the recommended adult dose. Discontinuation of hypnotics may have beneficial effects on cognition and postural stability.Older patients prescribed hypnotics should be closely monitored to determine if the prescription continues to be justified.Long term hypnotic use and stopping hypnoticsBenzodiazepines and the Z-drugs (zopiclone, zolpidem, zaleplon) are all addictive and can cause craving, tolerance, dependence and withdrawal symptoms. Withdrawal syndrome can be prolonged and may develop at any time up to 3 weeks after stopping a long acting hypnotic or a few hours after stopping a short acting hypnotic. The withdrawal syndrome includes anxiety, depression, nausea and perceptual changes. Rebound insomnia also occurs and is characterised by a worsening of the original symptoms of insomnia.The risk of dependency may be increased by short duration of action, long term use, high dose, high potency, alcoholism and other drug dependency, personality disorders and use without medical supervision. On long term use, hypnotics will produce sleep, but they will reduce or stop rapid eye movement (REM) sleep which is important for feeling refreshed the following day. In the long term this can increase confusion, cause poor short term memory and an inability to make decisions. Patients may also suffer an increase in early morning wakening as the body attempts to achieve REM sleep. Healthcare professionals should ensure patients are counselled on the risk of dependence and withdrawal syndromes. The information leaflet in appendix 1 can be used for this purpose and patients should be encouraged to stop using hypnotics with the support of a healthcare professional.If a hypnotic has been used for less than 4 weeks, it can usually be stopped immediately.If a hypnotic has been used for longer than 4 weeks, the dose should be gradually reduced to a minimum dose and then introduce intermittent dosing before stopping completely. Intermittent dosing can be achieved through taking a hypnotic on alternate days, only using during the week, only using at weekends etc. Doses can be reduced at a frequency determined by how well the patient tolerates the reductions. As a guide, this could be weekly to monthly or greater if necessary. For withdrawal after long term use, it may be possible to switch to an alternative drug that is easier to withdraw such as promethazine. REFERENCESBritish National Formulary, Edition 70. September 2015. Pharmaceutical PressThe Maudsley Prescribing Guidelines in Psychiatry 12th EditionNICE TA77, Guidance on the use of zaleplon, zolpidem and zopiclone for the short term management of insomnia, 2004Appendix 1- Patient information leaflet - Stopping HypnoticsWhy should I come off sleeping tablets?Everyone has a different sleeping pattern, but a “normal” one will have several periods of light sleep, and deep sleep, and also REM (rapid eye movement) sleep, which is the time your brain uses to process all the information it has taken in during the day before, and process it and “file” it so it is ready for the following day.AWAKEREMLIGHT SLEEPSLEEP DEEP SLEEPCOMA-LIKE SLEEP-5080175895“NORMAL” NIGHT’SSLEEP 00“NORMAL” NIGHT’SSLEEP -190515875 WITH FIRST DOSES OF SLEEPING TABLET00 WITH FIRST DOSES OF SLEEPING TABLETSleeping tablets will give your body a rest, and improve sleep, but they do not allow for any REM sleep. They are good for the short term, but without the REM sleep you may still find you feel tired in the morning. Higher doses will make your sleep deeper and longer, but your brain still wants that REM period and in trying to reach it may cause you to suddenly wake up in the early hours.What are the side-effects?In the short-term, you will be less alert, tired in the mornings, and less able to drive or to operate machinery.In the long term you may become dependent on your tablets, and want to take bigger and bigger doses. You may have falls or accidents more often, a poorer memory, and a feeling of not engaging or a lack of emotion. You may take longer to do things. There is a risk of reducing life expectancy.What happens if I stop them?This depends on how long you have been taking them, and everyone is different, but withdrawal has caused Difficulty in getting to sleep or staying asleepNightmares or vivid dreamsAnxiety and restlessnessHot or cold sweatsPanicChanges in your bowel (constipation, diarrhoea, colicky pains)How can I avoid problems with withdrawal?If you have been taking them for less than 4 weeks you should be able to stop straight away.If you have used them for longer, your doctor may change you to a different tablet that is easier to come off.Make a plan to reduce the size of the dose gradually, maybe over weeks or months, then consider tablet-free nights, maybe starting at the weekends and increasing until they have stopped.Involve the people you are close to (partner or carer or friend) to encourage you and to talk to. Can I use tablets in future when I can’t sleep?If all other ways have not worked or you have an urgent need, use them for a short time only (3-5 days) to give you a sleep pattern that works for you. Poor sleep may be a symptom of something else, so do talk to your doctor about it.Driving regulations while on sleeping tabletsIt’s illegal in England and Wales to drive with legal drugs in your body if it impairs your driving.It’s an offence to drive if you have over the specified limits of certain drugs in your blood and you haven’t been prescribed them.Talk to your doctor about whether you should drive if you’ve been prescribed any of the following drugs: clonazepamclonazepamdiazepamflunitrazepamlorazepammethadonemorphine or opiate and opioid-based drugs, eg codeine, tramadol or fentanyloxazepamtemazepamYou can drive after taking these drugs if:you’ve been prescribed them and followed advice on how to take them by a healthcare professionalthey aren’t causing you to be unfit to drive even if you’re above the specified limit ................
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