Sleeping pills have been considered a better option than benzodiazepines for the drug for many years treatment of insomnia. However, there is little convincing evidence to distinguish between the two drugs. This article aims to sleeping pills such as zolpidem en benzodiazepines such as alprazolam in terms of their efficacy, safety and abuse potential.
Insomnia is characterized by a disturbance in normal sleep patterns - either a shortening of sleep time, a delay in the onset of sleep, or waking up too early in the morning. It has been associated with reduced quality of life, mental health problems, drug abuse, achievement difficulties and traffic accidents, a greater risk of depression and anxiety and possibly even cardiovascular disease. These all have an impact on the economy due to reduced productivity and absenteeism. Aromatherapy with lavender oil or herbal remedies, such as valerian, is widely used to relieve sleep problems. However, their efficacy has not been proven and they should be used with some caution. Non-pharmacological treatments improve symptoms in 70-80% of patients, but they can have lasting effects. Cognitive behavioral therapy has been shown to be as effective as pharmacological treatments, but a combination of both is usually recommended. If non-pharmacological interventions fail or if daytime insomnia causes significant dysfunction and stress, hypnotics can be used. Allowed treatments include benzodiazepines (nitrazepam, temazepam, diazepam, lorazepam etc.) and hypnotics (zopiclone, zaleplon, zolpidem). Sleeping pills are structurally different from benzodiazepines and were developed in an effort to optimize the pharmacodynamic properties of benzodiazepines, such as faster onset and rapid clearance to minimize or eliminate daytime sedation, in addition to removing the potential, dependence and withdrawal from use. Research shows that hypnotics are more prescribed than benzodiazepines because they are perceived to be more effective and safer (especially in older people) and because they are less addictive.
Both benzodiazepines and sleeping pills work by enhancing GABA activity in the brain. Benzodiazepines bind to GABA receptors in the alpha 1, 2, 3 and 5 subtypes. They have been used as hypnotics since the 1s and have a clear and clinically meaningful effect on sleep duration compared to placebo. In addition, they are less effective in reducing sleep latency. Sleep aids, on the other hand, are GABA-A receptor agonists. Zolpidem and zaleplon are effective sedatives because they selectively bind to the alpha-XNUMX (hypnotic) subunit, and zopiclone uniquely interacts with the receptor.
In a meta-analysis comparing zolpidem and benzodiazepines with benzodiazepines found in patients aged 65 years and under, they were found to be as effective as placebo. However, it turned out that patients older than 65 years had an increased risk of side effects. Statistically, Zolpidem provides significantly fewer awakenings, greater ease of sleep onset and improved sleep time. Studies comparing the hypnotic properties of zopiclone (a cyclopyrrolone) with benzodiazepines (a cyclopyrrolone) have also shown that they are equal to or better than benzodiazepines. Patients taking zopiclone reported better and longer sleep. In addition, they also took less time to fall asleep. These benefits significantly outweigh the risks associated with taking zopiclone.
The beneficial effects of using hypnotics for insomnia are small compared to the risk of side effects. Benzodiazepines have a higher receptor occupancy than sleeping pills, leading to profound pharmacodynamic actions. The adverse effects of benzodiazepines include headache, blurred vision, gastrointestinal upset, confusion, ataxia and paradoxical reactions. All of these outweigh the potential clinical benefits. The side effects of hypnotics are similar to those of benzodiazepines, but a meta-analysis of randomized controlled trials has shown that side effects are less common and less serious for zolpidem and zaleplon, among others. The most commonly reported adverse reactions were considered, which were more frequent for the benzodiazepines and also included a number of other symptoms such as somnolence, headache, dizziness and nausea. Fatigue was not reported by people taking sleep medications.
However, both drugs, especially zolpidem, can induce complex behaviors such as sleepwalking, driving under the influence of sleep and hypnopompic hallucinations. However, it is unclear why it does not happen to some and others. Some patients may be predisposed to a certain condition.
Both benzodiazepines and sleeping pills can cause respiratory depression. However, this is more likely with a benzodiazepine. Also, comorbid respiratory disorders such as COPD and obstructive sleep apnea can be aggravated by benzodiazepines.
Benzodiazepines potentiate central nervous system depression in combination with other sedatives such as alcohol. There is also an increased risk of suicidal behavior when benzodiazepines are taken with alcohol. However, this was much less reported by people taking sleep medications.
A major concern for patient safety is impaired driving ability, which may be hypnosis or sleep deprivation induced. Benzodiazepines, as well as zopiclone and zolpidem, increase the risk of traffic accidents. The European Medicines Agency issued an opinion on zolpidem in 2014. The recommended dose should be a single dose, just before going to bed, and the patient should not drive or engage in activities that require alertness for at least eight hours after dosing. It should not be used in conjunction with other sedatives such as alcohol or illegal drugs as these greatly increase the risk of side effects.
Addiction potential and tolerance
All hypnotics have abuse potential. The risk of this is increased with chronic use of shorter acting hypnotics at higher doses, a history of drug addiction, personality disorders and the lack of medical supervision. They are well known to cause addiction and withdrawal. Chronic benzodiazepine use is associated with tolerance and dependence (but not in all patients). It is estimated that 10-30% of patients on benzodiazepines chronically are physically dependent and that at least a third have problems stopping or decreasing their dose.
Short-acting benzodiazepines, such as lorazepam, are associated with the greatest risk of withdrawal symptoms, and withdrawal symptoms have also been reported after discontinuation of all hypnotics. These include temporary worsening of insomnia, headache or myalgia, confusion, severe anxiety, restlessness, and irritability.
The current perception that sleep medications are safer than benzodiazepines is imprecise. They only tend to work faster. However, they have similar side effects, so they are not suitable substitutes. There is also a difference between the different half-lives. Hypnotics with a shorter half-life are generally safer and produce fewer side effects in most patients, but have a higher risk of withdrawal symptoms and should therefore be used only in the short term. Benzodiazepines still have the greatest risk of tolerance and abuse potential compared to sleeping pills. It is vital to consider patient characteristics and drug differences before prescribing a hypnotic drug. All hypnotics should be used briefly or intermittently and this should be reviewed regularly. This caution should be explained to patients, along with information about the hypnotic agents that are prescribed to minimize the potential for abuse.