“Please don’t wake me up for a sleeping pill.”
When I began working fairly regularly at one of the nursing homes, the nurses would ask for a standing order for sleeping pills for certain patients at bedtime daily instead of just as needed. My response “Doesn’t that mean that you would have to wake the patients up to carry out the order even if they were asleep already?” “Yes, I guess it means that.” My reply, “No way.”
Generally speaking, except for a few cases noted below, sedatives are habit forming. Simply stated: this means that a sleeping pill taken nightly for a few weeks becomes a requirement. It becomes necessary in order to sleep as well as that person’s previous pattern of sleep. This means habit forming. Sedatives, sleeping pills and anti-anxiety medications hit the same receptor in the brain as alcohol. This makes them especially treacherous for reformed alcoholics.
Another hazard for the elderly: these medications addle the mind, which may push a susceptible oldster over the threshold of incompetence for self care. When such a person enters the nursing home, the regulation of all dosages by the staff results in dramatic improvement in a week or so to the point of being competent to live alone again. If the doctor is “having a bad day” and neglects to ask the relatives to clean out the medicine closet at home, that person is highly likely to be back in a few weeks. Compare with the “revolving door” after drying out any substance abuser. The most rapid acting of any class of habit forming drugs, including sedatives, are the most immediately satisfying in terms of symptom relief, whether anxiety or insomnia, but the most rapid acting are also the most habit forming. A few years ago there was a sleeping pill promoted as not habit forming. Truly it was not habit forming because it was so long acting - weeks - that it covered its own withdrawal as if by a gradual dose reduction of some other sedative. Its fatal flaw (it is scarcely used anymore): it accumulates over a period of weeks producing incompetence (compare with drunkenness) but so gradually that the cause might not be recognized.
What about over-the-counter sleeping pills? About ten years ago the then available antihistamine medications (for hayfever) became available over-the-counter (without prescription). One of them, Benadryl (diphenhydramine), has the offensive side effect of excessive sleepiness. Drug manufacturers recognized this as an opportunity to market over-the-counter sleeping pills. I don’t think the FDA (Federal Drug Administration) anticipated this result but fortunately Benadryl hasn’t been much of a problem when used as a sleeping pill. The fine print on the label specifies “diphenhydramine” as the active ingredient not “Benadryl.” A number of anti-depressant medications also have sleepiness as a side effect and also have not been a problem about habit. This point is emphasized by the fact that they have no “street value.”
A number of years after my intransigence at not permitting anybody to be awakened for a sleeping pill, I was looking over a report issued by the State of Wisconsin tabulating the use of various types of medications by sizable nursing homes (of the order of a hundred beds) throughout the state. The particular nursing home had nobody, not even one patient, on any sleeping pill. This report comes out quarterly and I have continued to look it over. Usually, my favorite nursing home still has no one on sleeping pills and I have seen no others on the list with nobody on sleeping pills, not even once in these quarterly reports.
Interpretation: The corporate culture at this nursing home changed resulting in benefits to the entire population of patients, regardless of who a particular patient’s attending physician happened to be. Intransigence, to an extent only similar to stubbornness, can be the backside of a virtue. And unquestionably the nurses and ancillary staff are the major heroes of this result.
John A. Frantz, M.D.
Chairman, Monroe City Council Board of Health
November 5, 2002