Frequently Asked Questions (FAQs)

You have probably discovered that you may have been taking more and more of your sleep medication over time, or if you don’t take it, your
problem falling asleep seems to get worse.  You are correct if you suspect your brain has adapted to the medication
to the point that you are having trouble discontinuing its use.  This will happen pretty quickly if you have been taking one of the benzodiazepines as a sleep aide, but trouble discontinuing sleep medication also happens with any of the commonly-prescribed
or over-the-counter medications. 

To get off your medication, we would want to work with the provider who is prescribing your medication to work out a very gradual tapering
schedule.  It has been my experience that most physicians try to get patients to cut back too quickly, and the effort fails.  By tapering, we mean taking perhaps only ¾ of the prescribed dose for say, a week, then reducing this to ½ of the dose for a week, etc.   It is best done slowly over time if you have been taking medication for a long time.  Stopping abruptly or tapering too quickly causes what we call an “insomnia rebound” (this is insomnia returning with a vengeance when one stops taking sleep meds).    Also, abruptly stopping some medications people take for sleep is quite dangerous if they have been on high doses (e.g., risk of seizures). 

As a prior university researcher, I am always investigating new ways to help improve  treatments in the area of health psychology.  In the case
of tapering sleep medication, some principles discovered by psychologists who study learning are relevant here.  One of these principles is called classical conditioning (you can read about this anywhere on the internet).   My informal work with physicians who prescribe
sleep medication suggests that tapering medication is much easier if we ca develop a strong association between the physiological effects of the medication (drowsiness, sleepiness) and an external, situational cue, such as something wecan listen to, an auditory cue.  Working with your provider, we would coach you to never again take the medication at night without pairing it with a sound source.  The audio source could be an electric fan you would use only night or using ear buds to have you listen at a very low volume to repetitive sounds of the ocean, the rain forest, etc.   If you opt for soft nature sounds, you’d obtain a recording lasting about an hour (download from YouTube).  It is important to play the very same audio track every night, or turn on the electric fan or other “white noise” source only at bedtime.  If you sleep with a partner, wearing soft earbuds will isolate the sound so you won’t disturb them.  (The earbuds will harmlessly fall out of your ears sometime during the night).  The learning principle is that night after night, you repeatedly become drowsy from the medication and your brain also associates drowsiness with the sound of the very same low volume audio.   Over time, the audio will acquire drowsiness properties and help signal your
brain to prepare for sleep. 

Some other details:  
You would take your medication about 20 min before bedtime, climb into bed, and start the audio, at very low volume.  It is very important to
concentrate on the sounds
.  In the case of an electric fan for example, you will notice a very slight rhythm to the sound and would concentrate or track this in your mind.  In the case of say, sounds of the ocean, you would imagine seeing what you hear.  You would concentrate on what you imagine the waves look like, what it feels like to walk on the beach as you listen to the audio.  

Another very key point is that for people with insomnia, concentrating on the audio is  incompatible with your night time thinking, worrying,
problem-solving, planning etc.  You cannot do both at the very same time.  We want the audio to effectively disrupt your usual night time trains of thought.  You will find that at first, your mind will want to quickly shift away from the audio/sounds and back to your usual trains of night time thinking and worrying.  However, with practice, you can pull your mind back to focus only the audio.  In fact, patients report to me that this battle for attentional focus almost always happens many times at first.  However,  with practice, you will be able to “stay with” the audio for longer and longer periods of time.  At first, it will be only a minute or so, but with continued practice, two, three, minutes, etc.  We want you falling asleep to the sounds.  

After several weeks of associating the drowsiness effects of the medication with the audio procedure, your brain will begin to associate listening to the audio with “getting sleeping”.   You will now more easily be able to taper your sleep medication.  However, you need to continue listening to the audio, every night.  As I have mentioned the audio will start to become a signal to your brain that it is “time to sleep”.   You should eventually find that the sleep preparation behaviors you have practiced, relaxation training, and listening to your conditioned audio that signals “sleep” can now substitute for effectively for sleep medication and that tapering your medication becomes much easier.      

I want to emphasize that as far as I know, there are no systematic research studies investigating the effectiveness of this classical conditioning procedure.  I developed this approach independently,  based on my knowledge of various psychological principles and continue informal case studies.   It is certainly a harmless procedure, as it contributes to the  goal—helping make medication tapering much easier.  Also,  it is always a healthful goal to reduce one’s use of sleep medication, as meds usually disrupt healthy sleep cycling.  I can attest to the fact that in the past 6 years of my work in primary care settings, several dozen patients who have not been able to get off their sleep medication for many years tried the procedure and either greatly reduced their use of medication, or stopped it altogether.  I can also tell you that full compliance with the procedure has unfortunately, been low.  Only about 3 in 10 patients actually follow the procedure consistently. They seem to either give up (this does take some sustained effort over time), or continue working the procedure “off and on”.   Commonly. they report that they ‘forget’ to do the procedure.  I speculate that it is a bit anxiety-provoking for most people to think about giving up medication that has helped them for many months or years, though rationally, they know they should.

Everyone’s sleep problem is unique and I would welcome the opportunity to talk to you further about what will work best for your insomnia problem.   

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Copyright 2019  David M. Stein, Ph.D.  Readers are welcome to llink to this article.   Coping this article without the written permission of the author is not permitted.  Coping the article and presenting it on one’s website without appropriately crediting the present author is considered plagiarism.  This action will be reported to state or provincial licensing boards as an ethical violation. 


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