How can primary care physicians (PCPs) best help patients who want to learn how to be a morning person, avoid sleeping pill hangovers, and adjust sleep schedules before and after traveling through multiple time zones? And those with complex sleep behavior (CSB) who have an abnormal blending of wakefulness and sleep, either REM sleep where they’re dreaming, or NREM?

“Sometimes being awakened abruptly from a deep stage of sleep, like from an alarm clock – when the person is still under the influence of sedating medications – can lead to this phenomenon,” said Tracey Marks, MD, an Atlanta-based psychiatrist/psychotherapist and author of the award-winning Master Your Sleep: Proven Methods Simplified (Bascom Hill Publishing Group, 2011), who often consults with PCPs about patients with CSBs such as sleep driving, sexomnia, sleepwalking, sleep eating and sleep violence.

“This problem has gotten media attention and some patients are afraid to take sleeping pills because of this,” said Marks, a Duke grad who earned a medical degree from the University of Florida and created the clever blog site, BeyondBurnoutBlog.com.

Marks pointed out that CSB is not unique to Ambien. 

“It’s just the one that’s gotten the most press, probably because it’s so popular,” she said. “The risk of CSB occurs with all hypnotics, so it’s a medication class warning.”

CSB is more prevalent in people who have a history of parasomnias or sleepwalked as children. 

“Even if it stopped after adulthood, those who did at some point are more vulnerable to the effect from hypnotics,” she said. “So the PCP should ask about this. It doesn’t mean the person shouldn’t take it; it just means they should be cautious the first time they take something and watch for abnormal behaviors. A possible precaution would be to take the medication for the first time on the weekend – and when there is someone else in the home.”

Ways to decrease the chance of having CSB are obvious to the medical community, said Marks, yet patients may need to be reminded of a few tips for sleep success: 

• Stick to the recommend maximum of the medication. “It’s very easy for patients to become tolerant to the effects of sleeping pills,” she explained. “Many on their own will take ‘just one more’ to get it to continue working. This is especially true with Ambien and Lunesta, where the recommended maximum amounts are 10mg and 3mg, respectively. PCPs have to emphasize the importance of not taking more – even when the medication stops working. Taking a break from the medication and skipping days is the better way to lengthen the time for which it is effective.”
• Cut off alcohol consumption several hours before taking sleeping medication. “Again, the reason is the cumulative effect of the alcohol and sleeping medication,” she said. “It’s best to abstain completely from alcohol if planning to take a sleeping pill later on.”
• Don’t take sleeping pills late in the evening, with the exception of Intermezzo, a short-term sleeping medication new to the consumer market. “Some patients will try and wait to see if they can fall asleep on their own, then get frustrated at 1 a.m. and take something. This is a no-no unless it’s Intermezzo.”
• Reduce the combination of benzodiazepines and sleeping pills. “Often in a primary care setting, a patient will be on benzos for anxiety and then have a sleeping pill added a later time in the course of their treatment,” she said. “It’s easy to overlook the fact that the patient takes Klonopin at night and doesn’t intuitively know to eliminate their evening dose of Klonopin if they’re going to take a sleeping pill. They take both and yikes! So the doctor has to remember to check their other meds, especially if they’re getting meds from other doctors and ask specifically about what else they’re taking at night.”

The new medication for middle-of-the-night insomnia – Intermezzo – is bringing relief to many insomniacs who try to fall asleep on their own without success.

“Intermezzo is better than having patients break off a piece of Ambien to take, which is what a lot of them will do when they can’t fall asleep at 3 a.m.,” she said. “But taking (even a partial amount of) Ambien at 3 a.m. can lead to sleep driving, which is the context in which this issue of complex sleep behaviors came up.”

Intermezzo is a smaller dose formulation of zolpidem (Ambien) that’s taken sublingually. The recommended dose for women is 1.75 and 3.5mg for men.  

“Ambien is designed to last seven or eight hours; Intermezzo is designed to last approximately four hours,” said Marks. “This middle-of-the-night insomnia medication was sorely needed for those waking up at 2 a.m. – or not falling asleep until then – and wanting to take something to fall back asleep before the alarm sounds at 6 a.m.”

Marks pointed out that Intermezzo is “still not a free-for-all” and has a few rules: Patients must have four hours left to sleep and must not drive for an hour after waking.

“To reduce risk of complex sleep behaviors, it’s also recommended you don’t combine it with other sleeping pills,” she said. “In other words, don’t take sleeping pill X to help you sleep the first few hours of the night, and then take Intermezzo when you wake at 3 a.m.  Why? Most sleeping pills are designed to be active in your system for seven or eight hours, even if they don’t seem to be working the entire night. So taking an additional sleeping pill on top of what you took a few hours earlier may have a cumulative sedating/cognitive slowing effect.”