I have insomnia and rarely sleep for more than three hours a night. But when I started taking the sleeping tablet zolpidem, I slept for six or seven hours for the first time in my life. Are there any problems with using these pills long-term?
Stanley Smith, via email.
Before answering your specific question on the long-term use of zolpidem, I must outline current views about sleep disorders.
A reader wonders if there are any problems with using sleeping pills long-term
In short, I believe that insomnia — where someone either fails to get off to sleep, or has difficulty staying asleep — is generally not well-managed by GPs.
What is needed is a detailed assessment of lifestyle and medical history.
But this is often not done, as there isn’t enough training or enough time in a typical consultation. As a result, all too easily, drugs are prescribed rather than considering other therapeutic approaches, such as cognitive behavioural therapy or, indeed, all underlying causes for these problems — for example, mood or life adversity.
The ease with which these sleeping pills are prescribed increases the likelihood of the major problem associated with all of them: dependence.
Insomnia is often the result of an event, such as a bereavement or stress, says Dr Scurr
Over the years, I have seen numerous classes of sleeping pills being used — including barbiturates, certain benzodiazepines and, more recently, the ‘z drugs’, such as the zolpidem you have been taking.
All of these drugs affect nerve pathways deep in the brain associated with regulating wakefulness. The problem is that their effect on brain chemicals — which, in many cases, are not fully understood — means they can lead to dependence and withdrawal symptoms when used for long periods.
For your information, zolpidem has a licence for the short-term treatment of insomnia and, therefore, should only be taken for a maximum of four weeks in order to avoid these problems.
But, despite reportedly helping you get to sleep, I question whether you need medication at all.
As you say in your longer letter, you’ve suffered from difficulty sleeping for years — and this prompts me to think perhaps you have primary sleep disorder, rather than insomnia.
The difference is that insomnia is sleep disruption often as a result of an event, such as a bereavement or stress.
With primary sleep disorder, there does not appear to be a clear cause.
What you need is an evaluation by specialists at a sleep clinic. This would involve you sleeping in a laboratory overnight.
Specialists will record your brainwave activity, heart rate and oxygen levels while you sleep and will also take a video recording of you sleeping, in case there are any clues in the way you sleep that could suggest a cause or trigger for your sleep problems.
The treatment that follows will depend upon the findings, but won’t be drug-based.
Instead, behavioural therapies, which may include sleep hygiene education (for example, training you not to use your phone or TV in the bedroom), relaxation therapies or cognitive behavioural therapy will be recommended.
Whatever the recommendation, the key is to stick with it.
Just as you won’t improve your physique after a week or even a month at the gym, so you need patience and determination to treat your sleep disorder.
Ask your GP about referral to a sleep clinic.
I suffer from peripheral neuropathy in my feet and legs. What is the cause and is there a cure? I am 70 years old.
John Hunter, St Ives, Cambridgeshire.
Peripheral neuropathy is a general term that describes symptoms as a result of damage to the peripheral nerves, that run from the brain and spinal cord to all parts of the body, including the hands, feet and organs.
This damage means that the messages that travel along these nerves are disrupted, leading to pain (often a burning or uncomfortable tingling sensation) and numbness.
This can be debilitating but, in most cases, is manageable.
The condition affects one in 50 people, and there can be a variety of causes.
Most commonly, this is diabetes, as high blood sugar levels damage nerves, but alcohol abuse, viruses or an injury such as a fractured bone can all trigger it.
Or it can be the result of an inherited susceptibility.
A lack of vitamin B12 is another cause, as this nutrient helps with nerve signalling and function, but this will be revealed with a blood test.
More often than not, no specific cause can be found and there is no effective treatment available, other than addressing individual symptoms.
Sadly, there is little we can do for numbness, but pain can be treated with medication. From the information you have given me, it is unclear exactly what has caused the peripheral pain in your feet and legs, but it appears to me that, in your case, a number of nerves have been affected simultaneously, as a large area is involved.
To distinguish the cause, you need a physical examination from your GP or a specialist in hospital.
This will include testing responses to light touch, the ability to distinguish between hot and cold and sensing vibrations (which is why doctors have a tuning fork on their desk).
This will confirm that there is a neuropathy and identifies the general area that’s damaged.
You will then be referred to hospital for an examination called a nerve conduction study, in which small electric shocks are applied to the damaged nerve to check the signals going through it.
This will identify the exact type of neuropathy — and the cause. This can subsequently determine the treatment.
I assume that your doctor has a fair idea of what has caused your symptoms and, based on the information you have given me, I would suggest there is already a background condition such as diabetes that is considered relevant and which may need closer observation.
By the way… I wouldn’t bother with probiotic pills
Do I need to take probiotics? I am often asked this question and, increasingly, I am inclined to say ‘no’.
Such enquiries have been driven by greater public awareness about the microbiome, the vast colony of micro-organisms that live within us, and which we are beginning to realise are a vital part of our health and metabolism.
in my practice about probiotic supplements, which had just burst onto the scene. Our conversation developed around whether or not these healthy bacteria taken by mouth (for example, the lactobacilli found naturally in live yoghurt and kefir) could survive the very strong acid conditions in the stomach, as well as the digestive enzymes of the small intestine.
We set about looking for research on the subject — and I’ve found that, in fact, many of these friendly bacteria in supplement form won’t survive the journey to their proposed home, the large intestine.
I have since been introduced to the term prebiotic, which is not a culture of living organisms, but food (or rather, a type of plant fibre) — also available in supplement form — that nurtures and amplifies the colony of friendly bacteria already in our guts. A prebiotic supplement will survive stomach acid and the digestive process, so I believe this is where the value lies.
There is much research into the entire area and plenty more to come.
We will soon hear a lot more about prebiotics, which may turn out, as food supplements, to be much more important than probiotics.