A worsening of sleep or the onset of insomnia may be caused by the discontinuation or reduction of substances that are habitually taken. These may be substances taken as sleeping pills to which tolerance or dependence has developed, or substances taken regularly for other purposes, whether medications or not.
Insomnia may occur during detoxification from substances, especially when it is self-managed. This often happens after stopping or reducing alcohol and tranquilizers/sleeping pills, or after reducing opioids.
Sleep is not always disrupted immediately after stopping a substance, and this also depends on how quickly the substance is “cleared” from the body: when a substance is eliminated quickly, withdrawal begins early and intensely; when it is eliminated slowly, insomnia begins later. Depending on the degree of tolerance or dependence, insomnia may vary considerably in severity. The degree of tolerance or dependence cannot always be inferred from the dose expressed in number of drops or milligrams, because different sleeping pills and substances have different potencies even when they have similar mechanisms of action.
Insomnia caused by stopping a short-acting sleeping pill (lorazepam, triazolam, alprazolam) is immediate and consists of a worsening of insomnia, often to a level worse than the one for which the sleeping pill was originally started. The person usually becomes frightened and continues taking the sleeping pill. Even when the medication has not been completely stopped but only reduced, the immediate worsening of sleep may make it difficult to complete a gradual withdrawal.
In the case of stopping a long-acting sleeping pill, insomnia may begin later but last longer. For example, a gradual reduction may not cause immediate consequences but may be followed by a gradual worsening of sleep over the following days, even though the person has successfully reduced or stopped the medication. Typically, after several days of persistent insomnia, the person will tend to resume the sleeping pill. The withdrawal process therefore does not depend simply on the presence of residual amounts of the substance in the body, but on the brain’s readjustment to the absence of the substance.
Discontinuation of a sleeping pill to which tolerance or dependence has developed should always be carried out under medical supervision, particularly when the underlying disorder—usually involving anxiety or mood—is not adequately controlled. Otherwise, even a modest disturbance of sleep may be accompanied by a sudden increase in anxiety or a worsening of mood, leading the person urgently and fearfully back to the sleeping pill.
The most delicate situations in withdrawing from sleeping pills are chronic insomnia (that is, insomnia that has been present for a long time) complicated by the use of sleeping pills with rapid onset but long duration of action. In these cases, the person may be able to gradually discontinue the sleeping pill, but sleep may remain disturbed for longer because of a combination of an immediate but temporary worsening of sleep and a gradual increase in daytime anxiety. Furthermore, if the underlying mood or anxiety disorder usually associated with chronic insomnia is not adequately treated, sleep will remain fragmented, shallow, and non-restorative.
Vivid or disturbed dreams may occur during the reduction and discontinuation of sleeping pills, particularly when antidepressant treatment is also being used.
Self-management of withdrawal from sedatives and alcohol should be avoided, as should treating withdrawal symptoms individually as they arise. In fact, withdrawal from some substances, such as sleeping pills and alcohol, carries a risk of seizures. Someone managing withdrawal on their own may make the mistake of treating insomnia with a symptomatic medication that does not protect against the risk of seizures.