Stimulant medications such as amphetamines, pemoline(Drug information on pemoline) (Cylert) and methyl-phenidate (Ritalin) are increasingly used both for sleep disorders such as narcolepsy and idiopathic hypersomnolence and for psychiatric disturbances such as attention-deficit/ hyperactivity disorder and depression.
Feinberg and colleagues found that stimulant medications will prolong sleep latency and REM latency and decrease total sleep time. As tolerance develops to these effects, dosage escalation results. Careful monitoring of patient use, as well as education regarding the effects of such medication, is crucial. In withdrawal, stimulants will result in hypersomnia and frequently hyperphagia, as well as affective instability.Caffeine's Effects
Caffeine, along with the other methyl-xanthines, is probably the most frequently used and abused stimulant agent. The effects of caffeine(Drug information on caffeine) appear to vary, with some individuals being more sensitive to its effects than others. Ingestion of about a cup of brewed coffee prior to bedtime appears to significantly prolong sleep latency when compared with placebo. Total sleep time will be diminished, because arousals and awakenings are more frequent. Caffeine may effectively combat sleepiness, though tolerance does appear to develop with continued use.
Symptoms of anxiety, insomnia, psychomotor excitement and gastrointestinal disturbances may result from caffeine intoxication. In patients with those symptoms consuming more than the equivalent of three cups of brewed coffee per day (300 to 450 mg), it is important to taper the caffeine use as opposed to abrupt withdrawal, which can result in headache, gastrointestinal disturbance, sleepiness and marked irritability.Nicotine's Effects
Evidence suggests that nicotine(Drug information on nicotine) has a biphasic effect upon alertness. In low dosages it appears to cause sedation, while in higher dosages stimulation is more commonly experienced. The effects of nicotine and caffeine are often coupled in order to achieve the desired level of alertness. The plasma half-life of nicotine is approximately two hours, which for most smokers results in a fall in concentration of the drug throughout the night. Sleep laboratory recordings indicate that chronic smokers have a longer initial sleep latency than nonsmokers, and that this effect disappears upon cessation of smoking. However, chronic smokers also experience anxiety and marked restlessness in withdrawal, so that it is often difficult to assess the effects upon sleep. In general, good sleep hygiene means avoiding tobacco for several hours prior to desired sleep onset.Agents for Change
Sedative-hypnotic agents are among the most commonly prescribed medications in the world. Specifically, benzodiazepine agents will result in a shortening of sleep latency and reduction of wakefulness during sleep. They appear to alter sleep by binding to the benzodiazepine GABA receptor and modulating GABA transmission. When these agents are withdrawn, insomnia and sometimes nightmares may be seen.
Rebound insomnia may result following discontinuation of short half-life and intermediate half-life agents given for short periods of time. This can occur following even a single night of administration. Rebound insomnia does not appear to be a problem with short-term use of the newer hypnotic agent zolpidem(Drug information on zolpidem) (Ambien). While structurally distinct from the benzodiazepine agents, it too appears to act upon the GABA receptor. Unlike benzodiazepine agents, zolpidem does not lead to decreased slow wave sleep. As with all hypnotic agents, pharmacotherapy alone is not the solution for patients with chronic insomnia, and comprehensive assessments and treatment planning are necessary for sustained improvement.
Education regarding the effects of psychoactive substances is clearly indicated. The use of such substances raises significant public health concerns, not only when used in an abusive pattern, but when ingested in a socially accepted fashion.