Shirley is among tens of thousands of Australians who have become dependent on sleeping pills. About four in every 10 people who take benzodiazepines for longer than six weeks will become dependent, but the process can take as little as three weeks. Many don’t even know they are hooked. Guidelines for GPs recommend they be kept to the lowest possible dose and not be prescribed for longer than four weeks. Long-term use is not recommended. Evening commuters reach for copies of the afternoon mX newspaper reporting the news of the death of actor Heath Ledger. Ledger was found with sleeping pills, and several other drugs, in his system. Credit:John Pryke But many people remain unaware of these risks. And doctors continue to give them out.

“I was never, at any stage, by any medical professional, warned about them,” Shirley said. “Never warned they were drugs of dependence, and never warned they could have pretty drastic side effects.” Almost 6 million subsidised scripts for benzodiazepines (a group of drugs sold as Valium, Xanax and Serepax among others) were written last year for 1.7 million patients, according to an analysis of the data by NPS MedicineWise. The true number, once off-label and hospital scripts are included, is likely to be much higher, experts say. The recommended treatment for insomnia is psychological help, including relaxation techniques and advice on how to get a better night’s sleep. “The most effective treatment for insomnia is not drugs,” said Dr Alan Young, incoming president of the Australasian Sleep Association.

Pills should only be given out as a second option, guidelines recommend. But according to a 2009 study, nine times out of 10, people who show up at a GP’s office complaining of insomnia will be given a prescription for medication. About 20 per cent get advice and counselling on how to sleep better, and fewer than 1 per cent are referred to a psychologist. Janet Shaw, manager of Reconnexion. Just this week she received a referral from a man who had been taking sleeping pills for 50 years. Credit:Joe Armao “There is an incredibly strong risk of dependence, and for some people it can happen incredibly quickly,” said Janet Shaw, manager of Reconnexion, a specialist sleeping-pill dependency treatment service based in Malvern East. “But all the way along, they go ‘This must be fine, because my doctor is giving it to me’.”

But the Royal Australian College of GPs says that data is too old to be reliable. The way sleeping pills are prescribed has totally changed in the past decade, the college contends. “We are always concerned about incorrect use of medication, but I believe that most GPs are responsible and try to minimise the use of sleeping pills. Most people will suffer sleeping problems at some point in time in their lives, which may respond well to medication,” said Dr Harry Nespolon, the college’s president. “Just because a script is written it does not mean that the patient, in this case, will necessarily buy it or use all the medication.” Reconnexion sees about 60 clients a month; almost half have been prescribed sleeping pills for more than five years. About one in 10 has been prescribed a nightly pill for more than 20 years. This week it received a referral from a man who had been prescribed them for 50 years. “A lot of doctors are great, and won’t prescribe them. But there are some who still don’t see the risks," Ms Shaw said.

Working with the patient’s GP, Reconnexion helps the patient slowly reduce the dose. A psychologist manages the withdrawal symptoms, which can commonly include pain, anxiety, depression, blurred vision, breathing difficulties, nightmares, nausea and even hypersensitivity to light. Benzodiazepine use quickly leads to tolerance – in some cases after only a few days – leading to users needing more and more to sleep. Withdrawal can cause rebound insomnia, making it harder to sleep. People think their initial insomnia has returned, leading them to start taking the pills again. “So they end up in a worst position than where they started,” says Associate Professor Suzanne Nielsen, deputy director of the Monash Addiction Research Centre. “Many, many patients end up being on them in the long term.” Then there are the side effects. In the short term, ‘benzos’ such as Valium can cause amnesia, impair thinking and memory, and may increase depression. Zolpidem, a different class of sleeping pill sold as Stilnox, comes with a warning it can cause sleep walking, sleep driving, and “other bizarre behaviours”.

Long-term use of both drugs has been linked to depression, anxiety, and problems thinking and remembering. Dementia Australia says there is “some convincing evidence” long-term benzo use increases the risk of developing dementia – as much as doubling it in some reviews. Shirley developed anxiety which she medicated by taking even more pills. “I was having to take more drugs to treat the symptom the drugs caused,” she says. Eventually, she developed depression – severe enough to be hospitalised. A new psychologist warned her the pills were very likely a major factor. Shirley tried to slowly cut back, but after eight years of near-daily use the withdrawal effects caused “intense physical and psychological suffering”.