Athletes, Insomnia, and Sleep medications

Athletes, Insomnia, and Sleep medications

30 Mar 2016 2:48 PMRosemary Clancy

Now that Olympic athletes' use of sleep prescription “hypnotic” medications benzodiazepines (such as Valium, Ativan, Xanax, Mogadon) and “Z-drugs” (Stilnox and Imovane) has been curtailed, let’s look at why this might cause athletes disquiet.

Some believe the ban will, in taking away a safety net of sorts, cost our country medals.  We can understand how they feel. After all, we’re just like the athletes in  wanting our sleep to be regular and reliable, with deep sleep and nice dreams stretching over a roughly 8 hour period at night, ending in a refreshed and energised wakeup just before the alarm goes off.  Like the athletes we tend to link our daytime functioning to our sleep quality or quantity, on a bad day attributing our tiredness and forgetfulness to what must have been poor sleep the night before.

For athletes, though, the pressure to sleep well is more urgent, particularly in the night before competition.  Everything they’ve trained for culminates in the success of often one event’s, and winning or losing amongst highly-trained and fit athletes can depend on small differences in attention, reaction time, and perceived energy levels.  The stakes have never been higher, and the pressure on sleep immense to deliver them refreshed to the competition arena.

What an irony then, that this pressure on sleep immediately sets up a situation in which the brain is under pressure to make it happen, so the central nervous system and attention focus are obliged to be on full alert for anything that could go wrong, thus increasing the likelihood that sleep will indeed, go “wrong”.  This paradoxical struggle is the core of insomnia, a struggle which understandably impels many to go looking for “insurance”, or pharmaceutical backup, to lower the performance pressure, and take the responsibility for such an important outcome from an unreliable brain and body.

Unfortunately the more you practise not trusting your brain to regulate sleep, the less you trust your brain to do a basic and yet complex job. The less confident you become with letting your brain have responsibility, the more hypervigilant you become for its unreliability; the more practised you become at scanning constantly for threats (too hot or cold, too noisy, too bright, too uncomfortable), and the more likely you will turn to medication to help.

So why the focus on the prescription sleep medications benzodiazepines and Z drugs?  After all there are non-habit forming antidepressant medications and melatonin-sleep-hormone –influencing medications. These are not the subject of bans. Well, because the ones being banned work so well – at first.  Athletes believe, like everyone else, that they’ve discovered the holy grail of sleep. And so they use the medications night after night. Depending on whether it’s a short or long-acting medication, the individual starts to supplement a medication to get the required “hours” of sleep through the night.  And then within days or weeks of taking these medications, tolerance builds and the effectiveness drops, and one is left with the frustration of having  to take more medication to get the same or near-enough effect. Eventually, the need to continue the now-subtherapeutic  medications just to prevent withdrawal, rises alongside the chronic frustration of being trapped into a medication regime with no certainty.

Government-sponsored warnings are advertised to prospective gamblers in pubs and casinos, warning about the unfavourable odds in playing pokies so that individuals know to continue at their own risk. Perhaps similar warnings could be offered with benzodiazepines and z-drugs prescribed for sleep, with a  qualifier that medications won’t do the whole job and people should also be responsible for concurrent thinking and behaviour change and especially meditation practice, to increase their odds of achieving sleep success.

The thinking and behavior change strategies come from an intervention model called Cognitive behavior therapy, or CBT. This involves cognitive therapy, or strategies targeting faulty beliefs, worries, and expectations about sleep and daytime functioning that worsen insomnia; and behavior therapy, or behavior change strategies that target the unhelpful insomnia habits that you’ve unintentionally become conditioned to.  Some of these behavior change strategies include Stimulus control therapy. This strategy works to help us re-associate the bed environment with sleep and to re-establish a consistent sleep-wake cycle.  Also aligned with this is Sleep restriction therapy which is about shrinking time spent in bed to close to the actual number of hours slept, to increase sleep efficiency (ie getting the most sleep out of your time in bed).

Generally athletes are well versed in relaxation exercises to reduce muscle tension, central nervous system activation and racing thoughts which can get in the way of sleep.  Sleep hygiene education incorporates  guidelines about lifestyle change (eg diet, exercise, alcohol/substance use) and bed environment change (light, noise, temperature) that can help improve sleep.  Alongside this information about what’s normal in sleep, and how sleep changes with age without necessarily decreasing in quality, can reduce sleep-loss fears.

In conjunction with CBT strategies, Mindfulness therapy gets people learning to be aware of, and pay attention to, unfolding experience in the present moment.  Athletes are generally already good at catching up negative appraisals that can affect their confidence and fluid performance, so can find it easier than many to purposefully experience and observe their thoughts, feelings and sensations with curiosity, without reacting to them disproportionately.  Mindfulness therapy helps to manage worry, rumination and hypervigilance that condition an association between bed and frustrated wakefulness.

Athletes can also benefit from Acceptance and Commitment Therapy (ACT) principles of mindfulness, acceptance and values, helping promote acceptance of all unfolding experience, even unpleasant or distressing thoughts, feelings and sensations, while moving towards meaningful goals.

The optimal benefit that athletes (and the rest of us) can derive from using prescribed sleep medications, specifically benzodiazepines and z-drugs, is to discover the part we must play in helping the medications work, right from the first use.   That is, stack the stable sleep odds in our favour by the learning about sleep processes, recognise the importance of what we do and say to ourselves about our sleep processes, and practise sleep-protective behaviours and thinking that will condition good sleep, dissipate self-doubt and fear, and let sleep happen.

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