How to safely wean yourself off sleeping pills

Life can be hard and sleep elusive. Many Americans deal with occasional or chronic insomnia by taking sleeping pills.

In 2020, 8 percent of Americans said they took sleep medication every day or most days to help them fall or stay asleep. As a sleep psychologist, I see a large number of such patients.

Most start using over-the-counter or prescription pills to counter poor sleep caused by short-term disturbances such as travel, unusual stress and hospitalization, or longer-term conditions such as chronic insomnia (or another sleep disorder), depression, anxiety and hyperthyroidism.

Most of my patients want to get off their sleeping pills, but many have been reluctant to try. They have different reasons for wanting to stop, such as:

Their or their doctor’s concerns about overreliance on medication.
Side effects.
Waning effectiveness.
Individual health considerations such as a pregnancy, an upcoming surgery or drug interactions.

They also have different reasons for staying on pills, including:

Relief in the assurance of a good night’s sleep and doubt about their ability to sleep without medication.
High anxiety about poor sleep.
Failed attempts at tapering during which they endured difficult insomnia, anxiety or other withdrawal symptoms.

If, like my patients, you want to reduce or get off your medication, but are feeling discouraged, resigned, anxious and self-doubting, I want to assure you that there is hope.

No single approach to reducing sleep aids

Sleeping pills are not a unitary category. Hypnotic and sedative medications comprise different types of drugs, each with its own mode and duration of action, and discontinuation challenges. There is no one-size-fits-all approach to reducing or stopping such varied agents. There is no one-size-fits-all approach to reducing or stopping such varied agents.

Practical considerations also vary from medication to medication. Some pills are not meant to be cut. Others can be cut, but some are too tiny to do so with precision. Some people need to substitute another medication to help them off the first one, or need to figure out which of two or more medications to reduce first.

There are many other considerations. For example, if you’ve only been on a medication for a month, the approach to tapering will probably be more rapid (to avoid prolonged use) than the gradual approach described below for those who have taken medications long term.

Ways to prepare to reduce or get off sleeping pills

There are a few general principles to help you succeed in tapering:

Work closely with your doctor to determine a safe rate and method.
Pharmacists can help, whether by dividing pills or assisting with liquid formulations or compounding to create fractional doses.
Go slowly. The biggest mistake my patients make is to go too quickly. They end up back on their full dose, chastened and discouraged by the experience.

Before you start tapering, though, know what you are medicating. It’s not good to remove a pill if you don’t have suitable treatment for the underlying sleep condition. There are many instances of undiagnosed restless legs syndrome, sleep apnea, depression or other conditions that result in poor sleep. Sleep physicians are excellent at sorting out diagnoses.

I have a patient who tried many times over several years to reduce her benzodiazepine intake. Every time, though, she experienced unmanageable insomnia. I used this metaphor to explain why going slowly was important:

Picture a swimming pool with shallow and deep ends. Imagine a ramp that connects the two, and it is not a steep drop-off but a gradual descent. You are safe in the shallow end — not out of your depth — if you are sleeping well with the aid of medication. Your goal, though, is to be a competent and confident swimmer in the deep end — to be able to sleep well without medication (or with less).

There are three reasons to taper slowly:

Going slowly minimizes withdrawal, or the insomnia, anxiety and other symptoms that may come with dosage reductions. If you are cutting back by tiny amounts very gradually, your system will barely register the change. You are taking one tiny step at a time down the ramp.

The slow approach is a form of graded exposure therapy. Each new step down the ramp, each new dose reduction allows you to minimize and perhaps even overcome your anxiety before you proceed to a harder step, which may no longer feel harder because you have mastered the foregoing step. It also feels relatively non-threatening to take small steps.

A slow taper affords time to develop sleep skills to replace the medication. I have written about some of these skills. You may not have needed them because you had medication. By going slowly, you master swimming skills at each new depth. By the time you progress to the deep end, you will be an excellent swimmer.

Over the course of about a year, with her doctor’s support, my patient reduced her dose to one-fourth of what it was.

Steps to stop using or reduce sleeping pills

Here is one way to taper gradually if your doctor approves. My patients tend to find it easy and non-threatening. For simplicity, I will assume you are on one whole pill and want to get down to nothing.

Establish step sizes and milestones. Decide whether you want to reduce by one-eighth of a pill at a time or one-fourth or some other fraction. Let’s say it’s one-eighth. Your first milestone is seven-eighths of a pill. You work toward that milestone and only that milestone at first.

Gradually increase the number of nights per week that you take the milestone dose (for instance, seven-eighths) vs. the full dose (one pill). You might start with once per week at the lower dose, and gradually increase to seven times per week, always taking the higher dose on the nights you don’t take the lower one. You don’t have to hit every number on your journey from zero to seven nights per week at the lesser dose.

Spread out the lower doses — for instance, every fourth night if you are taking the smaller dose twice per week.

You can repeat weeks. If, for example, you are taking the lower dose every other night and the higher dose the other nights, you can repeat that pattern for another week or two.

Once you have reached your first milestone (for instance, seven-eighths of a pill every night), that dose becomes your new high dose and an additional step down (for example, three-quarters of a pill) becomes your new low dose. You are done with taking a full pill. Flexibly repeat the pattern that got you to your first milestone to achieve your second and subsequent milestones.

Slow the taper toward the end. Reducing by one-eighth of a pill is just a 12.5 percent reduction at first, but it’s a 50 percent reduction once you are down to one-fourth of a pill.

Try not to back up the ramp, but if you need to, return to the step where you were last sleeping well and stabilize there before resuming the taper more slowly.

Map out what you are going to take each night on an editable calendar to keep track of where you are and to maintain your resolve.

You should feel in control. The goal is not perfect sleep or zero anxiety; it is trust in your ability to weather the hard times. You set the pace.

Lisa Strauss, PhD, is a clinical psychologist in private practice in the Boston area. She specializes in sleep disorders.

We welcome your comments on this column at OnYourMind@washpost.com.

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How to safely wean yourself off sleeping pills

No single approach to reducing sleep aids

Ways to prepare to reduce or get off sleeping pills

Steps to stop using or reduce sleeping pills