Wake up to insomnia

As the nation reports increasing levels of tiredness, pharmacy teams have the chance to help customers address their fatigue, and the stress that is contributing to it

If you’ve ever laid awake at night wondering why it’s so hard to get back to sleep, you are not alone. A third of UK adults – particularly older people – experience problems sleeping, according to NHS Inform. In fact, a recent survey by makers of evidence-backed essential oils Puressentiel found that 48 per cent of respondents said they get less than six hours of sleep a night.

Pandemic patterns

Unsurprisingly, the Covid-19 pandemic restrictions and lockdowns have had an effect on people’s sleep. “We’ve probably all experienced a change in our sleep pattern since the pandemic began,” says chemist, natural health expert and Puressentiel spokesperson Tim Bond, “whether that is interrupted sleep as our confused minds don’t know when to switch off, more sleep because of not commuting, or simply for no reason.”

According to a recent poll by the Mental Health Foundation, more than six in 10 adults (62 per cent) felt anxious or worried because of the pandemic. The knock-on effect of this stress for many is poor quality of sleep, and data from Anxiety UK reveals that 44 per cent of people say their sleep has worsened since the start of the pandemic. Of those, 81 per cent cited stress or anxiety as the main cause of disruption.

While low levels of stress are part of life, prolonged high levels of stress can have serious health consequences.“When stress becomes excessive or persists over a period of time, the knock-on effects can have a vast impact on our mental and physical wellbeing, and in particular our quality of sleep, by disrupting the balance of hormones released,” says Kalms product manager Liz Hughes-Gapper. “As we continue to accrue a sleep deficit – the cumulative effect of not getting enough sleep – our ability to concentrate worsens, mood drops and productivity decreases, all of which can emphasise feelings of stress. When this process repeats, a stress-sleep cycle is formed.”

Occasional episodes of insomnia may come and go without causing any serious problems, but for some people, it can last for months or even years at a time, which is why pharmacy teams are in the perfect position to spot customers who may need some help and advice managing stress in order to head off any related problems around getting to sleep or staying asleep.

Recognising and reacting

Lisa Artis, deputy CEO of The Sleep Charity, says it’s important to help customers recognise their stress-sleep cycle so they can tackle it effectively. “In times of stress, we may under- or overeat, lose interest in activities, feel agitated and struggle to concentrate, as well as experiencing problems falling asleep and staying asleep,” says Lisa. “Therefore, it’s really important to talk to customers about maintaining a healthy diet, continuing to exercise and encouraging them to prioritise their sleep.”

Liz recommends pharmacy teams encourage customers to talk to colleagues, friends and family about their stress, to help them see things in a different way and gain perspective on a situation. As work can be another significant source of stress for some people, Liz says we should “work smarter not harder, working regular hours, taking breaks and using up leave entitlement”. She is also a proponent of meditation, adding: “Numerous studies have shown that meditation is an effective stress management tool, ultimately reprogramming the brain to the extent that meditators end up with more capacity to manage stress.”

High performance psychologist and mindfulness specialist Dr Aria Campbell-Danesh also advocates a mindful approach and suggests an ‘ABC Framework’ to better manage stress. “The ‘A’ is for allowing thoughts and emotions to arise and to pass, and accepting the present moment,” says Aria. “The ‘B’ is for breath. It may sound overly simple, but focused breathing exercises have been shown to reduce negative emotiona

l response to adverse circumstances by 20 per cent. And ‘C’ is for choosing what to focus on. Negativity is like a magnet for our attention, but with emotional awareness, we can focus on what we can control in the ‘now’.”

Sleep hygiene

Some of the things pharmacy staff can help customers to control when tackling insomnia relate to ‘sleep hygiene’. These are measures that can be adopted to ensure healthy sleep habits and good quality sleep.

“Sleep hygiene should be practised regularly – and also assessed regularly – to keep sleep in tip-top shape and help with any niggling sleep issues,” says Lisa. “Often, people neglect the obvious basics, such as a good sleep-orientated environment (black out blinds, eye masks, ear plugs), a comfortable bed and pillow, and proper bedtime wind down routines.”

Pharmacist Gareth Evans is president of the British Society of Pharmacy Sleep Services, which launched in July to support pharmacy’s interactions and signposting for customers with sleep problems. His top sleep hygiene tips that pharmacy teams can offer customers are:

• Keep calm and don’t take worries to bed
• Do not self-medicate with alcohol. Whilst a small amount may help people fall asleep, it reduces the quality of sleep
• Stick to a sleep routine. Get up and go to bed at the same time and do not nap during the day
• Get up and do something relaxing away from the bedroom if sleep is still elusive after 20 minute 
• Charge phones out of the bedroom to avoid the stress and temptations associated with the digital age, and the blue light that harms sleep.

And while it sounds counter-intuitive, Sultan ‘Sid’ Dajani, owner and superintendent pharmacist at Wainwrights Chemist and spokesperson for Dragonfly CBD, advises ensuring that bedroom clocks are not visible. “Watching the clock and seeing time tick away while desperately trying to sleep is a recipe for anxiety and likely to ensure failure to drop off,” he says. “Similarly, remove fitness trackers when sleeping, as there has been research to show that relying on a sleep tracker in order to maintain quality of sleep could actually lead to sleep anxiety.”

Over-the-counter options

In the meantime, there are plenty of temporary solutions and self care tips that pharmacy teams can recommend to customers. These include tablet and liquid sleep aids containing diphenhydramine – a type of antihistamine that can cause drowsiness. However, taking these regularly is not recommended because they don’t tackle the underlying cause of insomnia, and drowsiness can make activities such as driving and operating machinery dangerous. Customers who appear to be requesting these tablets on a regular basis should be referred to the pharmacist or to their GP for further advice.

Some 61 per cent of respondents in a Dragonfly CBD poll said that they would try a natural therapy to improve their sleep. As well as CBD, there are a variety of traditional remedies that some people find useful for coping with the stress-sleep cycle. Liz recommends products containing valerian root as a “popular choice that has long been used to promote relaxation, reduce stress, and improve sleep”. Tim adds that essential oils can be helpful, particularly lavender, which he says “has been used as a sleep aid for centuries, and is acknowledged as a soporific and relaxant by both the European Medicines Agency and the World Health Organization”. 

Support and signposting

People often consider sleeping aids in an attempt to relieve a sleeping problem, but Lisa advises that “if these are used regularly then they are not a solution in the long term as it doesn’t tackle the root of the problem, so it’s more important that people understand the importance of good sleep and how to achieve it”.

This is why pharmacy staff have a vital role to play when it comes to supporting messages about sleep. “They can identify and intervene with opportunistic advice at the counter, and signpost individuals suffering from potential sleep disorders to the pharmacist for further assessment, advice and signposting locally and nationally,” says Gareth. “As well as GPs, this signposting can include private dentists, who can help with snoring-related sleep problems, and qualified sleep practitioners.”

What’s more, Gareth says it’s about offering long-term support as opposed to just a single transaction: “Sleep disorders invariably require much more intervention for a successful solution, so pharmacy teams can enhance their sleep services by suggesting the customer keeps a daily sleep diary that they can discuss weekly with a named member of staff to ensure continuity of care and build trust, in person or via the phone or video call,” he says. He also suggests recording any sales of antihistamines for short-term use for insomnia to track repeat purchasing and following up on OTC sales of basic sleep aids to track efficacy. Above all, he says pharmacy teams can reassure customers that “the current climate of anxiety, stress and subsequent sleep issues is a completely natural response to the pandemic”.

In many instances, this reassurance, and the associated advice about how to tackle the associated stress and sleeplessness that results, will be exactly what’s needed to show tired customers the way back to the land of nod.

Further sleep support

“Sleep is the glue that holds us all together, so without sleep, we will suffer,” says Regan Saveall, chief executive of Dragonfly CBD. “Sleep deprivation can have profound consequences on our physical and mental health. Regular poor sleep can even put people at risk of serious medical conditions such as obesity, heart disease and diabetes.”

With this in mind, pharmacy teams should suggest customers make an appointment to see their GP if they are regularly fi nding it diffi cult to get to sleep or stay asleep and this is affecting their daily life – particularly if it has been a problem for a month or more and self care measures have not helped.

The GP will most likely ask about their sleeping routines and general lifestyle habits, such as diet and exercise, as well as checking for any illness or medication that may be contributing to their insomnia. The GP’s aim will be to identify and treat any underlying health conditions, such as anxiety, that may be causing the sleep problems, in order to avoid resorting to prescription medications for insomnia as much as possible.

Sleeping tablets – the lowdown

The National Institute for Health and Care Excellence (NICE) advises that doctors avoid prescribing sleeping tablets – such as benzodiazepines and Z-drugs – because they don’t treat the cause of insomnia and they are associated with a number of side effects, depending on the drug, such as drowsiness and dizziness, cognitive impairment and falls. Because sleeping tablets can also become less effective over time, some people become dependent on them, and may become addicted. For these reasons, prescription sleeping tablets are usually only considered as a last resort and should be used for only a few days or weeks at a time if sleep hygiene measures fail and severe insomnia is interfering with normal daily life.

However, despite warnings about the long-term use of benzodiazepines and Z-drugs, millions of prescriptions are still issued for them in primary care each year. People on long-term benzodiazepines or Z-drugs should be referred to the pharmacist and advised to stop taking them with appropriate support and guidance.