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12 CHAPTER THREE HYPNOTICS AND SLEEP-PROMOTING COMPOUNDS INTRODUCTION TO SLEEP-PROMOTING prescription hypnotics, (2) prescription nonbenzodiazepine CHEMICALS medications and others, (3) the synthetic sleep-inducing hor- mone melatonin, (4) first- and second-generation antihista- The best approach to fostering driver alertness and manag- mines, and (5) alcohol when used as a sleep-promoting ing driver fatigue on the roadway is to establish for oneself chemical. After each separate compound is described, some a suitable workrest schedule, and especially to adhere to literature reporting on performance effects is cited, and then a sleep management plan during extended or sustained work- a short assessment of its pertinence to the issues facing the ing hours, such as might be encountered during over-the-road commercial driving community is presented. operations (O'Neill et al. 1996; Orris et al. 2005). Obtaining adequate quantity and quality sleep is crucial for a commercial Performance after sleeping. The goal of many labo- driver to maintain alertness on the job. Drivers preferably ratory studies in the literature appeared to illustrate should obtain 7 to 8 h of sleep each 24-h day, which includes what performance detriments hypnotics produce when a contiguous stretch of at least 4 to 5 h of uninterrupted sleep a person attempts to perform (e.g., to drive a vehicle) (Krueger 1997, 2003; National Sleep Foundation 2010). in the immediate period after taking a sleep-promoting drug, when sleep would be a naturally expected con- sequence. Such studies generally report decreased The FMCSA's current hours of service (HOS) rules for performance owing to effects of benzodiazepines, commercial drivers took effect in January 2004 (www.fmcsa. benzodiazepine-like drugs, first-generation antihista- dot.gov). Specifically, the new HOS rules permit a 14-h work mines, tricyclic antidepressants, narcotic analgesics, and day (duty shift) of which 11 h can be driving, but require that antipsychotics (O'Hanlon and DeGier 1986; Ramaekers 2003; Vermeeren 2004; DeGier 2005). Other studies on-duty periods be followed by 10 h off duty (the so-called addressed population-based driving risks following pre- 1410 schedule). Under these HOS rules, drivers are expected scription use of both benzodiazepine and nonbenzo- to have more influence than they did previously for matching diazepine hypnotics. This synthesis literature review is their working hours with known periodicities in circadian less concerned with the "effects of hypnotics on driver rhythm physiology, and thus make it more likely that drivers performance soon after ingesting the medication" (under the influence), particularly if the driver's inten- have the time during their weekly work schedules to obtain tion is to take a hypnotic to sleep. Rather, the goal close to the desired 7 to 8 or more hours of restorative sleep here is to identify sleep-promoting compounds that can per day. be used safely by commercial drivers to assist them to fall asleep; to help them obtain restful, restorative If commercial drivers cannot obtain 7 to 8 h of continuous quantity and quality of sleep; and then to ensure that there are no important sleep inertia aftereffects soon sleep, they then need to augment the sleep they obtain by after awakening and upon resuming driving (concern taking supplemental naps each day (O'Neill et al. 1996; is for safe driving after awakening from drug-assisted Krueger 1989, 1997, 2003). However, work schedules for sleep periods). many commercial drivers do not always permit enough time for them to take additional naps, nor are delivery schedules Sleep disorders. Some commercial drivers experience always conducive to drivers obtaining adequate sleep at the insomnia and other sleep maladies whether they have been medically diagnosed for them or not (e.g., Pack right physiological times on the 24-h clock (e.g., it is often et al. 2002, 2006). Any sleep initiation or maintenance difficult to sleep during daylight after driving through the disorder that reduces sleep efficiency has the potential dark hours of night). Applying what is known about sleep to affect transportation safety. Discussion of prescribing needs and circadian physiology is a key to maintaining driving hypnotic medications for treatment of sleep disorders alertness. [e.g., insomnia, shiftwork sleep disorder (SWSD), sleep apnea, and restless legs syndrome] is beyond the scope of this report. For an outline of treatment pro- The topic also raises issues of whether as a part of their tocols involving recommended drug doses for sleep sleep management plan drivers might judiciously enact pro- disturbed patients who continue to drive, see DeGier tocols employing hypnotic or sleep-promoting medications (2005) and O'Hanlon and Volkerts (1986) whose to induce and maintain sleep, and upon awakening to resume work, done in conjunction with the activities of the ICADTS Working Group, was formulated as a guidance and maintain safe driving practices. This literature review document, "Prescribing and Dispensing Guidelines covers performance effects regarding: (1) classes of depressant for Medicinal Drugs affecting Driving Performance" medications such as benzodiazepines and other closely allied (ICADTS 2001).