What medications are best for athletes to maximize Non-Rapid Eye Movement (NREM) 3 sleep and relaxation?

Optimal Medications for Athletes to Maximize NREM3 Sleep and Relaxation

Non-pharmacological interventions—specifically cognitive behavioral therapy for insomnia (CBT-I), sleep hygiene optimization, and sleep extension—should be the primary approach for athletes seeking to maximize deep sleep and relaxation, as pharmacological sleep aids are broadly discouraged in this population due to cognitive side effects and potential for adverse events. 1

Why Medications Are Not Recommended for Athletes

The NCAA Interassociation Task Force on Sleep explicitly states that hypnotic medication use among collegiate athletes is broadly discouraged due to cognitive side effects and potential for adverse events when used with other drugs (such as alcohol). 1 Despite 18.7% of NCAA athletes reporting prescription sleep aid use and 3% using non-prescription sleep aids, there is a dearth of literature supporting pharmacological treatment of sleep issues in athletes. 1

Insomnia-related complaints in athletes should be managed behaviorally, since CBT-I produces similar short-term treatment outcomes and superior long-term treatment outcomes compared with pharmacotherapy. 1

Evidence-Based Non-Pharmacological Approaches

First-Line Intervention: Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I has shown large effect sizes across numerous studies and is the gold standard for treating sleep issues in athletes. 1
• CBT-I specifically targets insomnia complaints and produces superior long-term outcomes compared to medications. 1
• This approach should be prioritized before any consideration of supplements or medications. 2

Sleep Extension for Performance Enhancement

• Sleep extension (increasing daily sleep duration to >9-10 hours) for 1 week to 5-7 weeks significantly increases sleep duration, decreases sleepiness, and improves sport-specific performance. 1
• Studies in basketball and tennis players showed improvements in shooting accuracy, serve accuracy, sprint times, and faster reaction times with sleep extension. 1
• Sleep extension is the intervention with the most beneficial effects on subsequent athletic performance. 3

Comprehensive Sleep Hygiene Implementation

The following sleep hygiene practices are essential for maximizing deep sleep and relaxation in athletes 1:

• Maintain a regular sleep schedule, including weekends, or establish a consistent bedtime routine if schedule variability is unavoidable. 1
• Avoid caffeine (coffee, energy drinks, certain sodas and teas) at least 6 hours before bedtime. 1, 2
• Avoid nicotine and alcohol close to bedtime—while alcohol may reduce time to fall asleep, it adversely impacts sleep quality. 1, 2
• Keep the bedroom cool, dark, and comfortable. 1, 2
• Seek bright light exposure during the day, especially morning, and avoid bright light at night, particularly later in the evening. 1
• Avoid evening use of electronic devices, as they suppress melatonin levels and increase alertness, delaying sleep onset. 1
• Use beds for sleep (and sex) only—practice stimulus control by getting out of bed if unable to fall asleep. 1

Relaxation and Mindfulness Interventions

• Relaxation and mindfulness interventions as stand-alone approaches generally lead to moderate sleep improvements in college students. 1
• However, progressive muscle relaxation led to only minimal improvements in sleep among dancers, suggesting variable effectiveness across athletic populations. 1

Limited Role for Supplements

Glycine Supplementation

• Glycine supplementation (3g before bedtime) may be a low-risk, potentially beneficial adjunct for individuals with mild sleep complaints who have already optimized sleep hygiene practices. 2
• This should only be considered after implementing comprehensive sleep hygiene and behavioral interventions. 2

Melatonin

• Melatonin has more extensive research supporting its use for sleep onset, duration, and efficiency compared to other supplements, with established dosing protocols. 2
• Melatonin is drug-free and non-habit forming, typically used at 3mg doses for occasional sleeplessness. 4
• However, melatonin should still be considered secondary to behavioral interventions. 2

Critical Considerations for Athletes

Sport-Specific Factors

• Sports requiring speed, tactical strategy, and technical skill are most sensitive to sleep duration manipulations. 5
• Longer-term sleep manipulations (weeks) are more likely than acute interventions to affect athletic performance. 5

Common Pitfalls to Avoid

• Caffeine, alcohol, marijuana, other illicit drugs, and non-medical use of prescription stimulants all interfere with neurochemical control of sleep. 1
• Athletes often practice poor sleep hygiene habits despite spending 27-41 hours per week on athletics. 1
• Less than one-quarter of NCAA Division I athletes regard sleep as a way to recover from a game, highlighting the need for education. 1

When to Consider Medical Evaluation

• If behavioral interventions fail to improve sleep, refer to a sleep specialist for evaluation of sleep disorders rather than initiating pharmacological treatment. 6
• Screen for obstructive sleep apnea, which is common in athletes and must be treated before addressing other sleep issues. 6

Algorithm for Optimizing Athlete Sleep

1. Implement comprehensive sleep hygiene practices (regular schedule, cool/dark bedroom, avoid caffeine >6 hours before bed, avoid evening electronics). 1, 2

2. Initiate sleep extension protocol (target >9-10 hours sleep for 5-7 weeks if performance enhancement is the goal). 1

3. Consider CBT-I if insomnia complaints persist despite sleep hygiene optimization. 1

4. Add relaxation/mindfulness techniques as adjunctive interventions. 1

5. Consider glycine 3g before bedtime only after steps 1-4 are optimized, for mild residual sleep complaints. 2

6. Refer to sleep specialist if behavioral interventions are insufficient, rather than initiating prescription sleep medications. 1, 6