Insomnia is one of the more frequent complaints that I get in the clinic. Most of the time, the problem has to do with falling asleep termed delayed sleep onset latency. Very rarely do I see a patient after 1-2 sleepless nights; it’s usually something that they have been dealing with for weeks, months or even years. The majority do not have an identifiable cause of their insomnia such as recent travel, shift work or stimulant use/abuse and almost all of them have already attempted numerous treatments including over-the-counter sleep aides, herbal supplements and some form of behavior modification. My job, as I see it, is not only to help them develop good long-term control over their own sleep but also to offer some immediate relief.
There are numerous causes of insomnia some of which could be due to serious medical conditions such as depression, chronic pain or chronic medication use. As I mentioned previously however, most of the patients that I see do not suffer from one of these conditions. Their insomnia is most likely due to stress, anxiety and/or poor sleep habits. If you are having trouble falling asleep, staying asleep or staying alert during the day, talk to your doctor or PA especially if this has persisted beyond 2 weeks.
The first line treatment for such individuals suffering from insomnia include “non-pharmacologic” interventions, i.e. behavior modification. We will discuss these later. There is also mounting evidence for CBT or cognitive behavioral therapy which is a type of guided therapy that teaches an individual how to have greater control over the mind and body. What I really want to discuss in this article however is the use of prescription sleep aides.
A few new studies have been published within the last year creating some negative publicity for the most common prescription drugs used to treat insomnia such as Ambien (zolpidem). Back in February of 2012, this caused several articles to be published via major news outlets such as the LA Times and US News. All of the articles discussed the claim that this new research discovered a link between sleeping pills and increased death rates. This has caused quite a stir among the medical community and has caused many patients to question this information when they see me in clinic.
Let me first state that I am not one to push pills, especially when it comes to putting patients on medication for their chronic insomnia. But I do believe that these articles have caused some confusion that might prevent some people from obtaining necessary relief.
Let’s start by listing some of the claims commonly made in these articles. At the top of the heap is one from US News that includes such statements as “sleeping pills [are linked] with a nearly five-fold increased risk of early death” and "In 2010, sleeping pill use may have contributed to up to 500,000 ‘excess deaths’ in the United States”. The LA Times reports that “those who use prescription sleep medications… are more likely to develop cancer”. The author of the most recent study himself concludes that “sleeping pills could be as risky as smoking cigarettes”.
While this information certainly is alarming, let’s take a step back. First of all, nothing in these articles or in the study itself suggests that sleeping pills cause cancer, death or anything else. They are simply suggesting a correlation, or a relationship. This can be very deceiving. For example, there is a correlation between ice cream and boating accidents: When ice cream consumption goes up, so do the number of boating accidents. Why? Because they are both more common during the summer! No one would suggest that ice cream causes boating accidents. Correlation does not equal causation.
Several experts have weighed in on this most recent study, which was not the gold-standard double blind, placebo controlled type. In fact, it was merely a review of incomplete past medical records over a period of only a few years. This is a legitimate study design but far from game changing quality.
It’s also important to note that the number of sleeping pill users who actually died during the study was relatively small (6% of 10,000 vs 1% of 23,000 for non-users). The study also failed to identify cause of death so of that 6% we have to include everything from car accidents, injuries, suicides, and infections to chronic conditions like asthma and diabetes. Clearly, not all of these can be related to sleeping pills.
While the study focused on the most common prescription sleep aides such as Ambien and Restoril (temazepam), all sleep aides were included such as those available over the counter like Benadryl (diphenhydramine), commonly found in cough and cold medicines, and melatonin which is considered to be a natural supplement. Michael Yurcheshen, MD, head of the sleep fellowship program and assistant professor of neurology at the University of Rochester, N.Y. noted that it would be implausible to think that so many different medications, spread across several different drug classes, could have the same biological effects.
And last but not least, we must consider that many who take sleeping pills, especially on a long term basis, are simply in poor health. This was considered during the study's design phase and an attempt to control for heart disease, a major player, was made but it would be impossible to find a perfectly healthy population whose only complaint was insomnia.
Now before we talk about the best treatment for insomnia, behavior modification and the “proper” use of sleep medications, let’s talk about some of the risks of not treating chronic insomnia.
According to the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health, sleep is as essential for well-being as food and water. Insomnia may result in sleep deprivation which causes day-time fatigue. According to the National Highway Traffic Safety Administration, driver fatigue is responsible for an estimated 100,000 motor vehicle accidents and 1500 deaths each year. Studies show that sleep-deprived drivers often perform worse than those who are intoxicated. Severe sleep deprivation may also cause mood swings and even hallucinations. Those suffering mental conditions such as schizophrenia are much more sensitive to this. Lack of sleep can even trigger a manic episode in someone diagnosed with bipolar disorder.
There is also evidence that suggests sleep is essential to proper nervous and immune system function. There is truth to the common expression “beauty sleep” as restorative protein production, including release of growth hormone occurs during sleep. Good sleep also supports optimal emotional and social functioning as well as aiding in the learning process.
So what can you do on your own to promote better sleep and prevent chronic insomnia? Experts recommend taking a meticulous look at what we call “sleep hygiene”. This refers to your sleep habits and you would be surprised how specific we get!
The first thing I often do with patients complaining of trouble falling asleep is to have them keep a sleep journal. For 1-2 weeks, I want to know what time they are going to bed, what time they wake up, how long they think it took to fall asleep, etc. I’m also interested in their bedtime routine. This allows me a better look into what may be causing the problem.
The most common recommendations I make are as follows:
-Get on a schedule. Plan on going to bed and waking up at the same time every day. Wake up a little earlier than you might otherwise need to and no sleeping in on the weekends! This only disrupts your body’s natural clock. Try waking up with the sun and soaking up the natural light for a good hour or so. I also counsel patients to avoid napping; no more than 30 minutes and never in the afternoon.
-Create the optimal environment. The bed and the bedroom are for two things and two things only: Sleep and sex. Never, never, ever lie awake in bed for more than 15 minutes! Go find something relaxing to do until you're more tired. And along those same lines, get all distracting electronics such as TVs, cell phone and computers out of the bedroom. Also make sure that your bedroom is quiet, dark and comfortable.
-Create a routine. Start winding down 30 minutes to an hour before going to bed. Take a hot shower, brush your teeth, read a book—do whatever you need to do but do it methodically every night.
-Get healthy. See your doctor or PA about other worries that might be preventing you from getting a good night’s sleep. Set a goal to exercise for 30 minutes a day (but never right before bed). Avoid stimulants like caffeine and other unhealthy substances like nicotine and too much alcohol.
I truly believe that changing the way we view sleep and the way that we prepare for sleep will have the most profound effect upon our health, even for those who suffer from chronic insomnia. However, there are instances in which I believe that prescription sleep aides are perfectly safe and effective. As these recent articles remind us however, they are not without risk. After a thorough investigation into the best evidence we have available, including the most recent articles, I still believe that the benefit of prescription sleep aides outweighs the risk when used properly.