Prescription and over-the counter (OTC) sleep aids are among the most widely used medicines. Their popularity has been spurred by aggressive marketing over the last decade — almost every adult knows what Ambien is — but also by changes in our culture that have disrupted good sleep habits (TVs, computers, smartphones, the Internet, etc.) and exacerbated things for people prone to clinical insomnia (work and life stress, economic displacement).
Much has been written about this issue and the drugs themselves, with lots of hand-wringing and popular advice. But for the past 2 decades, physicians and public health officials mostly went with the societal flow — acceding to the growing demand for and use of prescription and OTC sleep aids.
That’s now beginning to change, and fast. More and more research and data show that these medicines are being abused, overused, and unwisely prescribed — and there are better solutions.
The latest research to reach this conclusion comes from the Agency for Healthcare Research and Quality (AHRQ), a federal government entity. Researchers contracted by AHRQ to probe all the recent studies on insomnia treatment found cognitive behavioral therapy (CBT) to be a more consistently effective way to combat chronic and intermittent insomnia — especially over the long term — compared with any insomnia or sleep medicine. (More about CBT below.)
The problem is that both the prescription and OTC sleep drugs are intended for short-term use — a week to 10 days — but are being widely used over longer periods. An analysis by Thomas Moore of the Institute for Safe Medication Practices found, for example, that two-thirds of people taking zolpidem (generic Ambien) used it for weeks, months or even years.
While that analysis focused on Ambien, the same problem likely exists for Ambien’s competitors Lunesta (eszopiclone) and Sonata (zaleplon).
Such long-term use has been associated with psychological addiction and a heightened risk of morning drowsiness, falls and accidents. These effects have been highlighted in numerous court cases surrounding fatal and non-fatal auto and other kinds of accidents.
In addition, Moore’s analysis found that 1 in 5 people who took Ambien combined it with an opioid. That combination vastly increases the risk of dangerous side effects and even potentially fatal depression of the central nervous system.
The good news: Prescriptions for these medicines are declining amid attention to their downsides and risks. But they are still prescribed way too often. Here are some numbers, compiled from IMS Health, which tracks drug sales worldwide:
- Prescriptions for Ambien declined from just above 3 million in December 2014 to 2.6 million in May 2016.
- Prescriptions for Lunesta declined from 249,000 in December 2014 to 240,000 in May 2016.
- Prescriptions for Sonata declined from 71,900 in December 2014 to 63,200 in May 2016.
- Prescriptions for Belsomra (suvorexant), the newest prescription sleep aid (approved by the FDA in August 2014 but not sold until early 2015) rose from 7,258 in February 2015 to 44,466 in March 2016, but declined to 39,914 in May 2016.
OTC Insomnia Drugs
As for the OTC sleep drugs, they can hook you as well, according to medical experts and Consumer Reports. There are dozens of kinds, but the big sellers are Advil PM, Nytol, Simply Sleep, Sominex, Tylenol PM, Unisom SleepMinis, and ZzzQuil, from the makers of NyQuil.
The active ingredient in all these drugs is diphenhydramine, a decades-old antihistamine used as a remedy for seasonal allergies. It works by blocking the histamine receptors in the brain that control wakefulness, so drowsiness is a side effect for most people.
The packaging on these medicines suggests they are “non-habit-forming” when used as directed — that is, for short periods. And the FDA requires the package inserts to tell consumers to see their doctor if insomnia persists for more than 2 weeks.
But a 2015 Consumer Reports survey of 4,023 adults found a troubling trend: Of the 20% who took an OTC sleep aid within the past year, 1 in 5 said they took it on a daily basis and 40% said they used the drugs for a year or longer.
That’s a problem for many reasons. Diphenhydramine can cause constipation, confusion, dizziness, and next-day drowsiness, according to the FDA. Also of concern: the “hangover effect”— impaired balance, coordination, and driving performance the day after you’ve taken the drug, heightening the risk for falls and accidents.
Diphenhydramine can also create psychological dependence, says Carl W. Bazil, MD, PhD, director of the Epilepsy and Sleep Division at Columbia University’s Department of Neurology. “The pills are not ‘addictive’ in the physical sense,” he says, “but there can certainly be a risk for a psychological dependency.”
So, What to Do?
If your sleep problems persist beyond 14 days or so, it’s time to see your doctor. If he or she is up on the latest research, you’ll be cautioned to minimize the use of prescription and OTC sleep medicines. Instead, he or she may direct you to a sleep clinic or therapist (usually a psychologist or clinical social worker, not a doctor) who does CBT.
CBT aims to change the way you think about and approach sleep, and your habits of going to bed and getting to sleep. Various techniques are used. Typically, after a full assessment, you’ll be prohibited from watching TV in bed, coached to go to sleep and get up at the same time every day, and taught relaxation and meditation techniques.
Related emotional and life problems will also be discussed, but usually just as they relate to your sleep patterns and troubles. If your insomnia has been triggered by a life event or by depression or anxiety — as is common — you’ll typically be referred to a counselor or psychotherapist. CBT involves, initially, 3 to 6 one-hour sessions.
The AHRQ analysis found that CBT helps 70 to 80% of people with chronic insomnia — shortening the time people fall asleep by 12 to 40 minutes, and adding 20 to 45 minutes of total sleep time.
And CBT is not restricted to people with chronic insomnia. Sleep specialists and clinics these days routinely use CBT to treat people who have intermittent bouts of insomnia as well. In addition, a recent review of 37 studies involving 2,189 people found that CBT was effective in those with co-existing illnesses and psychiatric conditions, including alcohol dependence, depression, post-traumatic stress disorder, cancer, chronic pain, and fibromyalgia.
The biggest benefit of all: No side effects or risks.
If you still decide to take insomnia drugs, do so for only a few days at a time, at the lowest recommended dose. Never drink alcohol while taking them, and don’t take an extra pill to get back to sleep — doing either can worsen the drug’s side effects.
Also, pay close attention to pill labels and, above all, avoid mixing narcotic painkillers with any kind of sleeping pill.
How to Correct Poor Sleep Habits
|Watching TV in bed||Don’t. TV viewing is not conducive to calming down.|
|Computer work in bed||Don’t work on a computer at all for at least an hour before going to bed. A tall order for many people, to be sure, but the light emitted from computers, mobile devices and smartphones (so-called “blue light”) signals daylight to the brain even more than ordinary light bulbs and has been shown in studies to delay falling asleep.|
|Drinking alcoholic or caffeinated drinks or chocolate at night||Alcohol often leads to sleep disruption later in the night and may contribute to awakenings. If you have an insomnia problem, caffeine in drinks and foods like chocolate should be consumed only in moderation and not after midafternoon.|
|Taking medicine late at night||Many prescription and nonprescription medicines can delay or disrupt sleep. If you take any on a regular basis, check with your doctor about this.|
|Big meals late at night||Not ideal, especially if you are prone to indigestion or heartburn. Allow at least 3 hours between dinner and going to bed.|
|Smoking at night||Don’t smoke for at least 3 hours before going to bed. (Better yet, quit.)|
|Lack of exercise||Just do it! Regular exercise promotes healthy sleep.|
|Exercise late at night||A no-no. Allow at least 4 hours between exercise and going to bed. It revs up your metabolism, making falling asleep harder.|
|Busy or stressful activities late at night||Another factor that will raise your alertness. Stop working or doing strenuous housework at least 2 hours before going to bed. The best preparation for a good night’s rest is unwinding and relaxing.|
|Varying bedtimes and wake-up times||Going to sleep at widely varying times – 10pm one night and 1am the next, for example – disrupts optimal sleep. The best practice is to go to sleep about the same time every night, even on weekends, and wake up about the same time every day, with not more than an hour’s difference on weekends.|
|Spending too much time in bed tossing and turning||Solving insomnia by spending too much time in bed is usually counterproductive; you’ll only become more frustrated. Don’t stay in bed if you are awake, tossing and turning. Get up and do something relaxing, such as reading, until you are ready to go to sleep.|
|Late-day napping||Naps can be wonderful, but should not be taken after 3pm because they can disrupt your ability to get to sleep at night. If you have sleeping problems, it may be best to avoid napping altogether.|
|Poor sleep environment||Noise, a room that’s too hot or not dark enough, an uncomfortable bed, covers, or pillow – all can prevent a good night’s sleep. Solve those problems if you have them.|
Source: Consumer Reports