Many people worry a lot about sleepless nights and try to avoid them with sleeping pills. This is a really bad idea – sleeping pills are often addictive, cause many dangerous side effects, and have a terrible risk/benefit ratio.
Recently, the American College of Physicians published guidelines for chronic insomnia. Surprisingly, they recommend Cognitive Behavioral Therapy, not meds, as the first-line of treatment. Sleeping pills are to be used only when CBT has failed – only short term – and only after the patient has been briefed on all the many problems they frequently cause.
A Step Further
It is a huge step forward for America’s leading doctors to recommend talk therapy, rather than the more routine practice of prescribing pills. But I would go even further than the American College and suggest that sleeping meds should rarely, if ever, be prescribed to anyone who is not already taking them. They are much more likely to harm than to help, often causing big long-term trouble for just a very small short-term gain.
Currently, many doctors are remarkably casual and careless in their prescription of sleeping pills. The Centers for Disease Control reports that 9 million Americans used a prescription sleeping pill at least once in the past month. Add this to the many millions of other people who buy over-the-counter remedies that often have a similarly poor risk/benefit ratio.
Rates of prescription sleeping pills are creeping up – now 4% of all adults regularly use sleeping pills; 5% of women, 3% of men. And the rate jumps to an incredible 7% in people over 80 years of age.
The elderly are especially vulnerable to harm from sleeping pills because they have less cognitive reserve, more prone to falls, and less able to clear and metabolize the active ingredients of sleeping pills. Whenever I see a confused old person, my first question is whether he is taking a sleeping pill. It is paradoxical and extremely stupid that the very people most likely to be harmed by sleeping pills are also the most likely to get a prescription for them.
Sleeping pills are so massively over-utilized in part because there is no gold standard of normal sleep. Individual variation is great in the number of hours needed, the timing of falling asleep and waking up, and how refreshed people feel in the morning. A night-owl has great difficulty keeping early bird hours, but might do just fine in a job that allows a later start. An early bird starling, like myself, has trouble staying awake for prime-time TV, but can alertly write a blog at 4 a.m. And people tend to be poor judges of how much they sleep – usually underestimating the number of hours compared to sleep lab testing results. Perfect sleep is an elusive goal that becomes dangerous if sleeping pills become the attempted means.
I have vast personal experience living with, and adapting to, strange sleep patterns. For at least the past decade, I have awakened about every ninety minutes almost every night – usually in the midst of a vivid and often entertaining dream. Sometimes, I fall right back to sleep. Sometimes, I can’t sleep for hours and instead do boring, but hopefully useful, stuff like writing this blog at 2 a.m. If I didn’t know better, I might be seduced into using sleeping pills to get through the night. Instead, I make the best of being able to get my work done nocturnally, without the usual interruptions – and I make up for it with a really treasured mid-day nap.
Preventing insomnia is much wiser than treating it with sleeping pills, but prevention is difficult because there are so many different causes, and many are difficult or impossible to avoid. Sleep is extremely sensitive to stress and worry. Bright screens reset our brains to keep us awake. Real and/or imagined 24/7 job responsibilities keep people burning candles at both ends. Shift work, jet-setting, and partying all screw up natural chronobiological rhythms. Substance use is a common culprit – obvious in heavy users; subtle, but still important, even for typical coffee or wine drinkers or smokers. Pain, medical illness, obesity, and breathing problems can make drifting off to sleep, and/or staying asleep, a nightly challenge. And older folks, like myself, usually discover, sooner or later, that they have permanently lost the gift of sleeping like a baby.
Just like every other bodily function, sleep architecture degenerates biologically with age – and sleep is also challenged by all those middle of the night trips to the bathroom.-Allen Frances
Dangers of Sleeping Pills
Sleeping pills are usually benign when taken as they should be prescribed – only occasionally, in response to a special, non-recurring situation. But addiction is a very big risk – too often the person gets hooked on the pills and comes to rely on them long-term. And all too often, the sleeping pills are used in conjunction with other psychiatric and pain meds that in combination can be dangerous, even deadly.
The most common side effects of sleeping pills are:
- Memory loss – people forget what they have done and what they need to do
- Confusion and fuzzy thinking
- Poor balance and falls – particularly common, dangerous, and even life-threatening in the elderly and those whose health is compromised in other ways
- Daytime drowsiness
- Car or work accidents
- Reduced work performance
- Weakness and fatigue
- Expense, not always covered by insurance
- Interactions and additive side effects with other pills the person is taking
- Withdrawal that can cause severe rebound insomnia and many other potentially dangerous symptoms
Sleeping Pills to Avoid
I would recommend against ever using any of the following sleeping pills except for a special night or two, now and then when sleep may be especially difficult and important. Short-term sleeping pill use is usually safe in itself, but it is impossible to predict with any certainty who will slide down the slippery slope into long-term chronic use.
- Sedative-hypnotics are the most commonly prescribed sleep meds. These include benzodiazepines (e.g., Halcion) and non-benzodiazepines (e.g., Ambien, Lunesta and Sonata). In a previous blog, I warned in more detail about the dangers of the benzos.
- The orexin receptor antagonists (e.g., Belsomra) have a different mechanism than sedative hypnotics, but can cause daytime drowsiness and sleepwalking.
- Melatonin receptor agonists (e.g., Rozerem) have few side effects, but don’t really work, except as placebo.
Drug companies have been clever in rebranding as sleep meds those psychiatric meds that cause so much sedation as a severe side effect that they are not useful as psych meds. These would include antipsychotics (e.g., Seroquel) and antidepressants (e.g., doxepin, trazodone). These all have troubling side effects.
If you must use a sleeping pill for that rare occasion, I would recommend an over-the-counter antihistamine (e.g., Benadryl). I must admit to occasionally using them myself, especially on long plane trips. The biggest risk is drowsiness on awakening – not a great idea if you have to drive to work the next day.
Most psychiatric and all substance disorders can cause or be associated with insomnia. For some people, insomnia is not a stand-alone problem, but rather a symptom of psychiatric and/or a substance abuse disorder and treating the insomnia in isolation won’t work. It is important to identify and treat the disorder and the insomnia will usually improve as a consequence.
Embracing Sleep Hygiene
Fortunately, most people don’t need sleeping pills to deal with sleeping problems. A change in expectations and the few simple steps of good sleep hygiene are usually enough to get people through the night:
- Accept that perfect sleep is unattainable and that attempts to achieve it are unproductive.
- Develop a sleep diary to identify daily factors that help or hurt sleep – stresses, substances, naps, hours slept, how refreshing, etc.
- Engage in regular daytime exercise, but no exercise just before bedtime.
- Exposure to sunlight during the day, but sleep in a dark room and avoid bright screens before sleep.
- Make sure you have a comfortable bed and comfortable room temperature.
- Reduce/eliminate use of coffee, alcohol, and nicotine.
- Check to see if any other meds or supplements you take can cause sleep problems.
- Understand that excessive worry about sleep contributes to the vicious cycle of of troubled sleep.
- Reactions to insomnia are worse than the insomnia.
- Don’t stay in bed tossing, turning, and worrying. This conditions bed as a place not to sleep – worrying about not being able to sleep becomes the biggest enemy of sleep.
- Distraction works wonders in breaking the cycle. Better to get up and do useful, but dull, work likely to make you drowsy. Make the most of insomnia by doing productive things whenever you can’t sleep.
- Naps can go either way – wonderfully restorative for some, a cause of nightly insomnia in others.
- Figure out what feels right and works best for you.
- A few sessions of Cognitive Behavioral therapy can be a useful adjunct if self-administered sleep hygiene is insufficient.
- Relaxation training, yoga, and meditation all may give you the peace of mind and body conducive to good sleep.
Sleep hygiene is the preferred first-line approach – self administered, practical, commonsensical, and usually works wonders. Help from a professional via brief CBT, relaxation exercises, yoga, and/or meditation is a very valuable and convenient second-line approach to be recommended whenever sleep hygiene is not enough.
Better to accept and find ways to live comfortably with imperfect sleep than to take on the much greater risks of sleeping pills.-Allen FrancesSleep meds are problematic and to be avoided, particularly in the elderly where they promote falls, confusion, accidents, and memory loss. If you are not already taking sleeping pills, the best bet is probably not to start. If you are now occasionally taking sleep meds, make sure you don’t go from occasional to regular. If you are already using sleep meds regularly, definitely don’t stop them suddenly or on your own. Withdrawal can be very disturbing and even dangerous. If you decide to try to get off, do it very slowly and only under close medical supervision.
It is important to accept sleep diversity-we are so very heterogeneous in our sleep patterns that defining normal sleep is difficult. For many of us, especially as we age, trouble sleeping is an inevitable part of life. Seeking sleep uniformity or perfection causes more harm than good.
Better to accept and find ways to live comfortably with imperfect sleep than to take on the much greater risks of sleeping pills.
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