by Brad Schnierow, Sleep Medicine Specialist
Have you seen the television commercial with the man tossing and turning in bed, unable to sleep until a glowing little butterfly floats into his room and eases him into dreamland?
The butterfly is a modern version of Mr. Sandman, and the commercial advertises one of a handful of new sleep medications that promise you a good night’s sleep without dependency, grogginess and other major side effects.
It is true that the new prescription sleep aids, such as Ambien, Lunesta and Sonata are milder and safer than the barbiturates used years ago.
They don’t adversely affect blood pressure or heart function like the older pills did, and it is far more difficult to overdose on them. They also are less likely to produce the sedating “hangover” feeling the following day. And, the side effects of abruptly stopping the newer medications are less serious — if you stopped taking barbiturates suddenly, the results could be fatal.
However, despite the advertised claims that Lunesta and the others are not habit-forming, a number of physicians have found that this may not always be true in real life.
When the pharmaceutical companies present such information to physicians, they will show that a patient doesn’t develop tolerance (meaning that a given dose doesn’t lose its effect over time).
Moreover, the manufacturers claim that patients who stop the medication will not experience a phenomenon called rebound insomnia, where the insomnia not only returns but is more severe.
Although the pharmaceutical companies do have such data, the subjects involved in their research studies are not your average insomnia patients. People who use alcohol, caffeine or medications or have any other medical problems aren’t likely to be represented; in fact, one company went so far as to exclude people who had a relative with any history of psychiatric illness.
Very few patients in our day-to-day practice meet those criteria, and most physicians we’ve spoken with have found that some patients do develop tolerance to these new medications, and rebound insomnia when they stop taking them.
Plus, they can be quite expensive compared to the older agents. At two to three dollars apiece, a month’s supply of Ambien or Lunesta may cost you $80 to $100.
Because the patents have expired for the older drugs, you can buy the lower-priced generic versions. The patent for Ambien, the most widely prescribed sleeping pill in the US, will expire next year, and generic versions will become available.
The manufacturer recently introduced Ambien CR (controlled release), which claims to last longer, but we have not yet seen data to show that Ambien CR has any actual advantage over the original Ambien.
How do these new medications compare to one another? We don’t know.
The manufacturers’ clinical studies only compare their pills to a placebo, not to similar medications. Because nobody has done head-to-head comparisons, no one can say their product is superior to any other.
Only Lunesta has FDA approval for long-term use, defined as greater than one month of continuous use, but only Lunesta’s manufacturers asked for that approval. Had the other manufacturers thought of it, they might have been able to get approval as well.
And while we’re on the subject of comparisons, some people mistakenly believe that if older sleeping medication didn’t help them sleep, the newer ones will. Actually, the opposite is more likely to be true. The older medications were more potent, so if they didn’t help, the newer, milder drugs probably won’t, either.
It’s important to realize that no sleep medications literally put people to sleep. As I tell my patients, people who expect sleeping pills to “knock them out” are giving themselves the message that they can’t sleep on their own. This isn’t true.
The actual ability to sleep is not lost; instead, anxiety and apprehension get in the way. Sleeping pills lower those hurdles, allowing natural sleep to come.
Sleep medications certainly can be useful in helping people get the rest they need. However, they shouldn’t be prescribed without careful consideration and discussion. I’ve found they are most useful when temporary stressors such as final exams, work projects, travel or even wedding plans create stress that interferes with sleep.
We call this “adjustment sleep disorder” and often find that once a patient adjusts to the stress, sleeping patterns return to normal. Sometimes, just knowing that a sleeping pill is available on the nightstand can be reassuring enough to help someone sleep without actually taking it.
Long-term use of sleep medications, however, is discouraged, because it increases the chances of developing tolerance and dependence.
Patients who suffer from chronic insomnia as their primary diagnosis, meaning there is no other physical or psychological reason for it, can often benefit from other treatments such as learning cognitive behavioral therapy, reducing or cutting out alcohol and caffeine, or adjusting their sleep schedules to better reflect their natural body clocks.
If you’re having problems sleeping, talk to your doctor or a sleep specialist. He or she can help make sure your insomnia is not secondary to a medical or psychiatric condition.With so many options available, there’s a very good chance you’ll soon be able to get the sleep you need.
This Scripps Health and Wellness information was provided by Brad Schnierow, M.D., a sleep medicine specialist at Scripps Memorial Hospital La Jolla.