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April 1, 2014

8 million people take prescription sleep aids, but these drugs have risks

Insomnia. "It's a lifestyle thing; everybody's got it," says Gregg Jacobs, an insomnia specialist at the Sleep Disorders Center at the University of Massachusetts Medical School. More than half of American adults, when asked, report that they suffer from insomnia symptoms — trouble falling asleep or waking up during the night — a few times a week, according to the National Sleep Foundation.

About 8 million adults turn to prescription sleeping pills for help every month, according to a study published last year by the Centers for Disease Control and Prevention. And yet, Jacobs warns, these medications all have flaws.

Popular prescription medications for insomnia include the so-called Z-drugs: Ambien (zolpidem), Lunesta (eszopiclone) and Sonata (zaleplon). These drugs have shorter durations of action than older drugs such as the benzodiazepine Dalmane (flurazepam). That means they may help you fall asleep, but their effects don't last very long. They also are less likely to lead to morning grogginess.

And yet, recent data show that even the Z-drugs can cause problems. Last year, the FDA recommended that prescribed doses of Ambien be lowered, particularly for women. This came after reports of lingering effects in the morning, including drowsiness and impaired driving.

There are concerns with the Z-drugs in elderly people as well, with persisting effects causing daytime confusion, memory problems and falls, Jacobs says. In fact, the American Geriatric Society, which publishes a list of medications that the elderly should avoid because their side effects outweigh their benefits, recently discouraged the use of Z-drugs for any period longer than 90 days. Benzodiazepines when taken for insomnia are on the list as well.

The Z-drugs have similar effects on the brain as Dalmane and other benzodiazepines such as Klonopin and Halcion. These drugs act on GABA receptors, inhibiting neuronal function and thus tending to dampen many brain functions, including a wakeful state. The Z-drugs, thought to interact with a smaller subset of GABA receptors than the benzodiazepines, were hoped to produce fewer side effects than those drugs. However, many studies have found little difference between them. Other drugs are prescribed for sleep, such as certain antidepressants (Desyrel and Sinequan) that tweak the balance of brain chemicals involved in mood and alertness, and the melatonin-mimicking drug Rozerem (ramelteon), which delivers sleepytime signals to the brain.

"It's important to pick the right medicine to match your problem," Thomas Roth, a sleep medicine researcher at the Henry Ford Hospital in Detroit, says. It's equally important to know that there's a non-drug alternative.

Indeed, cognitive behavioral therapy, which includes using relaxation techniques, controlling stimulation before bedtime and reframing how people think about their sleep needs, may work better than any pill. Ten years ago, Jacobs published a study that found cognitive behavioral therapy superior to Ambien, producing bigger effects in falling asleep time and in overall sleep-vs.-wakeful time in bed.

Behavioral treatment and Ambien in combination did not produce any greater effect than behavioral treatment alone.

If you do go the medicine route, understand that drugs' sleep-inducing effects are limited and side effects may make them not worth your while.

A review of clinical trials found that, on average, people taking Z-drugs fall asleep 22 minutes sooner than those taking a placebo pill. But these drugs don't last very long, so they don't help keep you asleep in the pre-alarm clock hours.

Short-term side effects can include:

— Hangovers, "especially if you're sensitive or slow to metabolize the drugs," Roth says. For instance, women typically metabolize Ambien more slowly than men.

— Amnesia. This may be why people report better sleep when they take the drugs, Jacobs says: They don't remember being awake even if they were.

— Abnormal behavior, such as sleep driving or sleep eating. This effect is rare, Roth says, and is associated with taking a higher than recommended dose, combining the medication with alcohol or taking it more than a hour before bedtime. "Take your meds and go to bed," he says.

— Abuse and addiction. "The risk is very small except in vulnerable people," Roth says. People with addiction or alcohol abuse history are at much greater risk of using sleeping pills to get high.

If you have taken the drug long term (beyond a month or three), side effects may include:

— Dependence. After months of nightly use, your body can get so used to the drug that stopping suddenly can cause withdrawal effects, including nervousness, dizziness, insomnia and even seizures. Reducing doses gradually can prevent this.

_Tolerance. This is when you need more drug to get the same effect and is less likely with the short-acting drugs. Roth co-authored a study that showed that the sleep benefits of a steady dose of Ambien were maintained over eight months of use.

— Risk of early death. A recent study found an association between sleeping pill use and mortality. However, whether the primary contributing factor was pill use could not be determined. For instance, insomnia is also associated with poor health and may play an important role in early death.

"Insomnia is a chronic disorder, and chronic problems require chronic treatment — under supervision," Roth says. "It's worth seeing a doctor who knows the meds and who also knows about behavioral treatments," he adds.

So if your sleep troubles are frequent and persistent, see a doctor — preferably a sleep specialist.

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