Straight Talk About Sleep and Sedatives

Roughly 15% of younger adults and older men, and over 30% of postmenopausal women, are prone to develop insomnia. This condition is associated with decreased ability to fall or stay asleep with functional difficulties the next day due to lack of sleep. There are many reasons for the development of insomnia, which is a symptom, not a disease. Management may require the assistance of a physician, but training in medical school is often lacking in this regard, except for a focus on prescribing medications when better ways of managing insomnia exist.
Amongst the most common medications prescribed in this country are sedative hypnotics, otherwise known as sleeping pills. The market for these medications is huge, and most sleep consultants who are seeing patients regularly encounter questions about them many times a day:
What is the best, the safest, the most readily available, the cheapest sleeping pill? The categories of sleeping pills include the z-drugs: zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta); tricyclics (doxepin, amitriptyline, nortriptyline, and mirtazapine); benzodiazepines (temazepam, triazolam, alprazolam, diazepam, and lorazepam); and sedating antidepressants (trazodone and paroxetine). The newest category includes Belsomra (suvorexant) which is chemically related to the sleeping condition Narcolepsy. A hormonal sleep aid is melatonin, which is made and released in the brain naturally starting at dusk.
The printed FDA guidance for use of sleeping pills states they are supposed to be considered short-term solutions for insomnia, but quite often a seeming short-term problem leads to a habit of taking these medications long term. The value of these medications declines with increasing duration of use, according to laboratory studies of measured sleep time, which is contrary to the beliefs of most people who take them. Then, getting off these medications can become difficult. Breaking the habit can nearly always be done, however, with a carefully constructed program and professional guidance.
Why is it important to try to avoid getting on sleeping medication long term? Research has now shown that the large majority of such medications, with a few notable exceptions, can increase risk of developing cognitive slowing with the aging process. In simple terms, the risk of developing dementia goes up with each passing month of using sleep pills, even if not using them each night of the week. It becomes a cumulative dose issue, not a consistency/frequency issue.
Just as alarming was the startling discovery coming from the work of Dr. Daniel Kripke at the University of California in San Diego. His well controlled comparison studies led to awareness that some sleeping pills, including temazepam and zolpidem, lead to much greater risk of developing cancer and having earlier mortality. Some direct causes of mortality were obvious associations, such as vehicular accidents and night time falls. Other associations, such as increased infections in the sleeping pill population, were more difficult to account for. Even very occasional users were much more likely to experience these serious results.
The best programs for treating persons with chronic insomnia are those referred to as Cognitive Behavioral Therapy. A lengthy discussion is beyond the scope of this article, but the premise involves healthy sleep hygiene, modifying sleeping environments and timing, regular daily exercise, some dietary management, and use of a sleep log. Addition of melatonin used judiciously is often helpful also. Individuals habituated to sleeping pills owe it to themselves to seek the counsel of sleep specialists for healthier solutions to treat chronic insomnia.
Kripke,D. , Langer, R.  Kline, L. “Hypnotics association with mortality or cancer: a matched cohort study.  Br M Jl, 2(1), 2012, e000850
Smith, M. et al. Comparative Meta-analysis of pharmacotherapy and behavioral therapy for persistent insomnia,  Am Jl  of Psych, 2002 V 159 (1):  5-11
Walker, M., Why we sleep, Simon and Schuster, 2017, pp 282-94