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Sleep trouble, insomnia, is one of the biggest reasons people go to see their doctors. It’s not surprising, then, that sleep aids are a huge business.
Over the counter (OTC) sleeping medications are a half a billion dollar industry. Prescription medications account for nearly an additional billion dollars.
This difference doesn’t mean that OTCs are used less. They’re not. Its just that the prescription drugs tend to cost more.
Unfortunately, all of these medications can cause significant problems, especially with memory. But they can also worsen sleep problems in the long run.
Why are you having sleep trouble?
One of the biggest concerns with simply taking something for sleep is that it doesn’t give an answer to why you can’t sleep. There are many types and reasons for sleep disturbances.
And if sleep trouble is occurring more than every now and then, it’s best to figure out why.
I had a patient who complained for weeks about trouble staying asleep, always being tired during the day, etc. She also was a pack and a half a day smoker.
I tried changing around the dose and timing of a medication she was already on for her psychiatric problem since it was usually pretty sedating. But that still didn’t remedy the problem.
So I had her do a sleep study (polysomnography).
It showed that the oxygen level in her blood dropped to dangerously low levels when she was asleep. What this meant was that her body was trying to save itself by refusing to let her sleep soundly.
If she'd slept hard enough, she might never have awakened again. Her brain and heart were getting too little oxygen to survive.
It was a good thing that she couldn’t sleep.
Sleep hygiene and all that jazz.
I’m not going to talk about the usual things you’re supposed to do if you have insomnia. This is what the experts refer to as "sleep hygiene." This includes such things as no lights in the bedroom, turning off the TV, going to bed at a usual time, and other things like that.
I suggest you look at the National Sleep Foundation (www.thensf.org) and the Centers for Disease Control (www.cdc.gov>sleep) for information on basic sleep recommendations.
Each has its own biases, but are still good resources for information on how to get better sleep.
Instead, I’m going to talk specifically about medications used for sleep and problems those drugs can cause.
Over-the-counter medications for sleep
I can't even guess how many people I work with take OTC sleep meds, also known as "sleepers."
They don’t even think about these as medications since they’re over the counter, don’t require a prescription, or have “safe” ingredients in them like acetaminophen (Tylenol®) and Benadryl® (diphenhydramine).
But neither or these “safe substances” are actually always safe. And certainly not in the kinds of doses people often use.
The “active” ingredient in the large majority of OTC sleepers is an antihistamine, either diphenhydramine ( Benadryl®, Nytol®, Tylenol PM®, Wal-sleep Z®, to name a few) or doxylamine (Unisom®, Wal-som®, Ultra Sleep® and others).
Most of us, if we think about antihistamines, think about treating allergies. And this is, in fact, a very common use for these drugs.
But if you take any of these older antihistamines (like diphenhydramine and doxylamine) drugs for allergies, you know you can get a dry, scratchy throat, dry eyes. Your heart rate goes up. You might also find that it’s hard to urinate or move your bowels.
And more importantly, you get sleepy.
The “side effect” of sleepiness is, of course, what makers of OTC sleepers are aiming for.
But again, just because it doesn’t need a prescription doesn’t mean these drugs can’t cause trouble.
While these sleepers do help many people for a while, usually this effect wears off. Many individuals find themselves increasing the dose, which also may work for a while, but eventually wears off.
And while the beneficial effect on sleep usually wears off, the side effects (increased heart rate, dry eyes, etc.) don't. In fact, the higher the dose, the more the side effects prevail.
Often when I see people who say their memory is getting worse and they’re tired all the time, I find that they’re taking one of these medications.
Unfortunately, just stopping these drugs doesn’t always reverse the memory problem that it may have caused or worsened. We're learning a lot about things that affect memory, especially in older people. Many of the "safe" things people take, including sleeping medications, are among the worst.
One other thing I need to mention is that drinking an alcoholic beverage and combining it with one of these sleeping medications can cause death.
There are often good reasons to take a sleeper once in a while. There probably is no harm in that. But best choice: don’t start taking a sleeper unless you and your doctor have decided it's safe. And don't take any sleeper continuously since the bad outweighs the good most of the time.
Prescription ‘z’ drugs for sleep
Among the most widely prescribed of all drugs in the US is the group of sleeping medications known as the ‘z’ drugs. These include Zolpidem (Ambien®), Zaleplon (Sonata®) and esZopiclone (Lunesta®).
They’re related to the valium family, benzodiazepines. But when they first came out they
were marketed as being a safe and non-addictive alternative to valium, Xanax and their cousins.
Of course, anything that sounds too good to be true probably isn’t. And this holds true for the z drugs.
There are so many reports of memory issues, binge eating while asleep and other sorts of behaviors that the person can’t remember at all, that you only have to Google ‘z’ drugs to get pages of horror stories.
And just like with the OTCs diphenhydramine and doxylamine, they can cause memory problems which may not improve just because you stop taking them.
On the other hand, stopping these medications will NOT worsen problems with memory and these troubles might improve.
Even the occasional use of the Z drugs can cause people, especially older ones, to become more forgetful.
If your doctor or other professional prescribes one of these drugs for once in a while, fine. But if you receive one of them for routine use, you should seriously question how informed the prescriber is about how dangerous these drugs can be.
What you need to do
There are other families of sleep medications that I haven’t covered here but will touch on in the future. However, the ones I mentioned above, the antihistamines and the ‘Z’ drugs, are the most widely used.
There are also many herbal and other non-pharmaceutical approaches to sleeping better. Some of these can cause significant side effects as well though. so not everything I write will be positive. I will discuss some of these in another write up, as time doesn’t permit me to cover them well here.
For now, you can go to the National Center for Complementary and Integrative Health (www.nccih.nih.gov) to review some of the natural substances for sleep.
This is such an important topic, and I get so many questions about it, that I know I’ll be coming back to talk about sleep, maybe repeatedly.
The message I want you to take away for now, though, is: before you take something, over the counter, by prescription or from the health food store, take a minute to think:
1. Is sleep a problem all the time or just some of the time?
2. If it’s only sometimes, maybe medication isn’t needed. Perhaps herbal tea or just riding it out can be a better approach.
3. If it’s all the time, try to figure out, maybe with your doctor’s help, why are you having trouble sleeping? If there is an underlying medical problem, treating it first may be all that's necessary.
4. If it isn't medical, are there things you can do rather than take a drug that can make you more comfortable?
If you’re already taking something for sleep take some time to look at problems they may be causing:
1. Are you noticing more difficulty with memory? Most OTC and prescription sleepers do have this as a side effect
2. Are you tired or dragging all day? Again, look to the sleeping medication as a likely source of this problem
3. Do people tell you about behaviors you’re having at night that you don’t recall? If so, this can be dangerous. Maybe it’s time to seriously question whether your sleeping medication is your friend or not.
Image of awake person by: © Can Stock Photo Inc. /orkidia
Image of pills in cart by: © Can Stock Photo Inc. /merznatalia
Image of hands and pill by: © Can Stock Photo Inc. /Zinkevych