Are sleeping pills dangerous?

On February 27, 2012 the online medical journal BMJ Open published article titled:  “Hypnotics association with mortality or cancer: a matched cohort study”. This study concluded that "receiving hypnotic prescriptions was associated with greater than threefold increased hazards of death even when prescribed <18 pills/year”. Online news outlets and social media sites have erupted with commentary regarding this study.  According to BBC News, “Report suggests sleeping pills linked to early death". WABC in New York ran an article titled "New sleeping pill dangers".  KHOU.com in Houston Texas reported that a “New study findings big risk for sleeping pills".  Social media sites are filled with people commenting on their worries about sleeping medication.  Advertisements for alternatives to sleeping pills are populating Facebook, Twitter and other social media outlets.  The big question on the minds of many sleeping pill users is:

Are sleeping pills going to kill me? 

The BMJ Open study does not answer that question. 

Every medical study must be carefully evaluated before it is applied to medical practice or is used to change recommendations in the lives of individual patients. Yesterday's article by doctors Kripke, Langer, and Kline published by the British Medical Journal provokes important discussion but the study is significantly limited. When a medical study is reviewed, the structure of the study, the patient population, and confounding factors need to be considered. The BMJ Open study had a significant number of patients (34,205). However, these people were not individuals seen by the researchers. This was a retrospective chart review study. This study did not compare the efficacy and safety of sleeping medication. This study compared patients who were taking sleeping medication to patients who were not treated with sleeping medication. Although the groups were matched for some confounding factors (age, gender, smoking, body mass index, ethnicity, marital status, alcohol use and prior cancer) other important factors were not included. The study did not match case and control patients for other medical illnesses or psychiatric problems such as depression which could have accounted for a significant portion of the increased death rate.

Most significantly, this study did not control for insomnia itself. Previous studies have shown that insomnia itself is associated with an increased risk of death.  The Wisconsin Sleep Cohort Study is an ongoing population based study which examines the natural history of sleep and sleep disorders on significant health outcomes. The Wisconsin Sleep Cohort Study has reported that patients with persisting symptoms of insomnia were more than twice is likely to die compared to people who did not have insomnia.  Other studies have indicated that people suffering from depression are more likely to die than people who do not have depression. It is also well known that people with chronic medical illnesses are more likely to have disrupted sleep. Furthermore, it is important to note that people who have medical and psychiatric disease are more likely to have insomnia.  People with obstructive sleep apnea often present with insomnia and obstructive sleep apnea is associated with a two-fold increase in cardiovascular disease events.  Medical and psychiatric diseases themselves are associated with increased risk of death.  

Since people with medical and psychiatric disorders are more likely to have insomnia as a consequence of their conditions, and people with insomnia are more likely to take medication to promote sleep, it is reasonable to conclude that people who take sleeping medication are more likely to have medical and psychiatric disease.  Concluding that people who take sleeping medications are more likely to die is similar to concluding that people who drive to work are more likely to have a motor vehicle accident than people who walk to work.  We cannot implicate the medications themselves based on this study.  The conditions resulting in the use of the medications need to be considered. 

The important conclusion one can draw from the BMJ Open study is that it is that prescribers of sleeping medications need to identify the underlying causes of sleep disturbances and treat them appropriately. Medical and psychiatric disease which resulted in insomnia should be managed appropriately. Disturbed sleep should be investigated and appropriate sleep hygiene and sleep behaviors implemented. Although it may be true that people who take sleeping medication are more likely to die than people who do not, this study does not prove that the medication is the cause of death. This study chart review suggests that the people with sleep disturbances treated with sleeping pills are more likely to have conditions which increase the risk of death. The practice of prescribing sleep medication should be coupled with investigation into the cause of sleep disturbances. 

Darius Zoroufy, M.D.

Does Chronic Sleep Deprivation Cause Diabetes?

There is increasing evidence that sleep disorders are linked to metabolic problems like sugar control disorders and weight management problems.  It is common for patients to note improvements in their blood sugars, reduction in their weight and a drop in their blood pressure when they effectively treat their sleep disorder and start to get adequate, well-consolidated sleep. 

The question is whether inadequate sleep or poor sleep is a minor cofactor or if it is a significant contributing cause of diabetes.  Roughly 30% of American adults sleep less than 7 hours per night and are therefore chronically sleep deprived.  Since the cycle of glucose levels in the bloodstream and the pancreatic function according to the 24 hour circadian sleep-wake cycle and fail to achieve full compensation with the curtailed sleep duration.  Other hormones such as growth hormone, corticotropin (affecting cortisol) as well as the adrenalin (sympathetic) and vagal (parasympathetic) all require a full sleep cycle to function properly and they all affect the glucose system directly or indirectly. 

Experiments as early as the 1960's showed that short term sleep deprivation showed glucose intolerance and high blood sugar levels.  Since then longer term studies on people in real life circumstances.  In the Sleep Heart Health Study patients who had reduced sleep had significantly more likely to have diabetes than those who slept 7-8 hours per night. 

Another study looking at patients with known diabetes and reduced sleep duration each night found that their Hemoglobin A1C was 1.1 points higher than those who slept a normal amount of sleep per night. 

Multiple studies have been performed over years to more than a decade following patients and their sleep habits and blood sugars.  Patients who sleep 6 hours per night or less versus 7-8 hours per night are 1.5 - 3 times as likely to develop type 2 diabetes. 

Although there are many suggested causes for this link.  Reduced sleep is known to be associated with excess weight gain, for example.  However, one thing is for certain: 

Chronic sleep deprivation is bad for the health.  Diabetes Mellitus Type 2 is another reason. 

Darius Zoroufy, M.D.

Cleveland Clinic Journal Of Medicine - Volume 78 - Number 8 - August 2011

Seasonal Affective Disorder

It seems like we find out new things are bad for us all of the time and the news often seems contradictory.  Alcohol is bad for us, but a little bit of red wine might be good for some people.  Fried fish is bad, but take the oil out of the fish and put it in a capsule and it is good for the cholesterol.  Sun exposure can cause skin cancer, but is absolutely necessary for Vitamin D production and, as it turns out, for normal brain functioning. 

Sitting indoors in dark rainy weather doesn't just feel dismal, it actually has a negative affect on the neurochemistry of the brain with wide ranging effects that can last for months.  In fact, sometime the effect can persist long after the seasons change back to sunny, warm weather and long days, well beyond the typical October to April, Autumn to Spring time frame.   

So now we have our diet, our alcohol, and even the calendar that we have to watch out for. Fortunately, there are ways of managing this condition, known as Seasonal Affective Disorder. 

Seasonal Affective Disorder does not affect everyone.  However, people in latitudes that are further from the equator (Seattle is one of those) are more likely to be affected because there are fewer hours of daylight during the winter.  Climate plays a significant role as well.  In areas with less sunlight, the residents of the area are more likely to be affected.  According to NOAA data, Seattle has sunshine 43% of the time.  Compare that statistic to California Cities San Francisco, Los Angeles, San Diego  at 66-76%, major desert Southwest cities 75-80%, and even Green Bay, Wisconsin (known for cold winter weather) at 54%. 

Short daylight time during fall, winter and spring months and limited sunlight are predisposing factors for many to develop Seasonal Affective Disorder.  However, there are factors within the individual that may predispose the person to suffering from this disorder.  Some are more obvious such as underlying depression or depressed mood.  Increased stress, excessive fatigue, disrupted sleep, limited outdoor activity and therefore limited exposure to the limited outdoor light that is present, uncontrolled medical illness such as diabetes, or othe medical or psychological issues. 

People with Seasonal Affective Disorder are often challenging to diagnose.  Their symptom patterns are frequently complicated and do not easily follow a seasonal pattern when first described because of the multiplicity of symptoms.  Patients can present with any of a wide variety of concerns and they
will not always seem directly tied to the change in the season when the patient
explains the symptoms.  Instead, the interconnectedness of symptoms, life stressors and coexisting problems can make diagnosis somewhat challenging.  Typical presenting symptoms include mood symptoms such as: depression, crying spells, irritability, sensitivity to social circumstances and rejection, loss of sex drive.  They may present with cognitive symptoms such as: trouble concentrating, memory effects. It is very common for there to be physical symptoms like: fatigue, body aches and body heaviness, decreased activity level.  Sleep disturbances happen quite often such as insomnia, prolonged sleep, unrefreshing sleep.  Surprisingly, there are metabolic changes like: overeating, especially of carbohydrates, with associated weight gain, and an increased rate of Metabolic Syndrome. Weight gain can affect other health conditions like diabetes and sleep apnea which can also affect sleep and fatigue. 

The official diagnosis requires that there is determination of depression symptoms in a cyclical, seasonal pattern for a minimum of 2 years.  Clearly, we do not wait 2 years to initiate treatment.  When there is a clinical pattern, we initiate treatment and follow the patient carefully to assess for improvement. 

Treatment for Seasonal Affective Disorder may include antidepressant medication, referral to a pychologist for psychotherapy, chronotherapy (managing the patient's sleep schedule), Vitamin D therapy, sleep hygiene (placinge the patient on a more appropriate and healthy sleep schedule, exercise therapy (which usually involves taking walks outdoors), and therapeutic light therapy. 

Therapeutic light therapy is bright light therapy that mimics the wavelength of light not available in traditional room lights.  These lights help to reset the hypothalamus to improve the dysfunction that occurs as the cause of Seasonal Affective Disorder.  Typically the person needs to be exposed to the light for roughly 30 minutes per day, with the light in the periphery of his or her vision.  It is safe for the eyes and has minimal side effects.  Staring at the light might give a person a headache.  Staring at the fluorescent tubes in your office at work might give you a headache, too.  The light is mood elevating to a mild degree.  A patient who has uncontrolled manic bipolar disorder might become irritable with the light.  Also, because it promotes alertness, looking at it during the few hours right before bed might make it hard to go to sleep. 

Seasonal Affective Disorder is common and likely significantly underdiagnosed.  Simple interventions could probably be used for some of the milder cases to dramatically improved their quality of life.  We could also significantly alter the course of the disease in more severe cases, if people came to medical attention. 

Treating Obstructive Sleep Apnea: The Mask and Beyond

 “I am not going to use one of those machines to breathe with,” my patient says making a smothering gesture over his face.  I know he is talking about CPAP, continuous positive airway pressure, the most effective form of treatment for obstructive sleep apnea.  In my practice most people tolerate CPAP very well.  It is also true that many people have negative ideas about CPAP before they try it.  As their physician I step them through the process of diagnosing their problem, educating them about the condition, and presenting their treatment alternatives. 

            Obstructive sleep apnea is diagnosed by a sleep study called a polysomnogram.  “Poly” means many, “somno” means sleep, and “gram” means recording.  If those three are put together it means that we are recording many physiologic parameters of sleep overnight.  In more practical terms a patient sleeps in a normal bed (a queen-sized Sleep Number bed in my sleep facility) with some wires attached with adhesive so we can monitor brain activity and sleep stages, breathing, heart rhythm, movements, oxygen levels, etc.  We record all of that data and analyze it.  If the patient stops breathing frequently during the night we can detect it, measure its severity and frequency, and stratify the degree of sleep apnea into mild, moderate or severe.  

It is important to stratify the severity of obstructive sleep apnea, because severity of sleep apnea correlates with degree of cardiac risk. Once obstructive sleep apnea has been diagnosed, the patient needs to be treated. 

The most commonly used treatment is CPAP which stands for Continuous Positive Airway Pressure.  Since Obstructive sleep apnea is a condition of soft tissues of the throat such as the tongue and soft palate collapsing and closing the airway the treatment needs to prevent that process from happening.  CPAP uses a tube and mask to deliver a specified setting of air pressure to inflate the airway and make an open conduit for breathing.  CPAP consists of a small, quiet machine, a mask and a tube, as well as a humidifier to make the air comfortable.  In the past the success rate was approximately 50%, not because of treatment failures but because patients simply found the devices too uncomfortable for daily use over the long term.  Newer CPAP units are much smaller and quieter with better humidifiers and airflow features that allow breathing to feel more normal and natural.  Masks are lighter, more comfortable and easier to use.  Some just fit at the nostrils.  Success rates are now 80-90% with CPAP. 

Another common treatment is a Mandibular Advancement Device.  This is an oral device that is somewhat like the mouth guard a dentist makes for people who grind their teeth except it is more sophisticated.  This device has a piece for top and bottom teeth and keeps the jaws held together when the person is sleeping to prevent the bottom jaw from sinking down and back which is a natural position for the bottom jaw in sleep.  Since the tongue and muscle under the tongue are attached to the bottom jaw, those structures are also held forward and they are less likely to collapse the airway. The advantages of this treatment are night time convenience and travel size.  The treatment is not always as successful as CPAP in every individual.  

Surgery is a treatment that has had a role in sleep apnea therapy since sleep apnea was first identified.  In fact, the first treatment for obstructive sleep apnea was a surgical tracheostomy to bypass the obstructed upper airway.  There were no other effective treatments to directly manage sleep apnea.  Today there are surgical methods to correct a deviated nasal septum and improve nasal airway obstruction to allow better airflow.  Procedures are performed to reduce the size of the soft palate as well as the base of the tongue to decrease the obstruction.  There are also procedures to tether the hyoid bone of the neck to help keep the airway from closing during sleep.  In children with sleep apnea tonsils and adenoid tissue are often removed to successfully treat sleep apnea.  There are even occasional adult cases benefiting from this procedure.  Surgery is usually considered a second-line treatment for adults with sleep apnea because surgery is actually less successful than CPAP and there can be a small possibility of surgical side effects.

Weight loss can have a remarkable effect on the upper airway and sleep apnea.  As a person loses excess weight, fat tissue is reduced in and around the neck opening the diameter of the upper airway and decreasing the obstruction of sleep apnea.  In some cases sleep apnea can be improved from severe sleep apnea to mild or even to the point where other treatment is no longer necessary.  It is often very hard to lose weight with untreated sleep apnea because of excessive fatigue, associated changes in eating behaviors, and metabolic changes caused by sleep apnea.  However, when a person has treated sleep apnea and then embarks on a weight loss regimen, we often see dramatic improvements in the degree of sleep apnea. 

A relatively new advance in the treatment of obstructive apnea is Provent^TM. It is a deceptively simple little device that looks a lot like a small oval band-aid.  In the center of the adhesive there is a small plastic valve.  One valve goes into each nostril and the adhesive holds it on the nose making an airtight seal.  Provent’s valves treat sleep apnea by taking advantage of the physiology of the upper airway by producing partial resistance to the exhale part of the respiratory cycle.  This resistance to flow increases the pressure in the airway and inflates it somewhat like CPAP does.  When the next inhale cycle occurs the valves have no resistance and the airway starts somewhat inflated and much less likely to collapse.  Provent^TM does not work for every sleep apnea patient, but can be effective and convenient for some patients. 

Long scoffed at by many sleep professionals, positional therapy is starting to take a role in serious sleep apnea management.  The principle is deceptively simple.  It does not take a full polysomnographic study lab to determine what bed partners will freely report:  a large percentage of sleep apnea sufferers exhibit some degree of worsening of their sleep apnea and snoring when they are on their backs.  When studied we can determine that some patients will manifest sleep apnea nearly exclusively on their backs.  Gravity is clearly having an effect on the airway structures on the front of their airways (the tongue, soft palate, uvula) and pulling them back to close the airway.  If we could simply prevent gravity from causing those structures to close the airway we would solve the sleep apnea.  In order to prevent the effects of gravity we could send every sleep apnea patient with this type of positional component to the International Space Station.  Unfortunately, there are millions with sleep apnea, so overcrowding would be a problem.  We could instruct all of the patients to get a t-shirt, sew a long pocket down the center of the back and tell them to put half a dozen tennis balls down the pocket.  Then that shirt is their new pajama shirt.  The idea is that the patient needs to sleep on his or her side.  Rolling onto the back will be very uncomfortable and cause the person to wake up and roll onto a side once again.  Since the tennis ball t-shirt was quite seriously the mainstay of physician directed positional therapy for sleep apnea, positional therapy was not considered a serious modality for years.  Many did not want sleep with a bizarre shirt.  Others found the discomfort of the tennis ball shirt unpleasant and annoying.  Surprisingly, some would sleep so deeply they would roll onto the tennis balls, stay asleep and wake with a backache.  A number of years ago one of my patients even fashioned a positional device out of an empty 2 liter soda bottle filled with sand strapped to his back with seatbelt straps so he would be physically unable to roll over onto his back. The space station might have been less inconvenient.  Today there are specific devices which can be worn comfortably and gently but firmly resist rolling from side to back.  One is called the Zzoma^TM which attaches around the torso and has a specially shaped foam block on the back. 

Treatments for obstructive sleep apnea continue to improve and exciting new advancements are in trials.  One promising development is an implantable device which electrically stimulates the hypoglossal nerve which is the nerve under the tongue that controls tongue muscle tone.  This pacemaker-type device is switched on at sleep time and stimulates the hypoglossal nerve which triggers a neuromuscular response to open the airway.  So far published trials have shown successful deployment of the devices and significant reduction in sleep apnea, even in severe cases.  As studies continue to go forward we are optimistic about this novel treatment.

Obstructive sleep apnea affects a significant percentage of the population and there is not a single treatment that is appropriate for every individual.  Fortunately, there are multiple ways to manage sleep apnea and with the support of a multidisciplinary sleep center a patient can explore options to resolve obstructive sleep apnea, its symptoms and its health risks. 

Specific Sleep Scheduling for Insomnia

If you are reading this because you have insomnia, you are not alone.  Insomnia affects 80% of people at some time in their lives.  Persistent insomnia, however, is a more challenging and frustrating problem and I am going to try to leave you with a few tips to help improve your symptoms. 

There are a few caveats to get out of the way:  If sleep seemed to get worse abruptly and then stayed poor, it is probably important to find out why.  See your doctor.  In some people poor sleep is a sign of a medical or other health condition. 

Most people with persistent insomnia should consider getting psychological therapy.  Even if a psychological problem was not the main cause of the sleep problem, prolonged insomnia often can affect the overall psychological state over time affecting not only the overall health but the recovery from the insomnia.  Ironically, the more patients tend to resist psychological care the more likely they are to benefit from their services. 

Treating ongoing insomnia can be very challenging because of the highly resistant nature of this condition. Often patients describe poor responses to sleeping medication, relaxation techniques, and other behavioral techniques. In fact, it is not unusual for some patients to claim that they have tried "everything" without success. It is under these circumstances a sleep professional needs to carefully go through the history and identify each and every intervention and assess the effectiveness of how each technique has been tried. For example, a relaxation technique is less likely to be very effective if the patient finishes 3 hours of work, brings the computer to bed to check e-mail for 45 minutes, sets the computer down, and then tries to relax for 10 minutes.  When someone keeps their brain highly active and perhaps under emotional distress and then expects a sudden shift to total relaxation, it is as if that person expects slamming on the brakes, shifting into reverse, pulling the wheel to do a 180 in the middle of the highway will be relaxing for the passenger. Nearly all human brains require wind down time after stress and high level mental activity. In fact there is evidence that a very small percentage can immediately transition from high stress to relaxed brain state with very low levels of stress hormones. But I would be willing to bet that you are not James Bond so the rest of this advice does apply to you.

An evening routine requires putting away any work followed by declining intensity activities.  Declining intensity means decreased speed, decreased physical demands, decreased psychological stress, etc.  Paying bills definitely needs to stop at least an hour before bed.  Cleaning out closets and shelves also needs to stop at least an hour before bed.  Any work becomes the work that winds down the day.  Folding laundry and leaving it in baskets for the next day, putting the last dishes in the dishwasher so it can be started, are reasonable tasks.  Housecleaning will have to wait.  Then brushing teeth and pajamas.  Plan for 20-30 minutes of reading or watching television without any other activity.  Avoid television in the bedroom.  Then go to bed at a consistent bedtime.  This bedtime may vary because of your work schedule.  Roughly 10-11:30 p.m. works for most people if they don't have trouble going to sleep.  If you have trouble going to sleep, go to bed an hour later. 

In your room it should be dark, cool, comfortable, and quiet.  If it isn't, fix whatever is disturbing you so it doesn't bother you.  As I said, no T.V.  We could debate the T.V. in the bedroom thing forever, but I would still say no.  No computer.  No smartphone.  No iPad.  No Playstation.  Nothing with a screen.  You can have your phone in your room, just don't touch it.  If you were my kids I would tell you that the phone builds up a fatal electric charge during the hours of 10 p.m. and 6 a.m. and if they touch it they will die a grisly electrocution death.  But they wouldn't believe me, because they grew up with me telling them ridiculous things like that.  Just don't use electronics at night. 

Give yourself some time to relax and fall asleep.  You might be surprised by actually falling asleep.  Sleep "how-to" books give specific amounts of time.  I think that if you are watching the clock at night, it is counterproductive and promotes wakefulness.
Do not have a visible clock in the room.  Your alarm clock can be in the room, but turn it away from you.  Reminding yourself that it is 2 a.m. and you are not asleep is not useful at all.  If you open your eyes and it is dark and your alarm has not rung yet, you still have time to sleep.  That's all you need to know.  The mental math of thinking how many hours you have been awake, how few hours you have left to sleep, how many hours you should be sleeping, how many nights it has been since you have slept well, and wondering when it will all crash down on you is not relaxing.  Those thoughts are stressful. 

So far: 
General health exam by doctor and possibly psychologist
No alcohol or caffeine during the time we are intervening on your sleep
No tech
Wind down time for at least an hour
Regular bedtime
No visible clock


Next:  if you wake up in the middle of the night and you can easily fall back to sleep, that's wonderful!  However, if you are awake and can't sleep again, get out of bed and go to the living room or some other suitable, quiet room where you can be alone.  Read something relaxing like a magazine or some fiction.  If you read non-fiction make sure it is something that does not activate your brain excessively.  Read about whales (unless you are a marine biologist) or something else pleasant.  Read about the Dynasties of China.  If you don't have a Kindle, consider getting one.  But it's the middle of the night and Amazon (http://www.amazon.com/) delivers fast but not that fast.  If you have a smart phone you can download the Kindle app and start reading books on your phone.  The is the only exception I give to the No Tech rule.  Now you can download thousands of books, many of them for free.  Consider watching television.  Watch something that pleases you.  DO NOT WATCH THE NEWS! News channels have changed their formats over recent years and they are highly visually triggering and the flow of the information is jarring.  Replace all of the interior windows of my standard transmission car with television screens that change channel every 3-5 seconds, configure the stereo so it plays 11 stations at once and then invite my 10 year old to drive at 90 miles per hour down I-90, grinding and clunking the gears all the way, and put Wolf Blitzer in the back seat interrupting everything all the time and we would have television news. 

No TV news for you.  It will not relax you.  Watch Dirty Jobs or Mythbusters.  Watch a movie.  Get Netflix http://www.netflix.com/  and you can stream a ton of movies and TV series to your TV instantly for pennies per day.  Relax.  You are going to be up for a while.  When you feel ready to go back to bed, go to bed and see if you can go to sleep. 

How does this help?  This sounds like what you were already doing, right?  You were already staying up at bedime and staying up during the night.  Then you would crash and sleep late some mornings when you were exhausted.  Okay, now we are going to apply a schedule to your sleep.  It works on the principle that your body, more specifically your brain needs sleep.  If you deprive your brain of sleep it will build up sleep pressure and eventually it will fall asleep. 

Let's take insomnia treatment X:  Patient 1 comes in with complaints of not being able to sleep.  The doctor straightens his collar, sticks out his chest and says, I can make sure you get a good long night of sleep.  Patient 1 is brought into the sleep testing laboratory, is connected to testing electrodes and the technologist is instructed to keep the patient awake for 72 hours.  At first it is no problem.  The patient reads, watches T.V., talks on the phone, etc.  By the end of 48 hours the patient is occasionally dozing off and needs to be watched.  By 60 hours the patient needs constant supervision and stimulation like talking, lifting the hand, etc.  The doctor indicates that it is time to let the patient sleep and they put her to bed.  She sleeps for 16 hours straight and wakes up feeling very rested, but stiff and groggy.  She has trouble sleeping the next night because of having just slept 16 hours, but for the next few days she sleeps with only mild difficulties.  However, the problems slowly return and in a few weeks she is back to the way she was. 

Insomnia treatment Y:  Patient 2 comes in with similar complaints of trouble falling and staying asleep.  The doctor advises relaxation, good sleep hygiene (behaviors) and schedules a 3 month follow-up appoinment.  The patient expresses frustration because "I've done all of that".  In fact, the patient has read a book and has tried a few of the recommendations for a night or two and got frustrated.  The fact is that the patient is too frustrated to try anything that does not have tangible and clear results. 

Insomnia treatment Z:  Patient 3 will be treated with relaxation, sleep hygiene (appropriate sleep/bedtime behavioral therapy) and sleep scheduling also known as sleep restriction. 

Sleep Restriction is one of the most effective and widely used treatments for insomnia.  It works quickly, it has a sustained beneficial effect.  It is often more powerful than medication but it can be used in conjunction with medication, if needed. 

When Sleep Restriction is first explained to patients, they almost universally do not like it.  The most favorable response is something akin to suggesting a colonoscopy.  Other responses are vehement arguments against it.  This is probably because Sleep Restriction seeks to take the already limited sleep in an exhausted patient and to substantially cut it down.  It seems like the logic of:  "Oh you are dying of thirst.  Okay, I'll dump some of your last water on the ground."  It is my job to explain why this protocol works. 

Let's take an example: 

Gretel gets home after a long day in the woods each day and makes dinner for her brother and her aunt.  Then she has to clean up the kitchen, do some housework before she gets to relax.  She likes to play "Pigs and Wolf" on XBox 360 and usually plays until after her witchy aunt goes to bed, typically after 11.  Then she brushes her teeth and gets into bed.  She thinks about how guilty she feels fattening up her brother, but her emotions are mixed because she doesn't want to get eaten.  They could try to get away but the place is rent-free and meals included and that kind of deal doesn't come along every day.  Plus, the old woman has serious diabetes.  If she kicks the bucket, the candy house would be theirs.  They could use the candy house to attract paying tenants and they would be set for life.  With all of these thoughts on her mind she spends hours in bend tossing and turning and unable to fall asleep.  When finally sleep comes to her the hacking cough of the warty nosed aunt wakes her and once again racing thoughts keep her from sleeping for quite a while.  When she awakens she poorly rested once again, yet having to start her busy day. 

For the sake of sleep math, let's say Gretel goes to bed at 11:30 p. m. and gets up at 6:30 a.m. 
From 11:30 - 1 a.m. she is unable to sleep. 
From 1 a.m. - 3 a.m. she sleeps.
From 3 a.m. - 4:30 a.m. she is awake again
From 4:30 a.m. - 6:30 a.m. she is asleep

Doing the sleep math:  She sleeps 4 hours and she is awake 3 hours.  She is in bed 7 hours.  She is asleep 4/7 of the time she is in bed which is just a little more than half. 

Patients would like us to be able to force them to sleep the other 3 hours.  There isn't a wand in the Hansel and Gretel story or in my clinic.  I can't make anyone sleep.  We can teach relaxation, sleep hygiene, and occasionally give medicine.   None of them will fix this by themselves.  Sleep Restriction works well.  Sleep Restriction is math. 

If we have a fraction of 4/7  and what we want is that fraction to be closer to equaling one, but we can't change the numerator, then we have to change the denomenator.  In other words, we have to decrease the amount of time in bed. 

The solution is to tell Gretel to get earplugs to block out Aunt Witchy's noise.  Then she needs to stop playing XBox so late.  Third, her sleep schedule has to change to midnight to 5 a.m.  This will eliminate both the insomnia at the beginning of the night as well as during the night. 

At first she will still have the same insomnia, she will just have less sleep.  However, after 2-4 days the pressure to fall asleep and stay asleep will overcome her insomnia disorder and she will fall asleep more easily and even if she wakes up she will return to sleep more easily.  She needs to limit her sleep duration however to maintain an ongoing amount of sleep pressure over the next several weeks, thus the early morning awakening.  When she is consistently falling asleep at midnight, not waking during the night and waking at 5 a.m. she will be getting 5 hours of consolidated sleep per night.  This is much better than her 4 hours of fragmented sleep she was getting before.  At this point she can start adding 30 min in the morning every 3-5 days alternating with 30 min in the night every 3-5 days until she is in bed 7 hours/night. 

She can always repeat this protocol if she needs to do so.  Typically, if a person has had do this protocol once there is a probability they will have to do it again.  The good news is it is easier subsequent times. 

Staying on a consistent sleep schedule it very important for people with insomnia. 


An example would be:

Hypnotics: Sleeping Pills, Part 2

In this section we will review some of the common and a few of the less common hypnotics (sleeping medications) and distinguishing characteristics.  I am going to break the medications down by pharmacologic class to make it easier and clearer, at least easier and clearer for me if not for the reader. 

First, we should start with alcohol (ethyl alcohol).  This drug has been widely available for millenia and since the invention of doctors, there have been doctors using alcohol as a medicine for their patients for sleep.  And for worms.  And for cankers.  And for scalp lice.  And for fever. And for pustules.  And for rat bites.  Alcohol is sedating.  It can promote sleep if given in large enough quantities.  However,  there is initially has reduced REM sleep followed by REM rebound and vivid dreams.  Sleep becomes fragmented by awakenings and is poorly restful.  Often people complain of insomnia.  Interestingly, the effects of alcohol on sleep can last hours after ingestion so that several drinks in the afternoon can cause insomnia for some people that night.  Furthermore, heavy alcohol users can have sleep disruption months after discontinuing alcohol.  Although alcohol is a fundamental component of social interaction and culinary preferences for many, it is best if it is not used pharmacologically and like most products, it should be avoided when side effects occur. 

Melatonin:  Take the hormone of the pineal gland and you have melatonin.  If you don't know where your pineal gland is, please stop guessing!  Some of you were just wrong.  Some of you were guessing in places I would rather not think about.  The pineal gland is in the brain.  It secretes melatonin.  It seems to do this to tell our brains that it is dark and we should go to sleep.  The eyes tell the hypothalamus which tells the pineal gland.  It is a mild but very useful effect to coax us to sleepy-land.  I suspect that when we were living in smaller hunter-gatherer groups it was much more useful to have a hormone that made hunter-gatherer me drowsy at night so I would tend to want to lay down and sleep rather than run around willy-nilly in the dark where I could trip and break something (no E.R. with orthopedic surgeon on call) or get eaten by something nocturnal.  Taking exogenous (pill) melatonin can be quite useful in three circumstances:  a) Jet Lag: take 1 hour before bedtime at your new time throughout your trip and for 1-2 weeks when you return.  b) Shift Work: take 1 hour before bedtime during day sleep.  c) Chronic Insomnia:  take 60-90 min before bedtime nightly.  Melatonin is generally considered to have relatively few side effects.  However, one major side effect is vivid dreams or nightmares.  If this side effect occurs and continues, you can try to cut down on the dose or stop and restart the medicine.  However, is is very likely that the side effect will return every time you take it. 

Barbiturates:  This class of medications is highly sedating and is very potent to induce sleep.  However, these medications are hardly ever used as sleeping medications due to the abuse potential and safety issues they carry.  Instead, they are now used primarily as anti-seizure medicines and anesthesia medications.  Examples include:  Secobarbital (Seconal), Pentobarbital (Nembutal - used for animal euthanasia, treatment of seizures, capital punishment, physician-assisted suicide), Butalbital (Fiorinal - migraine treatment), Phenobarbital (seizure treatment), among several others.  Getting good sleep is important, but it will never be so important that patients should take a couple of the capital punishment pills to get to sleep. 

Benzodiazepines:  This is a large class of medicines some of which are used for sleep, others are used for other purposes.  It ranges from the very short acting intravenous Midazolam which you are likely to receive when you have a procedure like a colonoscopy.  It is sedating and it affects the memory so that you stay comfortably resting and you wake up not remembering anything about the procedure, which is the best way to have a colonoscopy. When the colonoscopy is done, the medicine is wearing off.  On the other end of the spectrum is a medicine like valium.  It is a mildly sedating medicine which primarily works to blunt anxiety.  It works for many hours and it has active metabolic products that last more than 24 hours.  The purpose is a long, low level effect to blunt revved up anxiety.  In the middle of the spectrum are many medicines.  Some with more sedation effects and some with more anxiety reduction, each with their varying durations of effect.  The following are a list of medicines sometimes used to promote sleep.  Some are used to promote sleep when other conditions are present.  If these medications have been used regularly at higher doses, a taper should be used to come down off of the medicine. 
Triazolam (Halcion) 0.125 - 0.25 mg
Clonazepam (Klonopin) 0.25 - 1 mg
Lorazepam (Ativan) 0.25 - 1 mg
Alprazolam (Xanax) 0.25 -1 mg


BZRA's (Benzodiazepine Receptor Agonists) Think of this group as Ambien and its cousins.  You have got to give the pharmaceutical companies credit.  They came up with a great one.  Barbiturates are addictive and dangerous.  Benzodiazepines have long half-lives and other effects on the brain besides just sleep like affecting anxiety, mood, etc.  These scientists made a much more pure sleeping-only pill.  Unlike its predecessors it starts to work in 20 minutes, not 45 to an hour.  It wears off reliably in 6 hours.  They had a brilliant pill.  And they sold millions.  If it's so great why haven't we cured insomnia? The answer, as you might have guessed, is that pills do not solve complicated problems like insomnia.  Sleep hygiene (see subsequent blog post) is critical for good sleep.  Other health issues can get in the way.  Feeling sick while undergoing chemotherapy, worrying about one's business but feeling too sick to go to work, realizing that everything that was worked for is dissolving like that soggy cake in the annoying seventies song all can prevent sleep, ambien or not.  Then medical professionals need to step in.  Sleep professionals have specific training in these matters. 
Side effects and precautions:  There are many, but they occur infrequently. 
Side effects of these medicines:  temporary memory loss, sleep walking, sleep eating, there have been reports of sleep driving,
Precautions:  Notify living partners (adults) that you are taking a sleeping pill tonight.  If you seem to be walking in your sleep, they should verbally encourage you to return to bed.  If you seem to be doing something that you shouldn't, such as going outside in your pajamas in the rain at 3 a.m., they should direct you back to bed. After taking your sleeping pill, do not use the internet.  Ambien works quickly and you may not be thinking clearly when you make a purchase or send an email.  To your boss.  Calling him a name that describes the posterior portion of a donkey.

Currently available BZRA's are:
Zolpidem (Ambien) 2.5 - 10 mg
Escitalopram (Lunesta) 1-3 mg
Zolpidem (Ambien CR) 6.25 - 12.5 mg
Zaleplon (Sonata) 5-10 mg




Meltatonin receptor agonist:  Ramelteon (Rozerem) is the only currently available medication in its class. It can be effective in some patients with insomnia.  It is most beneficial after the patient has been using the medication for at least 1-2 weeks.  Side effects are limited.  There are some drug interactions that need to be checked with each prescription of Ramelteon. 

Hypnotics: Sleeping Pills, Part 1

Hypnotics – Sleeping Pills. 

Part 1

From the Greek word hypnotikos meaning “inclined to sleep, putting to sleep, sleepy” [Wordbook.com]. 

From the late Latin word hypnoticus  also referring to the inclination to sleep. 

From the 17^th century word hypnotic meaning the induction of sleep usually with drugs. 

From the mid-twentieth century United States, Las Vegas term “Amazing Hypnosis Phenomenon”, referring to cheesy shows in which members of the audience are fooled into clucking like a chicken for the entertainment of the crowd. 

Hypnotics are a class of medications that are intended to sedate and induce sleep.  There are several presumptions regarding hypnotics that are worth stating. 

1.       Sleep is best done without others getting involved in the process, no matter how well intentioned.  It is much like golf in this way.   Once sleep… or a golf swing… has been directed to relax and progress smoothly, nothing is going to make it work better.  Anything else, like sleeping pills, will only get in the way. 

2.       Nearly everything that prevents people from sleeping needs to be solved by changing their habits and behavior.   A sleeping pill will not solve unmanaged stress, poor sleep habits, turmoil in the household, psychological issues, or using tech (computers, phones, TV, etc) late at night.  Arguing that it works well for you even though it is devastating to the sleep of everyone else is not going to get you to sleep any faster. 

3.       Alcohol does not improve sleep.  It makes people drowsy.  Enough will make a person pass out.  It worsens sleep quality.  People with poor sleep need to stop alcohol. 

4.       Caffeine keeps some people awake.  Avoid late day caffeine. 

5.       If you are using a drug that shows up on a drug screen, stop it.  For about a hundred reasons.  But they will mess up your sleep, too. 

6.       Unlike the beliefs of many patients, there are no pills which are completely safe and guaranteed to induce sleep.  I am often asked for something “strong” but “safe” and I wonder if that was what Michael Jackson was after. 

7.       Everything that causes a physiologic effect on the brain could potentially be habit forming.  When patients ask for a sleeping pill that isn’t habit forming, I want to suggest Skittles.  Just don’t go to bed with them in your mouth, you might choke.  Actual pharmaceuticals have a habit forming potential.  So does cough syrup.  So does coffee.  So do pain killers.  Yet most people with coughs, breakfast beverages, and pain do not end up as junkies.  The same is true with sleep medications.  Most people use the medication correctly.  Even the people who use it incorrectly do not tend to develop substance abuse problems.  Sometimes their prescriptions run out early, but it is often because of the “if one is good, two must be better” philosophy.  In my career I have very rarely seen anyone abuse or sell their prescription for their sleeping medication.  I have never seen anyone suffer serious consequences from sleeping pill abuse.  I know it happens, but I believe other drugs are abused more frequently.  Patients should use their sleeping medications correctly and worry less about ending up in rehab. 

8.       It is normal to wake in the night.  It may take a while to return to sleep.  No medication will prevent the normal phenomenon of occasional nighttime awakenings. 

9.        ALL sleeping medications have side effects.  Don’t ask for one without side effects.  They made a seedless orange.  They made a seedless watermelon.  They made seedless grapes.  Now you can enjoy them without pesky seeds.  However, you are never going to have medicine without side effects.  The reason there will always be the potential for side effects is that if a medication is active in your body, it means it is changing the way your body’s physiology functions.  It is more accurate to say desired and undesired medication effects.  When taking any medication, some of the medication physiologic effects you were hoping to get (less prominent wrinkles following a botox injection).  Some medication physiologic effects you do not want (frozen face and loss of the ability to smile).  The medication is having the effects on the physiology, some are desired, some are not.   Some people call them side effects, but they are actually still the same physiologically active drug effects as the principal effect you were trying to get.  For example, when a sleeping pill makes you sleepy, you are happy about that.  It is doing its job.  When it makes you lose your memory for the details of a conversation you have while you are lying in bed and just about to go to sleep, you call it a side effect.  In fact, it is the same sedating physiologic effect.  Both consciousness and memory are affected.  Be alerted for all of the physiologic effects (side effects, if you will) of sleeping medications.  Typically, they are mild and tolerable, but one should be aware of them before taking the medication. 

10.   Do not Michael Jackson me.  What I mean is:  do take sleeping medication and then complain it doesn’t work and ask for more or stronger medication.  When a patient tells me that a very effective sleep aid taken in double or triple the usual dose “doesn’t work” I am 99% certain at that moment that the problem is not that there is too little medicine, the problem is that there is too little therapy dealing with the cause if the insomnia.  (For those of you with short memories or little interest in the King of Pop, Michael Jackson died due to a massive overdose of sedatives and the injectable anesthetic propofol administered by his doctor.  Mr. Jackson apparently suffered from insomnia for a long time and had a history of insisting on high doses of sedatives from his doctors.)