Insomnia and sleeping pills: Nothing to yawn about

Sleep is perhaps the most mysterious of all human activities. No one can really define its biological function — that is, why it is restful and necessary — or come up with a foolproof recipe for a good night’s sleep. Soldiers, health care professionals, call center workers, pilots and flight attendants, and many others suffer from insufficient sleep. If you’re older, you are also likely to sleep less soundly. Or you may have trouble falling asleep or staying asleep. An estimated one-third of us have insomnia, sometimes severe and chronic, sometimes “secondary,” meaning that it arises from such sleep disruptions as long plane flights, anxiety, pain, illness, late-night work, or too much alcohol. Insomnia can make you feel exhausted all the time, adversely affecting your ability to work, play, think, and drive.

There’s a lot of buzz in media these days about insomnia. What’s been called the “sleep-industrial complex” is busy persuading you that lack of sleep is an epidemic peculiar to modern life, as well as a serious health risk, and the first logical step is to spend more than P100,000 on a mattress. (Everybody needs a comfortable place to sleep, but an expensive bed is not likely to solve your problems. Millions of people sleep well on mats on the floor.) In most cases, practical self-help (as opposed to medical approaches) does the trick. But if this doesn’t help, and insomnia is ruining your ability to enjoy life, you may need to go further — perhaps seeking cognitive behavioral therapy, trying a sleeping pill, or going to a sleep disorder center.

Your Doctor’s Not Sleeping On The Job

Many people deal with insomnia at first by taking a sleeping pill. Such drugs can get you past jet lag, illness, or other temporary causes of insomnia. But if your problem persists over several weeks, you should talk to your doctor about it — not just ask for a prescription for a sleeping pill. Most people never mention their sleep problems to their doctors, and not all doctors are interested in discussing them. Your first step should be a consultation with a doctor who listens and asks questions. Illness, depression, medications, and other possible causes of insomnia should be considered. If pain at night keeps you awake, for instance, your doctor can help you manage it. Sleep apnea is another problem that can ruin your sleep and can be treated. Restless legs syndrome (characterized by uncontrollable leg movements and a jumpy feeling at night) can interfere with sleep, too, and you may decide to try a prescription drug for it.

You’ll need to describe your problems: for example, you may fall asleep but then wake up for hours; you may not fall asleep at all; you may toss and turn and never feel rested; or perhaps you wake up too early in the morning. Before you see your doctor, keep a sleep log for a week. Record the following:

• Time of retiring; periods of wakefulness; how many hours you think you actually slept; time of awakening.

• Napping habits.

• Factors disrupting your sleep (bed partner’s snoring, pets, children, pain, worry, and so on).

• Drugs you take; smoking; alcohol and caffeine consumption.

• Whether you feel rested in the morning.

You may also want to keep a log of your daily activities to help you pinpoint the cause of your insomnia.

Insomnia Triggers You Can Control

The following steps can help many people with insomnia:

• Limit alcohol. It may make you sleepy initially, but alcohol produces unsettled sleep (it reduces REM sleep, the phase when you dream) and middle-of-the-night wake-ups. Don’t use alcohol to help you sleep or induce drowsiness. Drink moderately, if at all — no more than one drink a day for a woman, two for a man.

• Cut down on coffee, especially in the afternoon and evening. Remember that most cola drinks and tea are caffeinated, too.

• Don’t smoke. Nicotine keeps some people awake.

• Eliminate noise. Try earplugs or a “white noise” machine.

• Make your bedroom sleep-friendly. Put up darker shades or make other changes to keep the room dark. A sleep mask can help. Your bed, linens, and pillows should feel comfortable. Most people sleep better in a cool (but not cold) room.

• Drink less liquid after dinner, so the need to urinate does not wake you.

• If stress keeps you awake, try to deal with the problems that cause it. You may need professional advice.

• Try to retreat from your problems at bedtime. Read, listen to music, knit, watch TV, meditate, work a puzzle — anything that qualifies as quiet relaxation.

• Set a regular time to retire and rise, and stick to it, even if you haven’t had enough sleep and on weekends. If you wake up in the night, get up and do something quiet, such as reading.

• Use your bed only for sleep and sex. Don’t bring paperwork or food to bed. Limit pillow talk, especially if the subject is upsetting.

• If you nap, keep it to 30 minutes maximum, and try to nap early in the day.

• Daytime exercise can relax you and promote sleep later. But don’t exercise strenuously in the evening, since that may have the opposite effect.

OTC Options

Ideally, no one should need sleeping pills. However, millions do take them. Most people start with over-the-counter remedies. These are usually antihistamines, which cause drowsiness. Though relatively risk-free, they can reduce alertness and impair driving performance the next day, even if you don’t feel drowsy — especially in older people. Antihistamines can also worsen urinary retention in men who have an enlarged prostate. Since tolerance can develop, don’t take the pills for more than three or four nights in a row. Melatonin supplements and herbal remedies (such as valerian), besides being unregulated, have unpredictable effects.

Prescription Choices

Most prescriptions for sleeping pills fall into two categories:

• Benzodiazepines, popularly called tranquilizers. Shorter-acting benzodiazepines such as estazolam (Esilgan), midazolam (Dormicum), and lorazepam (Ativan) are often prescribed for insomnia. In addition, some doctors prescribe alprazolam (Xanor) and diazepam (Valium), as well as similar drugs that are also used to treat anxiety. These tend to stay in the blood longer and are more likely to cause impairment or “hangover” the next day, especially in older people.

Nonbenzodiazepines include zolpidem (Stilnox in RP; Ambien in US), eszopiclone (Lunesta in the US), zaleplon (Sonata in the US), and ramelteon (Rozerem in the US). Only eszopiclone and ramelteon are FDA-approved for long-term use.

Each drug has its advantages and disadvantages. For instance, zolpidem and eszopilone should be used only when you expect to sleep eight hours. Zaleplon wears off after four hours and can be taken at the beginning of the night or for wee-hour wakefulness, if you know you have at least four hours to sleep. Low doses of some benzodiazepines work like this, too.

The Truth about Sleeping Pills

All sleeping pills, new and old, share some drawbacks. You may develop tolerance over time, so they become less effective. If you use them every night, you may become dependent. When you stop taking them, you may have “rebound insomnia.” In older people, sleeping pills may stay in the body longer, thus increasing grogginess the next day. Studies have linked sleeping pills in older people to falling, fractures, and accidents. A 2006 study in the American Journal of Geriatric Pharmacology concluded that long-term use of sleeping pills of any kind has never been shown to be safe for older people.

If you take sleeping pills, follow these precautions:

• Take the smallest effective dose. And don’t drink if you plan to take a pill.

• If you are a doctor or a nurse on call, a pilot, or the sole caregiver of a child or anyone else who may need help in the night, don’t take a sleeping pill.

• If you take a pill and feel groggy or exhausted in the morning, don’t drive a car or operate a heavy machinery. Even if you don’t feel groggy, you may be impaired.

Bottom line: No matter what the ads say, there is no “best” pill. Your ultimate goal is to sleep soundly without the need for sleeping pills, if possible. –Tyrone M. Reyes, M.D., Philippine Star