Part 3 Sleep is Critical - Sleeping Pills
Prescribed and Approved Treatments
To the detriment of sales, I am often quite supportive of the pharmaceutical industry. I get quite a number of furious emails from believers in “natural medicine” and believers of the “Big Pharma conspiracy” who turn to other brands as I do not support their ideology. The pharmaceutical industry has brought us numerous cures, and we live longer, healthier, better lives because of the work done. This does not mean that in all, or even most, cases drugs should replace better and safer practices, and does not mean that I am in support of all drugs, all the time. They are often employed when sufferers have not taken other precautions as a last line of resort.
Earlier this year, I was sitting in the ER on an antibiotic IV drip, the consequences of interfering in the cat fight I joked about in my talk with Dr. Holland. I watched a conversation between the ER doctor who treated me and was by all accounts friendly, attentive, and helpful (we even chit chatted about various scientific topics as it was fairly slow in the ER), and a patient, a man in his late 20s or 30s with his mother.
Watching how the conversation progressed, I was disgusted, but not surprised. The man was having issues sleeping, his back hurt, was getting “headaches” and had “low energy”. He was also at least 100 lbs overweight, slouched in his chair with abysmal posture. The ER doctor advised him, to his rage and dismay, that there was nothing wrong with him. As in, they found no serious issues, he had no disease or chronic condition. I cannot remember the battery of tests that he was given, but it was quite lengthy. The amount of taxpayer funds spent to find a problem with this man would have been significant.
The mother objected, slowly becoming irate that her son “wasn’t being helped”. The doctor advised the man, who was shaking his head in disbelief with his mouth open, that he believed his issues could be reduced or flat out removed by cleaning up his diet and starting an exercise program (based on the conversation, the man admitted he didn’t exercise). The mother pleaded with the doctor to “prescribe my son something to help him.” They weren’t looking for work or to change the son’s lifestyle, but a magic pill to take away his symptoms. I suspect in many cases, doctors may eventually fold and prescribe a drug, perhaps a sleeping pill or opioid, as a last resort; facing criticism they are only “treating symptoms” from those attacking them.
In the case of this ER doctor, he flat out refused to prescribe anything, but then waffled at the end as his repeated advice to eat better and exercise was causing increased frustration and anger, and suggested “you could try massage therapy or chiropractic for your back, it may help you sleep better.” The man and his mother both seemed abated by this and after looking at each other, got up to leave, but not before the man stared and shook his head at the doctor who was walking away.
While I emotionally felt anger, frustration, and contempt towards the man and his mother watching this transpire, upon reflection, I wonder what drives people to refuse the best advice for their health if it requires even limited effort. As I touched on in “Aim for Small Victories”, failures in physical health may often be attributed to deteriorating mental health, even if these issues are not yet diagnosable. The ER doctor in question could not have reasonably spent enough time to get to know the patient to help them work through their issues, that is not his role in medicine.
Perhaps this is how charlatans often win over those in need, they give the illusion that they care about the individual while capitalizing on the situations described above, which most of us have experienced when dealing with overworked doctors who often have too many patients, or ER or walk in clinic doctors who do not have a personal connection with those they are treating. We need better systems in place to care for people and encourage them to improve their own health before it’s too late. We need systems with evidence that work. We also need a way to pay for it, but I digress, back to sleep and the approved treatments…
Prescription Sleeping Pills
In many cases, sleeping pills can be necessary as a last line of resort. Even Peter Attia has admitted he has prescribed, and still will, sleeping pills in extreme cases as he tries to work out why patients have insomnia. This is a man who has quoted (to paraphrase):
“I tell patients I’d rather them put their genitals in a meat grinder than stay on sleeping pills permanently”
What Do the Experts Say About Sleeping Pills?
According to Matthew Walker during various talks, he has argued that powerful sedatives/hypnotics are not restorative sleep. He argues that simply being “unconscious” is not akin to the restorative qualities of sleep. Dr. Daniel J. Buysse, a sleep medicine expert and professor of psychiatry at the University of Pittsburgh, argued towards a more “personalized” assessment regarding the use of sleeping pills, quoting:
“Do you feel more rested, more alert, more able to concentrate, less irritable on medication versus off?" Dr. Buysse said. "If all those things are true then I would say it’s more restorative. If a hypnotic drug leaves you feeling hung over or more anxious, if it causes you to order five hickory smoked turkeys on the Internet without remembering, then it’s probably not good.”
This position seems to be supported by Dr. John Weyl Winkelman, a sleep disorders expert at Massachusetts General Hospital and Harvard Medical School. When asked what he’d tell a patient if asked whether medicated sleep was restorative, his response was
“I’d say: ‘You tell me.’”
While I’ve never taken sleeping pills, my experience with an opioid I was prescribed as a teenager following a nasty fracture just below the shoulder resulting in muscle being pierced and accompanying rolling spasms, left me hesitant to ever take an opioid again. Some of my experiences parallel what others have described with their memories during sleeping pill addiction and prolonged use.
Said drug, tradename Darvon, is now recalled in many countries, including Canada and the USA. In my experience, it resulted in minimal reduction in pain. What it did do was put me in a haze for the three months I took it. In fact, it is the one period in my adolescence where I have no clear, strong memories.
The opioid crisis, and ensuing black and white debate, is a topic for another time. I view much of what is debated quite like sleeping pill issues and debate. I believe they have a use in some cases, but are probably overused and over relied upon. Some people legitimately need these drugs, perhaps they are desperate and have circumstances where other methods have not worked.
So What Are the Risks of Long-Term Use of Sleeping Pills?
While not getting proper restorative sleep and experiencing morning grogginess and forgetfulness in some people is a major cause for concern, there are several other concerns surrounding long-term reliance on sleeping pills.
One 2012 study found that even occasional users of sleeping pills have a 5.3x higher risk of all death and 35% increase in the rate of cancer. The study was conducted by a team that published 18 papers on links between sleeping pills and negative health affects over almost four decades (and have published more work on the subject since). Following the international attention received, the work has been replicated by other teams since.iii
The FDA has recently ordered many manufacturers and marketers of sleeping pills to step up their warnings to consumers regarding serious side effects. They singled out Ambien, Sonata, and Lunesta, while bringing up worrisome behavioural reports, such as sleep walking, sleep driving and engaging in other activities while not fully awake. While this recent warning was just announced in May 2019, the FDA has previously warned about sleeping pills and potential worrisome effects as early as 2007.
A link was also found in 2012 between sleeping pills and an increased risk of pneumonia. More recently, research has established a link between increased pneumonia, sleeping pills and those with Alzheimer’s disease.
It has previously been discouraged to prescribe sleeping pills to those suffering traumatic brain injury due to negative effects in neural plasticity,iii while a recent animal model showed that animals dosed with sleeping pills slept longer than control animals, but had less, not more, brain plasticity. It led to a 50% unwiring of connections.iv
CBT-I as an Alternative
What is CBT-I?
Cognitive behavioural therapy for insomnia (CBT-I) is an approved treatment of insomnia that can be used as a stand-alone or alongside sleeping pills that aims to identify the underlying cause of insomnia and treat it based on improving habits and sleep hygiene ,while also incorporating numerous other methods. The exact protocol is typically tailored around the individual.
CBT-I was found roughly as effective in treating insomnia as sleeping pills, taking a bit longer to work, but showing a higher rate of deep sleep and better long-term results after treatment when directly compared to a hypnotic sleeping pill.v In fact, when CBT-I was compared as a stand-alone treatment against CBT-I and Ambien, the results were not statistically different. CBT-I worked as well on its own.vi
The efficacy of CBT-I has been established in numerous other trials and confirmed by meta-analysis,vii although another meta-analysis notes that while effective, there is room for improvement.viii Further, it is the preferred treatment by experts previously discussed in this series, such as Matthew Walker and Donn Posner. The efficacy has also been supported by Dr. Daniel Buysse, who previously quoted a neutral position on sleeping pills in a review him and colleagues conducted.ix Even computer generated CBT-I protocols are effective, even as effective as personalized approaches by sleep experts, providing opportunities to help more individuals in a more cost-effective manner.x
Based on the efficacy of CBT-I and the potential dangers of sleeping pills, it is likely preferable to attempt CBT-I first. That said, if CBT-I does not work for you, and the different strategies we discuss next week fail to find a benefit, it may be time to speak to your healthcare provider about temporarily trying sleeping pills.