Q: I have been taking a benzodiazepine for several months to
control my insomnia, but I hear that taking sleeping pills
long-term is not a good idea. What are the potential risks, and is
there such a thing as a safe long-term sleeping pill?
Q: I have been taking a benzodiazepine for several months to control my insomnia, but I hear that taking sleeping pills long-term is not a good idea. What are the potential risks, and is there such a thing as a safe long-term sleeping pill?
A: Insomnia is an occasional problem for about a quarter of all Americans, but nearly 1 adult in 10 struggles with a chronic sleep problem.
Older people are especially vulnerable. As you age, you spend less time in deep sleep, which is the kind of sleep that is most restful.
Conditions like arthritis, poor bladder control, and depression are some of the things that can keep people awake.
Many people try to deal with sleeplessness on their own.
About a quarter of people in one survey said they self-medicated with alcohol.
Alcohol can help you nod off, but it may backfire because the brain tends to become “hyper-aroused” as the blood alcohol level drops.
About the same number of people said they used over-the-counter sleep medications, which are usually antihistamines, drugs taken chiefly for allergies.
There’s no doubt that antihistamines are sedating, but they tend to linger in the body, so you can wake up feeling groggy.
Starting in the 1970s, doctors prescribed benzodiazepines (pronounced ben-zo-dye-AZE-uh-peens), the so-called tranquilizer drugs.
All benzodiazepines cause sleepiness, but sleep induced by benzodiazepines isn’t the same as natural sleep.
They tend to suppress the deeper, more restorative stages, while increasing the shallower and less restorative stages of sleep.
But less-than-ideal sleep is still a blessing for people struggling with insomnia.
Most sleep experts say that benzodiazepines are safe and effective – for the short term. It’s long-term use they worry about.
Some people develop a condition called tolerance, which in this context means needing larger and larger doses to get the same effect.
There’s also a risk of rebound insomnia once you stop taking the pills.
So the benzodiazepines are far from perfect. Enter zolpidem (Ambien), and zaleplon (Sonata) – the “Z drugs.”
Ambien and Sonata work differently in the brain than benzodiazepines, thereby producing fewer side effects. They’re also shorter-acting than many of the benzodiazepines.
Taking Ambien for more than a few weeks may result in tolerance, while studies of Sonata have shown no evidence of tolerance when it is taken for four weeks. Sonata’s effect on tolerance beyond four weeks needs more study.
But whether Ambien and Sonata are that much of an improvement over the short-acting benzodiazepines is debatable. Many doctors believe they are, but there are few side-by-side comparisons.
Regardless, as studies reveal the negative health consequences of insomnia and not getting enough sleep, people are beginning to view the drawbacks of sleeping pills differently.
All of this adds up to a great deal of interest in identifying drugs that could win FDA approval as long-term sleeping pills.
Right now there are two leading candidates for long-term sleeping pills: eszopiclone (Estorra) and indiplon. Sepracor, the Marlborough, Mass., company that makes Estorra, sponsored a 6-month-long study published in 2003 that showed that the drug helped with a variety of sleep problems.
The authors also said that Estorra showed no evidence of tolerance. The dropout rate (40 percent) was high, however.
Indiplon leaves the bloodstream very quickly, so the drug should produce little daytime drowsiness.
It’s also very selective in the way it affects the brain, reducing the chance of side effects.
Neurocrine Biosciences, the San Diego company that developed the drug, believes that it has overcome the disadvantages of a short-acting sleeping pill by developing a so-called modified-release version of indiplon.
Preliminary studies have shown that people taking indiplon do not show signs of tolerance with continued use.
Insomnia can be its own condition, but sometimes it’s a symptom of other conditions, such as depression or arthritis.
Rather than paper over such problems with a sleeping pill, skeptics ask, wouldn’t it be better to treat the root causes?
Some people have trouble sleeping because of bad habits: drinking caffeine too late in the day (noon is a good cutoff point), not going to bed at a regular time, or not getting enough exercise. Trying to break such habits before resorting to a sleeping pill makes sense.
Because insomnia is often caused by anxiety – and, indeed, anxiety about not sleeping often adds to the more general anxiety – therapies that relieve anxious feelings benefit some tossers and turners.
But Dr. David White, director of the sleep disorders program at Harvard-affiliated Brigham and Women’s Hospital, argues that success may require many hours of work with a counselor – and also considerable discipline on the part of the patient.
“A large percentage of people are just not interested,” he says. “They just want to get the problem fixed.”
For them, a supposedly problem-free, long-term sleeping pill is going to be very tempting.
If you would like to e-mail questions to the Harvard Medical School Adviser, you can submit questions to the Harvard Medical School Adviser at www.health.harvard.edu/adviser. Unfortunately, personal responses are not possible. For more consumer health information from Harvard Medical School, please visit www.health.harvard.edu.
