Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, M.D.
 29 June 2005

SLEEPING PILLS

            Sleep is every bit as important as food and water or even breathing.  As a group, children sleep easily, naturally.  But as the burdens of the world mount in adulthood, sleep disorders are one of the most common problems seen in the clinic.  It is estimated that 40% of our adult population has a sleep problem periodically.  Ten to twenty percent of our population has a chronic sleep problem.  Sleep disorders can occur in response to stressful situations, chronic anxiety problems, depression problems, and medication use or abuse.  Often times inappropriate use of caffeine and cola drinks can cause sleep problems.

            As might be expected, one of the common requests in a clinic is “something to make me go to sleep”.  For eons, alcohol has been known to put people to sleep.  A small glass of wine in the evening is often very helpful for some people.  Many years ago, a product called bromine was used but had many side effects and is no longer on the market.  Barbiturates came into being in the 1930’s and were the mainstay of sleep preparations for many years.  The hangovers and side effects and addictive potential of these drugs lead to their eventual replacement with better preparations.  The benzodiazepine group of sleep preparations including Valium and Librium, Ativan and Xanax, came into being in the 1960’s and were the next family of sleeping preparations.

            However, the benzodiazepine family causes hangovers and cumulative effects that can impair the patient’s function during the following day.  These products are still used for some individuals.

            In the past 15 years, the latest class of sleeping pills has come on the market.  The two older preparations are called zolpidem (Ambien) and zaleplon (Sonata).  These products have the advantage of quick onset so the person falls asleep quickly after going to bed.  They wear off relatively quickly so that there is no hangover in the morning.  For some people, this is a disadvantage if they awaken too early in the morning, not having slept through the night.  In the past 15 years, Ambien has become the most commonly used sleep preparation.

            A new product recently was introduced called esopiclone (Lunestra).  It is the first sleeping preparation that the FDA has recognized for long-term use.  As with most new patent products that come on the market, it is substantially more expensive than Ambien or Sonata. These are more expensive than the generically available benzodiazepine such as Valium or Xanax (Alprazolam).

            There are two other products worthy of mention in regard to insomnia problems.  One of these products is called amitriptyline (Elavil).  Amitriptyline is an anti-depressant that has a side effect of making people drowsy.  It is not a first line anti-depressant anymore but it does seem to help some people sleep if taken at bedtime.  Since it is generic, it is relatively cheaper than many of the other sleeping preparations. Amitriptyline often causes dry mouth and fast heart beat which some people find undesirable.

            The other medication that is often used to help with sleep is called trazodone (Desyrel).  This also is an anti-depressant that has a side effect of causing drowsiness.  The side effect profile for this product is relatively safe.

            Something to consider is what makes a person naturally go to sleep.  What chemical in the brain tells the brain that it is time to sleep?  Several years ago, a hormone called melatonin was discovered in the pineal gland.  The pineal gland is wired to a person’s eyes.  Melatonin is a hormone that is released by the pineal gland when there is no light in the person’s eyes.  The first time I read about this, I marveled at the poetry of nature that it provided us with a hormone that put us to sleep when it got dark.  Unfortunately for some people, this hormone is decreased in amount especially in stress situations and as people grow older.  A little know fact about sleep requirements is that elderly individuals definitely require less sleep than younger people.  Eight hours of sleep for school-aged children is a requirement to maintain health.  This decreases to about six hours a night when a person is in their 50 and 60’s and as low as four hours a night for people that are 80 years and older.  Why this would be is not clear.  It has been observed that as individuals grow older, the amount of melatonin that they produce is much less. This seems to be in conjunction with the decreased sleeping needs of the elderly individuals.

            One of the advantages of melatonin is that it wears out very quickly.  It puts a person to sleep and then some other natural mechanism maintains sleep.  Thus, if the person is using melatonin to go to sleep at 10:00 pm or 11:00 pm at night and they can’t go back to sleep after awakening at 3:00-4:00 am in the morning, they can take another dose of the same pill to help them get back to sleep again.

            On the horizon at this time, there is a new product called remelteon.  It is still in pre-marketing studies. The medication is designed to last longer than melatonin but looks very much like melatonin to the body.  Thus, hopefully would be a product that would help a person get to sleep quickly and maintain their sleep longer and with no hangover.

            As a closing remark, sleeping pills as a group have somewhat of a bad wrap.  They are valued as a drug of choice for people who want to commit suicide.  They are faulted by high- strung individuals who take stimulants during the day and then sleeping pills at night so they can sleep.  They are faulted as something that people get addicted to.  The truth is that a sleeping pill is like a knife or a fork or a hammer or a gun.  There is nothing intrinsically bad about the knife, the fork, the hammer or the gun but rather it how the item is used.  Sleeping pills have the capability for abuse and inappropriate use.  But they are not evil or bad by themselves.  For those 10-15% of our population that has chronic insomnia, an appropriately used sleeping preparation can be lifesaving.  Chronic insomnia carries with it a number of life threatening illnesses including heart attacks, heart failure and atrial fibrillation.  The healthcare providers at your local clinics can help prescribe an appropriate sleeping preparation at an appropriate dose and avoid misuse and abuse problems.