February 7, 2008
Insomnia Fuels Sleeping Pill Abuse
Napping is a necessity for Alissa Vladimir on many days, and it's not because she's a toddler. The 23-year-old public relations associate from Philadelphia has insomnia, a sleep disorder characterized by difficulty falling asleep, staying asleep or waking up too early.
Sleepless until the wee hours most nights, Vladimir often rises weary. "I am cranky and more easily annoyed when I have a bad night. On bad days I just want to get everything over with so I can lie down," she says.
To achieve slumber-filled nights, many insomniacs rely on prescription sleeping pills, which have experienced record sales in recent years. Heath Ledger, the 28-year-old actor who died Jan. 22, was reported to have had insomnia and was on medication for it. But sleeping pills were just part of the mix that caused his death, according to the New York City medical examiner's office, which ruled Wednesday that his death was caused by an accidental overdose from a mix of painkillers, sleeping pills, anti-anxiety medication and other prescription drugs. Most sleep experts say sleeping pills are safe if taken as directed under a doctor's care.
According to the National Institutes of Health, insomnia is common, affecting one-third of adults. About 10% complain of chronic insomnia, meaning their troubles last for more than one month and occur at least three nights a week.
In her new book, Insomniac (University of California Press), Gayle Greene, a professor of women's studies at Scripps College in Claremont, Calif., and a member of the American Academy of Sleep Medicine, a professional medical society for researchers and clinicians, calls insomnia an "invisible epidemic." There are no outward signs of it, she says in her book. "No wounds, scars, crutches, casts, wheelchairs."
The hidden nature of insomnia can lead to years of little or no treatment, leaving sleep-deprived individuals more vulnerable to illness and mood problems, and more accident-prone.
Michael Sateia, chief of sleep medicine at Dartmouth Medical School, says there are many problems that may give rise to insomnia. For example, a patient's rest may be disrupted due to sleep apnea, a sleep-related breathing disorder that can actually be exacerbated by sleeping-pill use. "An accurate diagnosis is critical to developing a treatment plan," he says.
There are two types of insomnia. Primary insomnia is not a side effect of another problem, and generally persists for one month or longer. The more common form, secondary insomnia, occurs as a side effect of some other problem, such as depression, anxiety, trauma or migraines.
Dagny Carretero, 57, of Palm Desert, Calif., has struggled with middle-of-the-night wakings since her brother died 12 years ago. Stress and depression after the death of her son nine months ago have compounded her problem. "It is so hard. I wake up at 2 or 3 in the morning and can't get back to sleep again," she says.
Secondary insomnia often goes away or improves by eliminating its cause, for example, too much caffeine or excessive stress. The disorder can hit at any age and affects women more often than men. Older adults are more prone to it, too.
It is not uncommon for a physician to dole out a prescription for sleeping pills. About 42 million were filled in 2005, according to research company IMS Health, up 60% from 2000.
Though barbiturates were employed to soothe insomniacs in the '50s and '60s, they had serious side effects, including addiction. They were replaced by benzodiazepines, but a newer class of drugs called benzodiazepine receptor agonists (BzRAs), which include Sonata and Lunesta, are now more commonly prescribed because they appear to be better tolerated. Sateia says these drugs can be helpful for some people in the short term, but he adds that patients should still use them for only the prescribed period, which is usually only a few weeks.
Although it is rare, accidental deaths can occasionally occur when a sleepy, confused user takes an extra dose, or when he mixes pills with alcohol, Sateia says.
According to a U.S. Department of Health and Human Services report, an estimated 172,388 emergency department visits were associated with abuse or misuse of benzodiazepine sleep drugs in 2005, a 19% increase from the previous year. Whether the increase is due to more prescriptions being written is unclear.
Jodi Mindell, associate director of the Sleep Center at The Children's Hospital of Philadelphia, says patients need to tell their doctors if they are on any other medications, because dangerous drug mixes can occur with some antidepressants, allergy drugs and certain other medications.
Visiting a sleep specialist can help. A sleep expert will make a thorough assessment and often start with non-drug treatments, which studies have found to be very effective in improving sleep, before suggesting pills.
A combination of lifestyle changes and "environmental modification," which involves making a patient's surroundings more sleep inducing, are employed. They include keeping lights low before bedtime, sleeping in a comfortably cool room, nixing caffeinated drugs late in the day and avoiding stressful activities before bed.
Though Carretero pops the occasional sleeping pill, she and Vladimir prefer non-drug methods to beat their nocturnal blues: "Even though my doctor says the medication can help, I don't want to rely on it or get addicted."