Sleeping pills and their side effects

Sleeping pills and their side effects

Here are some facts about sleeping pills and their side effects. I haven’t taken sleeping pills in a long time, and if you’re currently taking any prescribed medications to help you fall or stay asleep, I recommend that you stop as soon as possible.

Sleeping pills and quality — the stages of sleep

A full night of quality sleep is a complicated issue, and the terms ‘awake’ and ‘asleep’ do not fully capture or do justice to the complexity of the various levels of consciousness that are had in a single night. Sleep actually comes in at least three types, or ‘stages’, each of which is quite distinct from the others.

Stage 1 is the first level of sleep which is characterised by the brain moving from drowsy alpha waves to the beginning of theta waves. Thoughts may begin to wander and be quite bizarre. The difference between this and other dream states is that in Stage 1, you are still virtually conscious. Indeed, this ‘sleep’ is so light that in sleep tests, during this stage ‘patients often report having felt that they were awake’. A normal sleeper will only spend a few minutes in this stage before going deeper, but an insomniac can spend most of the night in this ‘half-sleep’.

Deep sleep, or ‘slow wave’ sleep is the deepest type of sleep in which no dreaming happens. It is also known as delta sleep, because it is characterised by delta brain waves. This type of sleep is the most physically refreshing, and when you have not had enough delta sleep, you may feel both physically and emotionally exhausted. If you often get up having dreamed vividly but feeling tense and unrefreshed, then you are probably not getting enough delta sleep.

REM sleep is the period of sleep in which we dream the most. REM stands for ‘rapid eye movement’. This is because during REM sleep our eyes look around while dreaming, just as if we were wide awake. REM seems to be vital for our mental rejuvenation and general emotional well-being.

Together, these stages make up one full sleep cycle. During a normal night, a normal sleeper will go through several complete cycles, and it is known that all three stages are essential for a refreshing night’s sleep. One effect of sleeping pills is the disruption of this cycle. People awaking from a night of drugged sleep often feel unrefreshed, ‘as if they hadn’t slept at all’. This is in part due to not having had a complete night’s sleep made up of all the essential stages.

The effects and side effects of sleeping pills
Hangover

Sleeping pills are known to reduce the amount of delta sleep obtained. This feeling of ‘not having had enough sleep’ associated with a lack of delta sleep makes the next day hangover all the more unpleasant. Almost every sleeping medication, including over-the-counter remedies, will leave you with a level of grogginess, thick-headedness, confusion or a ‘spaced-out’ feeling. These hangovers can be severe, affecting your reactions and ability to think, making driving or operating machinery very dangerous. In my experience, there is not a single conventional sleeping pill that does not cause some degree of hangover.

Depression and mood

Sleeping pill hangovers often seem to be associated with a very low mood. Overall, the feeling of a sleeping pill hangover can be worse than the feeling after a sleepless night. Not only is delta sleep reduced, but many prescription drugs are known to reduce the time spent in REM sleep, which means that they interfere with mental recovery and emotional well-being. Bearing this in mind, it is not surprising that sleeping pills often cause daytime anxiety and depression.

Because insomnia can cause depression, it is often thought that insomnia medication may help to treat depression, and conversely, depression is sometimes thought to be the cause of insomnia. This results in anti-depressants such as Prozac being prescribed for insomnia patients, whether or not they have actually ever claimed to be depressed.

However, recent research suggests that both these assumptions are mistaken. An analysis of data of clinical trials submitted to the FDA found that patients taking sedative hypnotics were much more likely to develop depression. In fact, the popular drugs zolpidem, zaleplon and ezopiclone, more than doubled the risks of developing depression compared with those taking placebo pills (1). Furthermore, studies have found that long-term users of sedative hypnotic drugs have a markedly raised suicide risk, particularly for men. The statistics showed that men who took a nightly sleeping pill actually had seven times the normal risk of suicide (2)! Prescribing sleeping pills in the hope that this will relieve or prevent depression would appear to be a very unwise move indeed. Far from helping depressed patients, sleeping medication may be more likely to cause depression.

Addiction

Like any other addictive drug, almost all hypnotic sleeping pills have two main ways in which they can be addictive.

1. Firstly, if you have taken sleeping pills you will be familiar with how, after a time, the medication seems to stop working. As a result, higher and higher doses are needed to obtain the same effect. A common occurrence is that the drug eventually stops working altogether.

2. In addition, almost all sleeping pills have been shown to be physically addictive which means that withdrawal symptoms can be severe, even life-threatening. This happens even though the drug may have stopped having any beneficial effect. Withdrawal symptoms may include shakiness, anxiety, panic, palpitations, epileptic fits, increased insomnia and even death.

Between the 1960s and 1980s, most sleeping pills prescribed were benzodiazepines. But these highly addictive drugs came with a whole host of negative side effects and some evidence suggests that benzodiazepine addiction can be more dangerous, and take longer to overcome, than heroin. However, while benzodiazepines are still often prescribed, these days you may be more likely to be given one of the newer ‘non-benzodiazepines’ including the ‘Z-drugs’ such as zopiclone (Imovane, Zimovane), ezopiclone (Lunesta), zolpidem (Ambien) and zaleplon (Sonata). If you have taken sleeping pills in the last ten years, then there is a good chance that you were prescribed one of these. Zopliclone is the drug most often prescribed for insomnia by the NHS. When non-benzodiazepines first appeared, they were hailed as having few or no addictive qualities or negative side effects, and they were gratefully received by the market of eager insomniacs. Medical opinion of these drugs has now changed somewhat and it now appears that in some cases they can be as troublesome as the benzodiazepine drugs they were created to replace.

Benzodiazepines were responsible for the largest ever lawsuit against drug manufacturers in the United Kingdom, involving 14,000 patients. However, research suggests that the now ironically named ‘non-benzodiazepines’ are almost identical in effect and side effect. In particular, research suggests that they have similarly addictive qualities.

A systematic review carried out in 2004 at the University of Liverpool compared the newer Z-drugs zaleplon, zolpidem and zopiclone with benzodiazepines and with each other. The factors compared in the review included: sleep onset latency, total sleep duration, number of awakenings, quality of sleep, adverse events, tolerance, rebound insomnia and daytime alertness. The report’s conclusion may come as a surprise. It reports that regarding benzodiazepines and non-benzodiazepines “there are few clear, consistent differences between the drugs” (3). It would appear that non-benzodiazepines such as zaleplon, zolpidem, zopiclone and ezopiclone may be no less addictive than the original benzodiazepines like Valium.

Performance

One of the most important reasons for needing sleep is to allow us to function well in the morning and go about our normal day’s activities. Astonishingly, research shows that the use of sleeping pills does not increase your ability to function the next day. On the contrary, those taking sleeping pills will, according to almost all clinical studies, function worse the next day than those who miss a night’s sleep (4)!

‘A person’s hope and belief that a prescription sleeping pill will improve the person’s function on the next day is consistently betrayed.’ (5)

Tellingly, several studies show that people involved in car accidents are unusually likely to have taken sleeping pills (6) (7).

Severe impairment can occur even after taking ‘harmless’ antihistamines prescribed for insomnia. Ucerax (hydroxine) is one such antihistamine, which is taken to help sleep. It is also prescribed for anxiety when the dosage can be as high as 50mg daily. Despite being billed as ‘gentle’, for some it appears to have a more powerful effect than any hypnotic. Personal and anecdotal evidence I have collected shows that even small doses of Ucerax can turn you into a walking ‘zombie’, unable to function properly at all and without the sense to realise that you are unfit to drive.

When it comes to next day performance, you may well be better off not having had any sleep than having had a full night of drugged sleep.

Rebound insomnia

This refers to the temporary worsened insomnia which occurs when a patient attempts to give up a sleeping medication. Rebound insomnia is actually a side effect of sleeping pill addiction and anyone embarking on a course of insomnia medication should bear in mind that worse is likely to come when the time comes to give up. Many people continue to take sleeping pills, not because they are benefiting in any way, but because they cannot stand the worsened insomnia which kicks in when they try to give up.

It is often once a medication has become almost ineffectual that a patient attempts to give it up. A study of flurazepam and triazolam showed that after five weeks of use, patients were sleeping no better than those receiving placebo (8). The only reason that patients so often continue to take medication after this point is because the rebound insomnia makes it simply too painful to stop. The patient becomes completely unable to sleep with or without pills. Sadly, they may become so desperate that a common response is to increase the dosage, even though the original good intention was to eliminate it altogether.

Non-effectiveness — sleeping pills that don’t make you sleep

The desperate desire to simply ‘fall asleep’, to be unconscious can make sleeping pills a tempting prospect, even for those who know a bad day will follow. But believe it or not, in many ‘successful’ drug trials the increase in time spent sleeping is in the range of just 20-40 minutes! More astonishing are the results of trials on the non-benzodiazepine, zaleplon (Sonata). These showed that while it decreased sleep onset time by a paltry 11–12 minutes, it was not found to increase total sleep time (9)! This means that while patients were falling asleep quicker, they were getting less sleep with Sonata than without it. Despite these results, zaleplon was licensed for sale and is still widely prescribed.

Early waking

The odd effect mentioned in the last point — that some drugs decrease the time it takes to fall asleep while not increasing the time spent sleeping (10) — may have a pharmacological explanation. Many people taking triazolam (Halcion), zaleplon (Sonata), zolpidem (Ambien), zopiclone (Zimovane, Imovane) and eszopiclone (Lunesta) find that they fall asleep quite quickly but wake very early in the morning, often in an agitated state, ranging from moderate unease to a mild panic attack. These medications are supposed to be ideal for those who find it hard to fall asleep, but who, once asleep, tend to stay asleep. Quite high doses are given to produce a sudden ‘hit’, but the drugs are very short acting, leaving the bloodstream completely after only a few hours. This is supposed to make them much less likely to cause a hangover the next day. The problem is that when the dose wears off in the early hours, the body can go into instant sudden withdrawal. Research suggests that it is this ‘comedown’ which wakes you up too early and causes anxiousness the next day, not the effect of the drug still in the bloodstream.

Mortality

Perhaps the most frightening fact about sleeping pills is that they increase your chances of dying! Sleeping pills may increase your chances of heart disease, serious illnesses, accidents and cancer (11). The mortality rate refers to the percentage of people who have died in a given test group of people over a set time period. In people who regularly take sleeping pills, this percentage is much higher. If you take a sleeping pill every night for six years, you are 25% more likely to die than those who take none. Astonishingly, even those who take the occasional sleeping drug are 15% more likely to be dead in six years. Think about this: if you take a pill every night, in just six years you are 25% less likely to be here.

Summary of effects

There are three ways in which a sleeping pill may be deemed effective.

1. It increases the time spent asleep.

2. It makes you fall asleep faster.

3. It increases next-day performance.

The sad truth is that no medication succeeds on all three counts. Most are effective in one way, but at the expense of one of the others. In addition, every sleeping pill comes with one or more of the following undesirable effects:

- Decreases the time taken to fall asleep by a negligible amount

- Does not increase the time spent asleep

- May wake you earlier than if you had not taken medication

- Does not improve your function the next day

- Is highly addictive

- Leaves you with an unpleasant hangover

- Increases your chances of developing serious illness, such as cancer and heart disease

- Causes depression and anxiety

- Increases your chances of dying by 25%

- Causes rebound insomnia

- Is not as effective as behavioural treatment for the treatment of insomnia

Treating long-term chronic insomnia with hypnotic sleeping pills is somewhat like treating depression with cocaine. When sleeping pills are prescribed, the symptom of ‘being awake’ is treated completely in isolation, with no regard for the cause of the problem or the side effects of the treatment. In both cases, the patient may become addicted. Both sleeping pills and cocaine come with a host of horrible side effects and with prolonged use, whatever positive effect they may have diminishes. The ideal outcome in both cases is that a person quickly comes to realise that the costs outweigh the benefits, and is able to stop before a real problem sets in. Therefore it is not an exaggeration to say that with cocaine and sleeping pills, the effect and outcome are almost identical. There would be an outcry if doctors started prescribing cocaine to depressives, but the prescribing of sleeping medication for insomniacs is standard practice.

The truth about sleeping pill research — who pays for it?

So, if these drugs really have so many disadvantages and side effects, why are they ever licensed for sale? It is a little-known fact that almost all research into sleeping pills is not independent but is funded by drug companies. In a recent article published in The Journal of Clinical Sleep Medicine (12), details were given of a systematic review of the medical literature concerning insomnia drugs. It found that over 90% of randomised controlled trials of drug treatments of insomnia are sponsored by the pharmaceutical industry itself. This means that there was almost no independent research at all. The most worrying evidence given in the article was that industry-sponsored drug trials were more than 3.5 times more likely to deem a drug effective than non- industry sponsored trials.

Some drugs were pronounced successful and effective and are now been currently prescribed, even though the test results were less than satisfactory. An increase of 11-12 minutes’ sleep has been enough for trials to be hailed as successful and consequently for a drug to be licensed for sale. Moreover, according to the review, the positive effects of a particular medication were overemphasised in the medical literature. For example, success might be reported with regard to sleep onset time, but with no discussion of associated adverse effects, such as significant increased levels of infection, cancers and increased mortality. According to the review, ‘major hypnotic trials are needed to more carefully study potential adverse effects of hypnotics such as daytime impairment, infection, cancer, death, and the resultant balance of benefits and risks.’

The extraordinary placebo effect of sleeping pills

A large study (13) was carried out on a group of chronic insomniacs who had also been succesfully taking benzodiazepines for an average of 13 years. The volunteers were randomly assigned to receive either Dalmane, midazolam, or to receive inactive placebo pills. Remarkably, after nine to 14 days of administration, there was no statistically-reliable increase at all in the sleep of the patients taking Dalmane or midazolam as compared with those receiving placebo. The patients had already become tolerant to the medication. Furthermore, by 14 days, both drugs were making next day performance significantly worse. Astonishingly, the patients themselves said that they thought the medication was good and that it was helping them, even when objective tests showed that the medications were making them worse.

But more interesting than this is that part of the reason that the sleeping pills showed no significant benefit was that the placebo group had also improved. Most tellingly, even the group receiving placebo reported that they rated the medication they had been given highly and would be happy to use it again. The group receiving either Dalmane or midazolam rated their pill slightly more highly than the placebo group, even although the active drugs were worse for the patients than the placebo.

‘These patients were self-deceived about the value of the medication, almost deluded, thinking the medicines made them better when they actually made them worse.’ (14)

The placebo effect is well-known with all drugs — but when dealing with insomnia, which is so powerfully affected by suggestion and belief, this effect may be even greater.

Some worrying facts about sleeping pill prescription

In a large study done in the US, around a third of people who regularly took sleeping pills reported never having had insomnia. A more worrying statistic concerns long-term chronic insomniacs. The rationale behind sleeping pills is that medication can be beneficial to people with short-term insomnia in helping to normalise sleeping patterns. However, when we look at patterns of prescription, a more complicated story emerges. While most people will only take a dozen or so doses in any one year, chronic users will take many more. It is to these chronic insomniacs, and not to the occasional sufferers, that most of the drugs are prescribed. The truth is that 65% of sleeping pills currently being taken are prescribed, not to short-term users, but to those who have been taking them every night for five years! This appalling statistic shows that the multi-million pound sleeping pill industry is ‘profiting primarily from chronic users who have become habituated or physically addicted to these medicines’ (15).

Mosquitoes — a case in point

The power of the drug companies over medical ‘knowledge’ and treatment should not be underestimated. I recently had a vivid personal illustration of this: I have suffered terribly with mosquitoes whenever I have spent time in a hot country. I have lost count of how many creams, antihistamines and cortisones I have been prescribed and sold by doctors and pharmacists over the decades. Only last year I was told of an old ‘folk remedy’ which involves applying very hot wet towels to the bites themselves. The theory is that the body can only make a certain amount of histamine in any ten hour period. By applying the hot cloth, all the histamine in that part of the body rushes to the skin at once. The body will then take up to ten hours to replenish its histamine levels, at which point the itch will start again. It works like magic! But the astonishing thing is that no medical professional ever knew of this free remedy… or, at least in all the years of my life, none has ever told me of this free remedy! After a lifetime of suffering on almost every holiday, and almost every summer, even in Canada, and after countless visits to the doctor and pharmacist, and countless amounts spent on remedies, I discovered a free and safe way to completely cure the itching from mosquito bites. And in all those years, not one healthcare professional in any country had done anything other than prescribe and sell me utterly useless pharmaceuticals. So folks, there is a safe, easy, virtually free and highly effective remedy for mosquito bite itching out there — and no doctor will ever tell you about it!

The secret no doctor will tell you — why sleeping pills can cause insomnia

Most of these negative aspects of sleeping medication are well known. But besides all these well-documented ‘medical’ dangers of sleeping pills, perhaps a greater concern are the psychological and emotional side effects of taking sleeping drugs. The remarkable but incontrovertible fact is:

Sleeping pills can make insomnia worse.

Note that this is a completely separate issue to the rebound insomnia which usually occurs when a person tries to give up. Because insomnia is treated by doctors as a medical condition, little time and consideration is given over to the emotional and psychological impact on beliefs about sleep. Consider, for a moment, the message implicit in the prescribing of a sleeping pill — ‘this pill will make you sleep.’

In the short term, this thought can be comforting. Because responsibility is taken away, you may stop worrying enough to fall asleep. No one tells us about the unacknowledged inherent danger in this — that in giving up responsibility, you give up your power. If you need a pill to make you sleep, then the implication is that you must be unable to sleep on your own. This means that when you take a sleeping pill, any success will be attributed to the medication. The result is that you come to trust more and more in the drug and less and less in yourself until, eventually, you have lost all belief and trust in your own ability to sleep. When your self-belief becomes completely eroded, natural and effortless sleep then becomes a distant memory.

If sleeping pills always came with some form of counselling, or guidelines which would work on increasing your own trust in yourself, then perhaps their effect would be more beneficial. Instead, when insomnia patients are prescribed medication, they are given a temporary, and inherently harmful, crutch with no suggestion of how to go about overcoming their underlying problem. This is why, in addition to any physically addictive qualities, all sleeping medications can be so incredibly habit-forming. The truth is that any artificial crutch will decrease your confidence in your own ability to sleep.

This is the main reason why sleeping tablets can never really cure insomnia. The problem will still always be there, hiding under the surface and waiting to pop out again as soon as the medication is stopped, or stops working, often in a much more virulent form than before. This is why sleeping pills can actually make insomnia worse.

You should aim to restore your normal ability to sleep naturally and unaided — there is not a single drug available that can do this.

1 Kripke, D.F. 2007. ‘Greater incidence of depression with hypnotic used than with placebo’. BMC Psychiatry, 21(7): 42

2 Kripke, D.F. et al. 2002. ‘Mortality associated with sleep duration and insomnia’. Arch Gen Psychiatry, 59:131-136

3 Dundar, Y. et al. 2004. ‘Comparative efficacy of newer hypnotic drugs for the short-term management of insomnia: a systematic review and meta-analysis.’ Hum Psychopharmacol. 19(5): 305 — 22

4 Johnson, L.C. et al. 1982. ‘Sedative-hypnotics and human performance.’ Psychopharmacology (Berlin). 76:101 — 113)

5 Kripke, D.F. The Dark Side of Sleeping Pills.

6 Hemmelgarn, B. et al. 1997. ‘Benzodiazepine use and the risk of motor vehicle crash in the elderly.’ JAMA. 278:27 — 31.; Betts, T.A. et al. 1982. ‘Effect of two hypnotic drugs on actual driving performance next morning.’ Br.Med.J, 25:285 — 852

7 Barbone, F., McMahon, A.D., Davey, P.G. et al. 1998. ‘Association of road-traffic accidents with benzodiazepine use’. Lancet, 352 (9137): 1331 — 6

8 Mitler, M.M. et al. 1984. ‘Comparative hypnotic effects of flurazepam, triazolam, and placebo: a long-term simultaneous night-time and daytime study’. J.Clin.Psychopharmacol, 4:2 — 15.

9 Buscemi, N., Vandermeer, B., Friesen, C., et al. 2007. ‘The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs’. J Gen Intern Med, 22:1335 — 50

10 Kripke, D.F. The Dark Side of Sleeping Pills

11 Kripke, D.F. ‘Evidence that new hypnotics cause cancer.’ BMC Psychiatry, 7:42

12 Kripke, D.F. 2007. ‘Who Should Sponsor Sleep Disorders Pharmaceutical Trials?,’ J Clin Sleep Med. 3(7): 671 — 673

13 Kripke, , D.F. et al. 1990. ‘Sleep evaluation in chronic insomniacs during 14-day use of flurazepam and midazolam.’ J.Clin.Psychopharmacol. 10(Supplement 4):32S — 43S.

14 Kripke, D.F. The Dark Side of Sleeping Pills, op. cit.

15 Kripke, D.F. Ibid.