We're up at night for a number of reasons. For some, the culprit may be diet: eating dinner too late, imbibing too much caffeine late in the day, or a nightcap habit that can't quite be kicked. For others, it's racing thoughts. Lying in bed is often the first time all day many have to process life's stressors. Then there are folks who work at night, which throws off the circadian rhythm. Others travel frequently, throwing another curveball to the circadian rhythm. And let's not forget about snoring partners, kids, and pets—the lovable sleep disruptors that they are.
- Frank Lipman, MD, functional medicine doctor and chief medical officer at The Well
- W. Christopher Winter, MD, neurologist, sleep specialist, and author of The Sleep Solution
For all these issues, there's a blanket solution millions of Americans turn to: prescription sleeping pills. The precise number of people filling sleeping pill prescriptions isn't well-monitored; the latest statistics, from a 2013 Centers for Disease Control and Prevention report, say that 9 million Americans rely on prescription drugs to fall asleep. The lack of data is startling, especially taking into account that the pandemic has made insomnia more prevalent.
Here's what else is interesting: Scientific studies show that prescription sleeping pills aren't all that effective at helping someone fall asleep. Some doctors even say they do more harm than good. So why are so many people taking them?
To be clear, the scientific studies and facts we're about to dig into focus specifically on prescription sleeping pills. Millions more Americans take over-the-counter drugs or melatonin for sleep. But, clearly, those solutions aren't cutting it for many, which is when they seek out doctor-prescribed goods. When do they work, when don't they, and are sleeping pills ultimately worth it? Let's get into it and find out.
How do sleeping pills work?
Zolpidem drugs (like Ambien and Lunesta; also known as z-drugs) and benzodiazepines (like Valium, Klonopin, and Xanax) all fall under the prescription sleeping pill umbrella. Sleep specialist and The Sleep Solution author W. Chris Winter, MD, explains that all these drugs work by activating GABAA, a neurotransmitter in the brain, which slows down the central nervous system. "There's a process in our brain for being awake and monitoring vigilance and there's a process in your brain for sleep," Dr. Winter says. "When one gets turned on, the other should get shut off." It's when both are turned on at the same time, Dr. Winter says, that sleeplessness occurs. When GABAA is activated, as zolpidem and benzodiazepine drugs work to do, it has a calming effect. That's what causes someone to feel sleepy after taking it.
Here's how zolpidem drugs and benzodiazepines are different. Benzodiazepines also serve as muscle relaxers; z-drugs won't have that effect. In fact, benzodiazepines are also known as tranquilizers because of their ability to relax both the body and mind. They're often used to treat seizures and muscle spasms as well as be sedative.
While Valium and Xanax work as tranquilizers, z-drugs work similarly to something most everyone has experienced the effects of: alcohol. "Alcohol actually works through GABAA receptors too," Dr. Winter says. Drugs like Ambien and Lunesta, for instance, affect the brain similarly to alcohol. Just like sleeping pills, alcohol is a central nervous system depressant. That's why it's dangerous to mix them; the effects can be too strong.
As with alcohol, popping an Ambien can be successful in helping someone fall asleep quicker. But the similarities also mean it can actually disrupt deep sleep the same way alcohol does, too. There's a reason why sleep experts don't recommend relying on booze for sleep. Alcohol cuts down on the time it takes to fall asleep, but it also reduces the amount of time someone spends in REM sleep. And you know what? The same thing happens with drugs like Ambien and Lunesta.
To counteract the disruption in REM sleep, Ambien is made with two layers: the first to help with falling asleep and the second, which dissolves more slowly, to help with staying in REM sleep longer. Still, the results are mixed. Only 67 percent of people taking Ambien and 55 percent of people taking Lunesta report that they think it's worth it.
Are they ever helpful?
Grace Poole, a blogger and the founder of Parenting Under Pressure, says she started taking a prescription sleeping pill a few months after giving birth. "I was experiencing severe postpartum anxiety and wasn't sleeping well at night," she says. "The combination of panic attacks and sleepless nights left me unable to cope." Her doctor prescribed her clonazepam (Klonopin) for sleep and Xanax for anxiety to take during the day.
Poole says they worked like a, well, dream—at least in terms of falling asleep. But she would wake up the next morning groggy and exhausted. "It wasn't just the 'I'm tired because I just woke up' type of exhausted," she recalls. "It was more like, 'my body somehow forgot how to function properly and the only way to get out of bed is to slide to the floor and worm myself slowly out of the room' type of exhausted." She adds that it took most of the day to completely shake off the effects of the sleeping pill. "By that time, it was already around 5 p.m. and I was supposed to take the next dose in a few hours."
After a week of this, she started taking just a quarter of the sleeping pill, which allowed her to fall asleep without waking up exhausted. She also says she believes it helped her anxiety; she stopped feeling stressed about things that she used to get worked up over, like a sink full of dishes. She does say that even scaling down to taking a quarter pill wasn't perfect. It affected her libido and she couldn't work up the energy to participate in sex. But for sleep, she said it was key for getting through a tough time in her life.
Jas Rawlinson , a public speaker, also sought out sleeping pills several months after having a baby. "After I had my son, I would lie awake because my body was hyper-alert. I was aware of every noise and my body didn't allow me to sleep," she says. "I'd never taken prescription sleeping pills before, but after a month of running on three hours of sleep a night, I told my doctor I needed help." At this point she had tried every over-the-counter option she could find, including melatonin. Her doctor prescribed her a very low dose of temazepam (a benzodiazepine) and only five days' worth. "She really scared me, saying I wouldn't hear my baby crying, so that's all she'd give me," Rawlinson says.
For her, they worked great. She slept well, didn't have any side effects, and woke up well-rested. (And she was still able to hear her baby when he cried out.) But when she went back to her doctor for more, she wouldn't prescribe them to her, worried she'd get addicted. Rawlinson obtained another prescription through another doctor and kept taking them for about a year and a half. "It sounds like a long time, but I actually didn't have any negative effects or any type of withdrawal," she says.
For specific moments in time—like after having a baby, after the death of a loved one, or trying to adjust to a new time zone—Dr. Winter says this is when he believes sleeping pills can be helpful and he has no problem prescribing them. "[Prescribing] a sleeping medication should always be for a specific reason, like jet lag," Dr. Winter says. "The reason to prescribe or take them is not, 'It's Tuesday night and I need a pill to sleep.' That is ridiculous. Our bodies sleep very well and don't need a lot of help doing it." Likewise, Frank Lipman, MD, a top functional medicine doctor and the co-author of the book Better Sleep Better You: Your No-Stress Guide for Getting Sleep You Need and the Life You Want says the same goes for him. "Sleeping pills are a Band-Aid, but sometimes people need Band-Aids," he says.
The problem, both doctors say, is when it becomes a habit and not something that's coming from a place of purpose. "I'm not against these type of drugs. I just think they get overused and then used for a long period of time," Dr. Lipman says. "That's when they become a problem." The solution, both doctors say, (and you probably knew this was coming) is getting to the root problem of what's keeping someone up and dealing with that. But, of course, pinpointing—and then treating—a source of anxiety, a problematic dietary habit, or another cause is more work for both patients and doctors. When a doctor only has roughly 10 minutes to spend with a patient, Dr. Winter says it's much easier to prescribe a pill than ask about their anxiety. And often, that's what happens. (Not from him though, he adds. Treating the core root causes of sleeplessness is his job, after all.)
"A doctor has very limited amount of time with a patient and often they've already spent 17 of those minutes dealing with a diabetic foot or out-of-control blood pressure," he says. "Then, near the end of the appointment, the patient may say, 'Oh, by the way, doc, I can't sleep. Got anything for that?'"
Dr. Winter says it also isn't exactly helpful that doctors don't get very much training about how sleeping pills work when they're in medical school. "Trouble sleeping or feeling tired all the time is one of the top complaints from patients, and yet the average doctor probably got one hour of education in medical school around sleep," he says.
Are sleeping pills the new opioids?
When people use sleeping pills habitually (aka not as a "Band-Aid"), the effects are detrimental. So detrimental, in fact, that Dr. Lipman calls them "the new opioids" in his book. "They're not benign," he says. "They're given out like candy because so many people can't sleep and they're a quick fix," he says.
Dr. Lipman says sleeping pills create more problems than they solve. In addition to the next-day grogginess (which 32 percent of people who take prescription sleeping pills experience), dizziness, digestive issues, heartburn, and brain fog are not unusual. Sometimes the side-effects are flat-out bizarre. Ilana (who requested her last name be withheld), says she was prescribed trazodone and Ambien when she was going through a tough breakup. "The Ambien definitely put me to sleep. But 10 or 20 minutes before I would fall asleep, I'll fully blackout and have no idea what I was doing," she says. "I'd wake up and see that I had texted people these really weird messages—including guys I went on dates with. Sometimes I'd send them 10 messages in a row."
In one particular instance, Ilana says she woke up to find that she'd texted a guy she went on a second date with that all she wanted was to eat truffles with him forever. She decided to stop taking both medications after that. Instead, she focused on managing her anxiety and stress holistically, and she says that's ultimately what worked for her.
Dr. Winter says the reasons why people sometimes do strange things under the influence of sleeping medications isn't clear, but he also says it's certainly not unusual. "Sleeping medications increase the chances of sleepwalking, sleep eating, and even sleep sex," he says. "This especially affects women to the point where Ambien actually had to start including a warning on the label." The weird behaviors people engage in after taking sleeping pills seems to be yet another way they act similar to alcohol.
Both Dr. Lipman and Dr. Winter also say that sleeping pills can be addictive. This is a major reason why Dr. Lipman compares them to opioids. In his book, he cites data stating that it's estimated that more than 30 percent of overdoses involving opioids also involve benzodiazepines. Additionally, in 2018, JAMA Internal Medicine published a study saying that 68 percent of people taking Ambien took it longer than advised (a length of 61 days or longer). It also found that 25 percent of Ambien users also took opioids, a dangerous combination as the unfortunate overdose stat shows.
What these stats also show, however, is that for many people sleeping pills aren't addictive. Rawlinson, for example, had no problem stopping taking them after a full year and a half. (Doctors would likely also debate whether she truly needed to take them that long.) The reality is, just like alcohol, sleeping pills affect people differently. They can cause some people to black out and do weird things. They can help others fall asleep fast and wake up fresh as a daisy. They can be addictive and habit-forming and they can not be. And they may or may not work.
What both doctors hope to emphasize is that while there can be a time and place for prescription sleeping pills, no drug can replace treating the core issue of bad sleep. Band-Aids are great for surface-level annoyances, but matters of the heart or brain require a different form of treatment.
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