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Some reasons why you should avoid sleeping pills

We’ve known for a long time that hypnotic drugs are not good to take for more than one to three weeks because they are habit-forming and increase the risk of accidents. And there’s now a growing body of…

There are effective non-drug options for treating insomnia. Alyssa L. Miller

We’ve known for a long time that hypnotic drugs are not good to take for more than one to three weeks because they are habit-forming and increase the risk of accidents. And there’s now a growing body of evidence that shows they could be increasing the risk of premature death.

Hypnotics are medicines prescribed specifically to help people suffering from insomnia get a good night’s sleep. This includes people who have difficulty getting to sleep as well as those who struggle to stay asleep.

The class of hypnotics prescribed the most are benzodiazepines or very closely related drugs. In this benzodiazapine class are temazepam (Normison, Temaze), flunitrazepam (Hypnodorm) and nitrazepam (Mogadon).

While these drugs are typically prescribed to people suffering from insomnia, some other well known benzodiazepines such as diazepam (Valium), oxazepam (Serepax) and alprazolam (Xanax) are also prescribed for anxiety.

The “Z” group of newer hypnotic medicines such as zolpidem (Stilnox) and zopiclone (Imovane, Imrest), are very similar to the benzodiazepines in their mechanisms of action and have identical issues.

Problems and more problems

Despite claims to the contrary, no hypnotic delivers sleep of the same quality as natural sleep. And there are a number of proven non-drug treatment options for insomnia, such as simple relaxation techniques that are definitely better in the long term.

The hypnotic drugs, on the other hand, are habit forming, dull cognitive abilities, increase the risk of hip fractures from falls and make other accidents more likely, especially when combined with alcohol.

They also cause serious withdrawal reactions when chronic use is stopped suddenly. Such reactions include seizures (with the risk of fractures), but more commonly, worse insomnia (and often anxiety) continue for weeks after stopping taking the drugs.

But despite these problems, a large and fairly static proportion of the population (about 6% to 10% of adults) continue to take these drugs over long periods of time. And this rate increases among older people, particularly women.

It gets worse

Adding to the already serious concerns about these drugs, there are now alarming reports linking all hypnotics with premature death and cancer.

There are a number of problems associated with long-term use of hypnotic medicines. Life Mental Health (Image cropped)

Most recently, a study of over 10,000 people with the average age of 54 years who were prescribed hypnotics found they had a threefold or more increase in the risk of death compared to those not taking the drugs.

The researchers estimated between 300,000 to 500,000 excess deaths each year in the United States alone associated with hypnotic use. It didn’t matter which hypnotic drug was examined, and this included the newer shorter acting “Z” drugs such as zolpidem (Stilnox).

This well-performed study adds to over 20 others linking these drugs to premature death and a cancer diagnosis.

A lingering criticism

The obvious criticism of this line of research is that people taking hypnotics already had cancer or poor health and that was part of the reason they had sleeping problems and were prescribed the drugs in the first place.

Indeed, it’s fair to accept the possibility of the results being confounded or distorted by some undetected medical condition in a high proportion of the group prescribed hypnotics. This is always a concern and a possibility of observational studies.

The ideal would be to do a controlled study over two and a half years and randomly allocate individuals with disrupted sleep to either hypnotic medicines or a matched placebo and see if the results hold up.

But while this ideal study would most likely eliminate substantial biases, it would not be ethical. Best practice for insomnia treatment is not to prescribe these drugs beyond a few weeks and to rely on proven methods not involving drugs at all.

So we’re unlikely to have much better proof that there’s a greater risk of death and cancer among people who take hypnotics.

Seek alternatives

The possible mechanisms for this apparently substantial effect (premature death) remain elusive, but there are a number of possible reasons.

We know that a combination of hypnotic drugs and alcohol increases the risk of depression of brain functions that can lead to slowing of breathing. This can be lethal, especially for people who have chronic heart or lung disease.

And people taking hypnotics are more likely to have car and other accidents due to the hangover effects the next day. The drugs also increase rates of depression and therefore the risk of suicide.

But despite remaining uncertainties, this is another strong signal for prescribers and the community to be wary of chronic use of hypnotic drugs.

There’s certainly no good rationale for long-term hypnotic use. And there are effective non-drug options for treating insomnia that are not pursued nearly often enough.

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31 Comments sorted by

    1. Jenny Shipley

      Brain Surgeon

      In reply to Barbara Flowers

      As stated in the article, there are better and safer alternatives, that dont contribute to cancer

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    2. Barbara Flowers
      Barbara Flowers is a Friend of The Conversation.

      Legal Research Librarian

      In reply to Jenny Shipley

      Except - my experience as a lifelong bad sleeper is they don't always work very well. I don't take sleeping pills much, maybe one every now and then. When I do I'm struck by what a good sleep feels like. And the long-term health problems of poor sleep? It would be interesting to read more on that too.

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    3. Ric Day

      Professor of Clinical Pharmacology at UNSW Australia

      In reply to Barbara Flowers

      Evidence indicates that the effectiveness of sleeping tablets wears off quite quickly - within weeks. Trying to institute other strategies to assist with sleep so that long term use of tablets is avoided is optimal - exercise, stress reduction, nightly routines conducive to sleep, cutting back on alcohol/tobacco etc. Not claiming any of these are easy or necessarily quick, but definitely better in the long term

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    4. Barbara Flowers
      Barbara Flowers is a Friend of The Conversation.

      Legal Research Librarian

      In reply to Ric Day

      Yeah I don't take sleeping tablets much, but I do often take, for reasons to do with food intolerances/sensitivities - anti-histamines - and they tend to help with sleep. But the other things you outline above I haven't found particularly helpful. They help a little, but can't countermand the effects of snoring, loud cars, possums on the roof, the full moon, etc etc etc. Good sleepers have no idea what a pain it is not to be able to sleep easily.

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  1. Victor Jones

    Freelance

    Sleeping pills reduce REM sleep and create more central apnoea events. Sleep apnoea is linked to all sorts of health problems.

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  2. Jenny Shipley

    Brain Surgeon

    Great to see good science starting to make headway. Its unbelievable the level of harm being inflicted on the wider public by profit focused medical companies.

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  3. Bob Constable

    logged in via Facebook

    Surely the people with insomnia who are randomly allocated a matched placebo will soon realise that they are being given a Placebo ? It might just occur to them in the wee small hours while they are lying sleepless.

    I would like to be able to stop taking sleeping medication but not sleeping is really not an option. Relaxation techniques have not worked and I have noticed that after years of using oxazepam 30mg is sometimes not enough to get me to sleep so I take another 15mg. Due to this, at…

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    1. Barbara Flowers
      Barbara Flowers is a Friend of The Conversation.

      Legal Research Librarian

      In reply to Bob Constable

      Hi Bob - my mother, who is as poor a sleeper as I am, has taken sleeping tablets for the last 40 years at least. She's about to turn 94 and has all her wits about her. It seems to be hard for good sleepers to understand what it's like to sleep badly and be unable to change that. I've been told by doctors that if I'm tired enough I'll sleep. Um. No. Not enough. And not really.

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    2. Ric Day

      Professor of Clinical Pharmacology at UNSW Australia

      In reply to Bob Constable

      One problem is that it's difficult to reduce intake of sleeping pills when they have been taken long term. This is due to the withdrawal symptoms of insomnia and anxiety commonly. Very gradual reduction over some time while pursuing the 'non pharmacological' approaches is the way to proceed - this should only be attempted under medical supervision however.

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  4. George Michaelson

    Person

    I was advised by two health professionals that a-periodic, intermittent use of temaze (I fly a lot and get jet-lag) was a low risk activity.

    I see nothing in what you've said here which contradicts that. I certainly wouldn't want to undermine the impact of longterm sustained, habituated use of these drugs and a question over their co-morbidity with things like cancer is very concerning.

    So.. any observations on deliberate non-regular, a-periodic, intermittent use of these drugs? 2 in a week and then none for 6 weeks? 4 in a week and then none for 3 months?

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  5. Luke Weston

    Physicist / electronic engineer

    There are many different "sleeping pills" as you correctly point out - it is a vague and broad term.

    If a patient says they use "sleeping pills" then this could mean any one of numerous different benzodiazapines, zolpidem, zopiclone, numerous sedating antihistamines such as but not limited to doxylamine, melatonin, or herbs of questionable efficacy such as valerian, or even homeopathic magic sugar pills enchanted with the spirit of caffeine.

    In fact, I would suspect that the S4 agents are less…

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    1. Ric Day

      Professor of Clinical Pharmacology at UNSW Australia

      In reply to Luke Weston

      The studies reporting the association between hypnotic use and death risk refer to prescribed i.e. S4 drugs and these are largely benzodiazepines or the closely related zolpidem/zopiclone group.

      Poor sleep is a problem for performance the next day especially it it is a chronic problem. So action to deal with this is needed. The question is can long-term use of hypnotics be avoided? The answer is yes - there is good evidence for the effectiveness of non-pharmacological measures notably cognitive…

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  6. peter prewett

    retired

    My wife is an insomniac and sleeping pills allow her to live a normal life.

    So saying stop taking is stupid as there is no alternative that works or has worked.

    So please indicate what to do to overcome the problem of lack of sleep, that works and is accessible to everyone, taking a pill is the last resort.

    Just saying that there are alternatives is not an answer.

    No doctor that my wife has seen has suggested, recommended anything other than a prescription so perhaps they need to be educated to provide help.

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    1. Ric Day

      Professor of Clinical Pharmacology at UNSW Australia

      In reply to peter prewett

      Good points -everyone involved needs education; prescribers, patients, pharmacists. There are alternatives. They are not easy but they work. It's better to avoid the problem early on as it is harder to stop these medicines if they have been taken for a long time. See the reference in my response to Luke.

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  7. Kaye Hargreaves

    Retired

    To be frank, I find your comments to be out of touch with the reality of life for people with chronic intractable sleep disorders and quite fatuous. "Simple relaxation techniques"? If it were that easy, we'd be laughing. I followed relaxation techniques taught to me by a psychiatrist, along with various other measures which I think would come under the heading of sleep-conducive bedtime habits. And doesn't your relaxation remedy imply that the insomnia is caused by not being relaxed? I don't think…

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    1. Ric Day

      Professor of Clinical Pharmacology at UNSW Australia

      In reply to Kaye Hargreaves

      I don't want to suggest that insomnia is a difficult problem for many people and that the non-pharmacological alternatives are easy. Your experience illustrates the challenges faced by some despite strenuous efforts, again as you describe. And experiences differ greatly such that remedies vary too. However many people are caught in the trap of taking these medications chronically before trying the alternatives or even knowing about them. I hope that some people in this category are helped.

      There is good proof of effectiveness of non pharmacological approaches but they don't work in everyone as your experience indicates.

      You're right that the approach taken comes down to 'risk benefit' assessment of the alternatives in individual cases. And there is a place for these drugs, but this becomes more of a 'double edged' sword with persistent use, especially with increasing age and with other health problems.

      I'm glad you don't have to take Stilnox anymore too

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  8. Jenny Shipley

    Brain Surgeon

    Healthy and regulated melatonin production can be achieved by implementing various regimes. It is certainly much harder than popping a pill, and continuing with habits that prevent healthful sleep.
    Quit caffeine and alcohol. For many the use causes endocrine disorder.
    Hot baths with relaxing oils near bedtime
    Avoid light emitting devices like computers, TV and electric lights after 6pm
    EMF's from cell phones, tower etc and house wiring may induce excitation currents in the body
    Metal springs…

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    1. Bob Constable

      logged in via Facebook

      In reply to Jenny Shipley

      People are saying they need sleeping pills to get enough sleep to live a normal life.
      Your suggested list is not for people who want to live a normal life.

      Avoiding computers, TV and electric lights after 6pm, cell phones house wiring, stimulation in the evening, even discussion Hmmm ... How? only way you could do that is to move to a cave somewhere without any companionship and sit with a candle.
      Hmmm...Go to work come home say hello to the wife and kids and then say goodbye and move to Hermit land at least when you wake up it would be easy to go out in the sun and exercise as you walk back home.
      Thats not really living a normal life though is it.

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  9. Chris Henderson

    GP + University GP tutor

    I read this article at 3am today, when I woke up (as usual), and thought how tired I am of seeing these arguments about sleeping pills. I've been a doctor for 38 years now, most of them as a GP and I must have seen hundreds of patients with insomnia. I just don't accept this blanket condemnation of hypnotics (especially of benzodiazepines - if you can remember prescribing barbiturates, then the difference with benzodiazepines was like night and day).

    A lot of patients don't sleep well. There…

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    1. Ric Day

      Professor of Clinical Pharmacology at UNSW Australia

      In reply to Chris Henderson

      Chris,

      What you say about helping people in your practice with insomnia makes sense and your approach is sensible. People have been banging on about use of hypnotics for a long time too. Why? The benzodiazepines are a big improvement on barbiturates, I agree but there are still too many people taking these medicines where the rationale for starting and continuing is not sound or the best for their long-term health. Prescribers and citizens need to know about this and know that for some people there are effective and safer alternatives. Also, the association with greater risk for death does need more work as you suggest.

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    2. Kaye Hargreaves

      Retired

      In reply to Ric Day

      Prof Day,

      I always wonder, when people say that "too many people are taking XYZ medication", or "it is being used when it shouldn't be", where the evidence comes from. Do you do "exit poll" research to evaluate the clinical judgement of GPs, which allows you to say that in X per cent of cases, the GP's prescription was appropriate and in Y per cent it was not? Or vice versa - how many patients leave their GP's consulting room without a prescription, sometimes rightly so, but maybe in other cases being denied something which might have helped? And in addition to that, how many people do not even seek medical attention for problems such as insomnia or anxiety, or symptoms of depression, and therefore go untreated, or in many cases presumably resort to self-medication, which may mean alcohol or other means, which are more harmful.

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    3. Ric Day

      Professor of Clinical Pharmacology at UNSW Australia

      In reply to Kaye Hargreaves

      Kaye, All good questions and good studies addressing them are available and are convincing. In summary, there are negative consequences and risks from long-term use of these medicines. Long term use is not necessary in a significant proportion of people suffering from insomnia without secondary causes such as various medical illnesses. There are generally effective non-pharmacological methods of dealing with insomnia for most people. Many studies indicate that too many people are taking these medicines long-term without adequate rationale.

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  10. peter prewett

    retired

    My wife read the link http://www.sleepfoundation.org/article/hot-topics/cognitive-behavioral-therapy-insomnia
    Found it interesting and then it says visit a clinic every week, now she wonders were is the nearest and is readily available my answer is no to both and that is without looking. A large proportion of the population does not live in or near a city and the specialists do not visit country towns.
    I have spent some time investigating this problem and tablets are the only answer to her insomnia.
    So please just do not say as Jenny Shipley does 'As stated in the article, there are better and safer alternatives, that dont contribute to cancer'
    Where are they how does my wife access them? As she desperately needs help, as 2 hours a night for a week now is making life impossible so it is a tablet again tonight.

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    1. Ric Day

      Professor of Clinical Pharmacology at UNSW Australia

      In reply to peter prewett

      Peter, I sympathise with you both. The Sleep Foundation site does give some useful suggestions to help with insomnia not involving pills that we have discussed in the 'conversation' so far. On the site there was reference to CBT via the net viz http://archpsyc.jamanetwork.com/article.aspx?articleid=483124. If this is well done by a reputable organisation this might be an option to add to the other non-drug approaches. Finding the reputable organisation is the challenge - I'd suggest contacting the Woolcock Organisation at U Sydney - http://woolcock.org.au/insomnia-research/

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    2. Kaye Hargreaves

      Retired

      In reply to Ric Day

      Hello Prof Day,

      One of my concerns about your approach is that it does not look at the cause of the insomnia. If you recommend relaxation, doesn't that suggest that lack of relation (e.g. anxiety, worrying and the like) is the cause? And if you recommend Cognitive Behavioural Therapy, doesn't that imply that there is some faulty or inappropriate cognition contributing to the insomnia? That might not be the case at all. These techniques may be useful management tools but they are not cure-alls. In fact treating them as such makes investigation of other causes less likely.

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    3. Ric Day

      Professor of Clinical Pharmacology at UNSW Australia

      In reply to Kaye Hargreaves

      Kaye, You are right - there might be causes that need specific attention. And I'd recommend that your GP is the best first stop to ascertain the cause and discuss the best management. If the insomnia is the common 'non-specific' form without underlying medical or psychological basis needing specific therapy, then there are proven 'non drug' approaches and one of them is CBT. But very much agree with your suggestion - what is the cause before embarking on treatment.

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    4. Chris Henderson

      GP + University GP tutor

      In reply to Kaye Hargreaves

      Kaye
      There are some specific causes of insomnia - depression, anxiety, pain etc which GPs are well aware of. I think you would find that a patient presenting with insomnia will have the appropriate questions asked in the first instance - it's not difficult and doesn't take long. If one of those causes is found then treating that will sometimes, but not always, fix the insomnia. Using psychotherapy doesn't imply a missed diagnosis.

      If it is necessary to treat the insomnia itself - whether a primary or secondary condition - then it can be done either with medication or psychotherapy of some sort. In general medication is cheap, available and effective but with side effects whereas psychotherapy is expensive, less available and less effective with virtually no side effects.

      It would be nice if it were the otherwise, but unfortunately it isn't.

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  11. Siddharth Saini

    logged in via Facebook

    Sleeping problems are a real nuisance. I can say that because I have seen it all. At an age when energy levels are at its peak and sleep comes at the very touch of your bed, I have spent nights literally counting the Seconds' arm go tick tock. I was almost like a wide alive zombie until my mother made me see our family doctor. Before having to see him, I somewhere at the back of my mind had a clue of that he's most likely to prescribe me those sleeping pills and along with being an almost insomniac…

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