We all want it. We all need it. And when we don't get it, we feel it. While, on average, we spend a third of our lives sleeping, the amount of sleep needed varies from person to person, and over the course of our lives. When our personal sleep architecture is altered for any reason -- worries, arthritis pain, the effects of medications, late night espresso -- we know it. And when it doesn't resolve itself pronto, we seek to remedy it.
Sleep problems in the general population are estimated to be as high as 35%. Sleep disorders express themselves in a variety of ways: trouble falling asleep, waking up too early, waking up every two hours, with the extremes being sleep apnea and narcolepsy.
Sleep abnormalities are often a manifestation of some other problem or event. Not being able to sleep at times may be a sort of physiological diagnostic function that forces us to "work things out" in our heads before being able to let the subject drop. Sleep disorders also can be a sign of a physical disorder or an adverse effect of a medication.
People will say they've "slept like a baby" to mean they slept very well. No one sleeps better. A newborn baby can sleep up to 16 hours a day.
The amount of time spent sleeping declines as people age. Studies show that people 24 to 35 years old awaken an average of one to three times each night. By age 75, the average number of awakenings increases to seven.Pharmacists can do much to counsel patients who come to them with sleep problems. They also can intervene with the physician who might be habitually writing refills for prescription sedatives, especially for older people.
In general, the newer agents are preferred because they have a shorter duration of action and milder adverse effects.
Halcion (triazolam) is controversial because it has been linked by some tabloid TV shows to alarming behavior, including the maniacal axing to death of a spouse while on the drug.
One 60-year-old man I know, a professional with no history of mental illness, got steady refills for triazolam that he used freely. After about a year, he started to become restless, excitable and aggressive to the point where he ripped a phone off the wall and stomped it into techno-heaven. I suggested he cut way back on the triazolam, using it only when absolutely necessary and to employ other nonpharmacological means, such as cooling down the bedroom, cutting back on tea and avoiding afternoon naps. He now uses the drug once a month and the inappropriate behavior has stopped.
Used appropriately, triazolam gets a patient to sleep quickly and keeps him that way all night. Because it is cleared from the body within five to 10 hours, the chances of next-day confusion are minimized, making it a better choice over many other drugs in this class.
Much of the debate over triazolam in scientific circles centers around its effect on memory, including the possibility that the drug can cause amnesia.
"All drugs that put you to sleep impair you in one way or another," says Thomas Roth, Ph.D., the director of the Sleep Disorders Center at Henry Ford Hospital, Detroit. "Patients are going to experience amnesia with Halcion and increased risk of accidents if they get up in the middle of the night," due to falling down.
Even though most of the most commonly used sedatives are in the benzodiazepine class, they work differently. Triazolam can work in under 30 minutes. Flurazepam (Dalmane) takes anywhere from 30 to 90 minutes to induce sleep. Temazepam (Restoril) was reformulated a year ago to shorten the onset of action to one hour.
Flurazepam is a long-acting sedative that should never be given to the elderly. It has a half-life of 34 to 287 (12 days!). This translates into daytime grogginess if a patient takes it night after night and the drug can build in the bloodstream, resulting in confusion and incoordination. If a pharmacist hears of a patient falling down the cellar steps, the patient's drug profile should be checked. Better yet, the pharmacist should convey this information to the physician who writes for this or any sedative for extended periods.
Zolpidem (Ambien) is a nonbenzodiazepine hypnotic with a half-life similar to triazolam, about two and a half hours. Although it is not a BZ, it does hit the BZ or omega receptor in the brain that leads to sedation and shares other BZ anxiolytic and myorelaxant properties. Next-day residual effects are minimal. "The most prescribed sedatives at our store are temazepam, some amitryptyline and even Xanax," says Mike Carpinelli, pharmacist at Giant Eagle Pharmacy, affiliated with Davis Supermarkets, Greensburg, Pa.
"Our biggest sedative is Halcion," says Carol Piper, pharmacist at a Dierbergs Markets store in Creve Coeur, Mo.
While the pharmacists admit they know of patients who have been on sedatives "for a long time," they have not had much luck in getting them off the medications.
"The only counseling we have had any success with is getting the patient to ask the physician to switch the prescription to Ambien, which is not a benzodiazepine and therefore less addictive," says Piper of Dierbergs. "Physicians are slowly starting to write more scripts for Ambien."
Older non-BZ drugs, such as the barbiturates, chloral hydrate and meprobamate, a sedative/ hypnotic, are enjoying a curious resurgence in states that use multiple prescription programs. Physicians, leery of prescribing too many BZs to patients (who might really need them), are dashing off scripts for these other drugs that are not subject to such scrutiny.
However, these drugs are not benign. Meprobamate can cause serious physiological dependence after use at high doses for more than a month. Barbiturates, such as secobarbital, rapidly lose effectiveness, tend to cause withdrawal insomnia and can be extremely toxic in overdose. Chloral hydrate loses its effects after a few nights and is more toxic than BZs in overdose.
Although these medications are less expensive than newer agents, cost should not be a significant issue in selecting a sedative, since therapy should always be short-term.
"The new drugs [the benzodiazepines] are less addictive than the older drugs and have less morning hangover," says Piper.
"The newer drugs are definitely safer than the barbiturates," agrees Carpinelli. "In terms of efficacy, I think they are better in general."
Common causes of sleep problems in people with no underlying medical conditions include jet lag and shift work. In jet lag, sleep disturbances typically last two to three days, but can linger for seven to 10 days if the number of time zones crossed is greater than eight. Here, triazolam can be used on alternate nights. Patients should also receive counseling on avoiding alcohol, and on the likelihood of rebound insomnia occurring once the drug is stopped.
Shift workers, who account for 20% of the work force, often experience insomnia on their nights off. These people should be counseled on extending their daytime sleep by sleeping in the afternoon or on days off from work. Hypnotics should be used sparingly, if at all, in such cases. In a 1984 study done on shift workers, published in the journal Sleep, daytime doses of BZs were associated with cognitive performance deficits.
A 1990 New England Journal of Medicine study found that another approach to improving alertness during night work and facilitate nighttime sleep during nights off did so by "fooling" the body with exposure to bright lights at night, and darkness during daylight hours.
Explaining that insomnia is a symptom, rather than an illness, is one of the kindest things a pharmacist can convey to a patient. People who label themselves as "insomniacs" are often people with bad sleep hygiene: a worn out mattress, a hot bedroom, and a tendency to eat chocolate or high-protein foods late at night.
In cases where symptoms are due to an underlying physical condition that makes one uncomfortable at night and can interfere with sleep, sedatives should rarely, if ever, be prescribed. Shortness of breath due to congestive heart failure, hiatal hernia, asthma, emphysema, a large prostate that sends one to the bathroom to urinate every hour, and arthritis pain can all erode sleep.
Sometimes a nighttime dose of acetaminophen is all that is needed to keep an arthritic asleep all night. Likewise, proper use of asthma medications may be the answer for someone who is plagued with insomnia because of breathing problems.
Drug-induced sleep, while still sleep, is not natural. It reduces dream activity and a healthy psyche needs dreams. Pharmacists should stress to patients that if they must use a sedative, they should use it for less than a week or once every week or so. Otherwise, they should be referred to a sleep therapist for further evaluation.
If all else fails, pharmacists should recommend that patients read "The Interpretation of Dreams" by Sigmund Freud. Does it unlock some of the mysteries of the subconscious? Who knows? Every time I pick up this 700-page tome and try to read it, I fall asleep in 10 minutes flat. It's the closest thing to a literary 'Lude there is.
