I write prescriptions for sleeping pills all the time, but it is never my own idea. My patients ask me for them. The TV advertising for sleeping pills is incredibly effectiveâ€”but are the pills?
Many of my patients feel as attached to their sleeping remedies as they might have once felt about a favorite blanket. They tell me that their sleep patterns with and without medicines are, in a manner of speaking, as different as night and day. I always wonder when I hear success stories from patients about their sleep medicines, because the results of studies tell a different tale. Studies show that sleeping pills have little effect on how long a person sleeps, and many people donâ€™t feel any better the next day.
No matter how I share the data with my own patients, none of them ever seems to lose faith in sleeping pills. My patients all seem to think they are exceptions to studies and statistics, and each one seems to enjoy results from sleeping pills that are way above average. But we canâ€™t all be above average. Â
Wake up and smell the coffee
Here is our best data about sleeping pills: In 2005, a panel of experts brought together by the National Institutes of Health (NIH) concluded that sleeping pills are rarely helpful. The NIH panel labeled as unhelpful or even dangerous old-fashioned sleep treatments such as antihistamines, benzodiazepines (Valium, Ativan, and others), and antidepressants such as Trazodone. The panel didnâ€™t criticize the newest and most widely prescribed medicines for sleep as harshly as they criticized older medications, and these newer medicines have remained wildly popular. They include zolpidem (Ambien/Ambien CR), eszopiclone (Lunesta), ramelteon (Rozerem), zaleplon (Sonata), and zopiclone (Imovane). More recently, however, research has revealed some discouraging facts about the newer medicines, too.Â
One of the most informative studies about these drugs was published this September in the Journal of General Internal Medicine. Based on this study, the newer sleep medicines hardly do anything to total sleep time. In this study, Canadian researchers systematically reviewed and combined data from 105 separate, randomized studies. These individual studies each showed how well sleeping medicines compared to placebos (sugar pills). The data came from formal sleep lab monitoring (not just from patient diaries).Â The analysis included results from more than 10,000 patients taking the newer sleep medicines.. Findings for all of the newer medicines except Rozerem were included.
The newer sleep medicines each had fairly similar results. On average, these drugs shortened the time it took for a person to fall asleep by only 12.8 minutes. The amount of time spent awake in the middle of the night decreased by only 7 minutes. After these small gains, people must have woken up slightly earlier in the morning, since the average increase in total sleep time was a whopping 11.4 minutes.
12.8 minutes? 11.4 minutes? Can these numbers be real? When I first read the study, I did a quick calculation in my head. These drugs cost between $2.00 and $3.50 per pill. That means you pay one dollar for every three to six minutes that you are spared lying awake.
In another study, the people who got the drugs for sleep were four times more likely to complain of daytime fatigue than those taking placebo. I would like to know the reason for this fact, but I can only guess at it. Maybe the sedating effects of the medicines linger into the next day, or maybe the sleep you get after taking the pills is less restoring. Older adults also have an increased risk for falls and balance difficulty after using these medicines. The people in the studies were all healthy and on relatively few other medications. If you take other medicines or if you have chronic health issues, I can guarantee you are more likely to have side effects from these medicines than we see in studies.
This March, the U.S. Food and Drug Administration issued a warning about alarming side effects that both newer and older sleep medicines can have. Some curious behaviors can occur during "drugged" sleep, including sleepwalking, driving, dialing and talking on the phone, romancing a partner, or preparing and eating food. These types of activities during sleep can result in serious injury due to accidents. One of my patients fell down a flight of stairs while sleepwalking and badly broke her ankle three days after starting the medicine.
Though itâ€™s likely that only a small number of people who take sleeping medicines actually get out of bed and do complex tasks such as walking or eating during their sleep, a large number are awake for parts of the night and donâ€™t remember this wakeful time in the morning. We know this because so many people who continue to toss, turn, and remain awake after taking these medicines curiously report that they think they went straight to sleep after using the drug, and they think they slept like a baby. For example, in the Canadian study people estimated that they got to sleep twice as quickly as they actually did.
Lying awake at night is no fun when you want to be sleepingâ€”it is enough to drive people crazy. But it is possible that a sleeping pill wonâ€™t spare you so much from your misery of lying awakeâ€”it may only spare you from remembering about it the next day.
If you take a sleeping pill and this is what happens, do you think you have been treated or do you think you have been tricked? Do you take sleeping pills, and do you trust them? If you feel more rested the following day, do you think you feel rested because of better sleep or for another reason?
Mary Pickett, M.D., is an Associate Professor of Medicine at Oregon Health & Science University where she is a primary care doctor for adults. Her field is Internal Medicine. She is also a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.