Sleeping Pills, Natural Sleep Aids & Medications What’s Best for You? It’s the middle of the night, and you’re staring at the bedroom ceiling, thinking about work, or bills, or the kids. Sleep just won’t come. You look anxiously at the clock again. If only you could fall asleep... In these circumstances, it’s often tempting to reach for a sleeping pill, but there are important things you need to know first. Sleep medications vary in safety and effectiveness and are rarely meant for more than short-term use. Persistent insomnia is usually a symptom of an underlying medical or psychological problem that cannot be treated with sleep medications. In many cases, making simple changes to your lifestyle is far more effective at ending sleepless nights than popping a pill. Are sleep aids, sleeping pills, or medications right for you? In general, sleeping pills and sleep medications are most effective when used sparingly for short-term situations, such as traveling across many time zones or recovering from a medical procedure. Sometimes sleep medications are used briefly at the beginning of behavioral treatment for insomnia, especially if the sleep deprivation has been severe. If medications are used over the long term, they are best used “as needed” instead of on a daily basis to avoid dependence and tolerance. Working with your healthcare professional is essential to ensure you get the maximum benefit and can safely monitor potential side- effects. The trouble with sleeping pills, over-the-counter sleep aids, and medications The idea of a pill that can instantly solve your sleep problems is very appealing. Unfortunately, sleep medications don't cure the underlying cause of the insomnia, and in fact can often make the problem worse in the long run. Concerns about the use of both over-the-counter (OTC) and prescription sleep medications include: • Side effects. Side effects can be severe and include prolonged drowsiness the next day, confusion, forgetfulness and dry mouth. • Drug tolerance. You may have to take more and more of the sleep aid for it to work, which in turn can lead to more side effects. • Drug dependence. You may come to rely on the medication to sleep, and will be unable to sleep or have even worse sleep without it. • Withdrawal symptoms. If you stop the medication abruptly, you may have withdrawal symptoms, such as nausea, sweating and shaking. • Drug interactions. If you are taking other medications, sleeping medications can interact with them. This can worsen side effects and be dangerous, especially with medications such as prescription painkillers and other sedatives. • Rebound insomnia. If you need to stop the medication, sometimes the insomnia can become even worse than before. • Masking an underlying problem. There may be an underlying medical or mental disorder, or even a sleep disorder, that if treated would provide more relief from insomnia. Side effects of sleep medications and sleeping pills All prescription sleeping pills have side effects, which can vary depending on the specific drug, the dosage and how long the drug lasts in your system. Check with your healthcare professional about any concerns you have. Common side effects can include headache, muscle aches, constipation, dry mouth, daytime sleepiness, trouble concentrating, dizziness, unsteadiness and rebound insomnia. Some serious risks of sleeping pills Sedative-hypnotic drug products (benzodiazepines and non-benzodiazepines) can cause severe allergic reaction, facial swelling, memory lapses, hallucinations, and complex sleep-related behaviors. These may include sleep-walking, sleep-driving (driving while not fully awake, with no memory of the event) and sleep-eating (eating in the middle of the night with no recollection, often resulting in weight-gain). If you experience any unusual sleep-related behavior, consult your doctor immediately. Does newer mean better and safer for sleep medications? Not necessarily. An older medication may work just as well depending on the type of insomnia you have and other medical considerations. Older medications often have many additional years of data from patient usageand may also be more cost effective if available in generic form. On the other hand, newer medications may have differences that minimize side effects of older medications. Bottom line: work with a healthcare professional that you trust in deciding which medication would best suit your needs. Over-the-counter (OTC) sleep aids and sleeping pills The main ingredient of over-the-counter sleeping pills is an antihistamine. Antihistamines are generally taken for allergies, hay fever and common cold symptoms, in brand name medication such as Benadryl. However, histamine, a chemical messenger in the brain, promotes wakefulness, so antihistamine has the effect of making some patients feel sleepy. While the positive effects have not been substantiated through research, the side effects, such as drowsiness the following day, can be common and severe. Some other OTC sleep medications combine antihistamines with the pain reliever Acetaminophen (found in brand names like Tylenol PM and Aspirin-Free Anacin PM). Others, such as NyQuil, combine antihistamines with alcohol. OTC sleep aids are meant to be used for short term insomnia only. Sleep experts generally advise against the use of over-the-counter (OTC) sleep aids because of side- effects, questions about their effectiveness, and lack of information about their safety over the long-term. Side effects of OTC sleep aids and medications The antihistamines used in OTC sleep aids can produce common side effects, some of them severe. As with any medication, it is advisable to consult your doctor before taking over-the-counter sleep medication. This is especially important if you have glaucoma, trouble urinating due to an enlarged prostate gland, or a breathing problem such as emphysema or chronic bronchitis. Talk to your doctor if you're currently taking an antidepressant such as a monoamine oxidase inhibitor (MAOI) or did so as recently as two weeks ago. Also check with your doctor first if you take any other drugs for depression or Parkinson's disease. Women who breast-feed should avoid OTC sleep aids. Common side effects of OTC sleep aids and sleeping pills • Moderate to severe drowsiness the • Constipation and urinary retention next day • Blurred vision • Dizziness and forgetfulness • Dry mouth and throat • Clumsiness, feeling off balance Prescription sleeping pills and sleep medications There are several different types of prescription sleeping pills. These medications are classified as sedative hypnotics. In general, the medications act by working on receptors in the brain to slow down the nervous system. Some medications are used more for inducing sleep, while others are used for staying asleep. Some last longer than others in your system (a longer half life), and some have a higher risk of becoming habit forming. For more information about a medication, follow the link in the table to a Physician’s Desk Reference review of each medication. Consult your healthcare professional if you have a specific question about a medication. Drawbacks to benzodiazepine sleeping pills Use of sleeping medications, especially benzodiazepines, can become troublesome for several reasons: • You can become both physically and psychologically dependent on the sleep medication. You may believe that you can’t sleep without it, and actually experience physical withdrawal symptoms like anxiety and rebound insomnia. • They can lose their effectiveness if used on a nightly basis, because the brain receptors become less sensitive to their effects. In as little as three to four weeks, benzodiazepines can become no more effective than a sugar pill. • The overall quality of your sleep can be reduced, with less restorative deep sleep and dream sleep. • You may experience next day cognitive slowing and drowsiness (the hangover effect), which may be even greater than from sleep deprivation. • Even if the medication is effective while taking it, insomnia returns once it is stopped. Drawbacks to benzodiazepine sleeping pills Use of sleeping medications, especially benzodiazepines, can become troublesome for several reasons: • You can become both physically and psychologically dependent on the sleep medication. You may believe that you can’t sleep without it, and actually experience physical withdrawal symptoms like anxiety and rebound insomnia. • They can lose their effectiveness if used on a nightly basis, because the brain receptors become less sensitive to their effects. In as little as three to four weeks, benzodiazepines can become no more effective than a sugar pill. • The overall quality of your sleep can be reduced, with less restorative deep sleep and dream sleep. • You may experience next day cognitive slowing and drowsiness (the hangover effect), which may be even greater than from sleep deprivation. • Even if the medication is effective while taking it, insomnia returns once it is stopped. Melatonin receptor agonist hypnotic sleeping pills This is the newest type of sleep medication and works by mimicking the sleep regulation hormone melatonin. It has little risk of physical dependency but does have side effects. It is used for sleep onset problems and is not effective for problems in staying asleep. Drawbacks to ramelteon Ramelteon’s most common side effect is dizziness. It may also worsen symptoms of depression and should not be used by those with severe liver damage. Antidepressants The Food and Drug Administration (FDA) has not approved these drugs for the treatment of insomnia, nor has their use been proven effective in treating sleeplessness. However, some physicians believe insomnia is related to depression. As with all depression medication, there is a small but significant risk of suicidal thoughts or worsening of depression, particularly in children and adolescents. Guidelines for using sleep medications If you decide to try sleeping pills or sleep aids, keep in mind the following guidelines. Talk to your doctor about • Other medications you are taking. This includes non-prescription medications such as pain relievers and allergy medicines, as well as herbal supplements. Combining medications can be very dangerous. • Specific instructions for decreasing and/or terminating use. In some cases, stopping medication abruptly can cause uncomfortable side effects and even rebound insomnia. • Using the medications intermittently, rather than nightly, in order to decrease the negative side effects and to increase the sleeping pills’ efficiency when you do use them. This is not appropriate with all medications, as some cause withdrawal symptoms when stopped abruptly. • Other medical conditions that you have. Some drugs can have serious side effects for people with medical problems such as high blood pressure, liver problems, glaucoma, depression and breathing difficulties. Remember to • Only take a sleeping pill when you will have enough time to get a full night of sleep (7 to 8 hours). Otherwise you may feel very drowsy the next day. • Carefully read the package insert that comes with your medication. Pay careful attention to the potential side effects. • Never drink alcohol near the time when you take a sleeping pill. Not only will alcohol disrupt your sleep even more, it can interact dangerously with the sleeping pill. • Never drive a car or operate machinery after taking a sleeping pill. Especially when you first start taking a new sleep aid, as you may not know how it will affect you. • Follow directions closely, starting with a very small dose and increasing gradually, according to the doctor’s schedule. Find out whether you should take your medication with or without food. For some medications, certain foods must be avoided. Herbs and natural sleep aids Many people with insomnia choose herbal remedies for treatment, although their effectiveness has not been evaluated by the FDA. Some remedies, such as lemon balm or chamomile tea are generally harmless. However, others can have more serious side effects and can interfere with prescribed medications, which can be dangerous. St. John’s Wort, for example, can limit the effectiveness of many prescribed medications such as blood thinners, birth control pills and some anticancer medications. Check with your healthcare professional if you are trying a herbal remedy. Herbal sleep aids There are several herbs thought to help sleep,including chamomile, valerian root, kava kava, lemon balm, passionflower, lavender, and St. John’s Wort. Many people drink chamomile tea for its gentle sedative properties, although it may cause allergic reactions in those with plant or pollen allergies. While there is some data showing valerian to be useful for insomnia, at high doses, it can cause vivid dreams, blurred vision, changes in heart rhythm, and excitability. Melatonin Melatonin is a naturally occurring hormone whose levels peak at night. It is triggered by dark and levels remain elevated throughout the night until light decreases it. However, most studies have not found melatonin to be beneficial when compared to a sugar pill (placebo). Some positive results have been shown in helping jet lag and night shift workers, but simple exposure to light at the right time might be just as effective. Long term effects of melatonin are unknown. Tryptophan, L-tryptophan Tryptophan is a basic amino acid used in the formation of the chemical messenger serotonin, a substance in the brain that helps tell your body to sleep. L-tryptophan is a common byproduct of tryptophan, which the body then can change into serotonin. Some studies have shown that L-tryptophan can help people fall asleep faster. Results, however, have been inconsistent. Alternatives to sleeping pills and sleep medications Research has shown that changing your sleep environment and bedtime behaviors is one of the most effective ways to combat insomnia. Even if you decide to use sleep medications in the short-term, experts recommend changes in lifestyle and bedtime behavior as a long-term remedy to sleeplessness. Behavioral and environmental changes can have more of a positive impact on sleep than sleeping pills, sleep aids or other medications, without the risk of side effects or dependence. Cognitive behavioral therapy (CBT) Many people complain that frustrating, negative thoughts and worries prevent them from sleeping at night. Cognitive-behavioral therapy (CBT) is a form of psychotherapy that treats problems by modifying dysfunctional or destructive thoughts, emotions and patterns of behavior. CBT is a relatively simple treatment that can improve sleep by changing your behavior before bedtime as well as changing the ways of thinking that keep you from falling asleep. It also focuses on improving relaxation skills and changing lifestyle habits that affect sleeping patterns. Relaxation techniques that can help you sleep • A relaxing bedtime routine. Focus on quiet, soothing activities, such as reading, knitting, or listening to soft music before bed. Keep the lights low. • Abdominal breathing. Most of us don’t breathe as deeply as we should. When we breathe deeply and fully, involving not only the chest, but also the belly, lower back, and ribcage, it can actually help the part of our nervous system that controls relaxation. Close your eyes and try taking deep, slow breaths, making each breath even deeper than the last. Breathe in through your nose and out through your mouth. Make each exhale a little longer than each inhale. • Progressive muscle relaxation is easier than it sounds. Lie down or make yourself comfortable. Starting with your feet, tense the muscles as tightly as you can. Hold for a count of 10, then relax. Continue to do this for every muscle group in your body, working your way up from your feet to the top of your head. Exercise to beat insomnia Studies have shown that exercise during the day can improve sleep at night. When we exercise we experience a significant rise in body temperature, followed a few hours later by a significant drop. This drop in body temperature makes it easier for us to fall asleep and stay asleep. To combat sleeplessness, the best time to exercise is late afternoon or early evening. However, it is important to avoid vigorous exercise late at night or just before going to bed as the stimulating effect of exercise and the rise in body temperature can make it harder to sleep. Aerobic exercises are the best to combat sleeplessness as they increase the amount of oxygen that reaches the blood. Try exercise such as jogging, walking briskly, using a stationary bike or treadmill, dancing, or jumping rope. Check with your doctor first to make sure you are healthy enough for physical activity and remember to stretch before and after your workouts.