By Dr. Peter Breggin
My most recent HuffPost blog, “Xanax Facts and Whitney Houston,” looked at how the benzodiazepine Xanax (alprazolam) might have contributed to the singer’s death, and reviews many of the hazards of this group of drugs.
Since then, a new study has added more warnings about the life-threatening risks of benzodiazepines and closely-related sleep aids. The article in BMJ’s Open Access Journal studied the effects of hypnotics on mortality and also specifically on the risk of cancer. The epidemiological study looked at more than 10,000 U.S. patients taking sleeping aids and compared them to a larger number of controls. The two drugs most commonly used to treat insomnia were the benzodiazepine temazepam (trade name, Restoril) and the closely-related sleeping aid zolpidem (Ambien). However, their study included all of the regularly-used prescription sleep aids, including eszopiclone (Lunesta), zaleplon (Sonata), other benzos, barbiturates, and sedative antihistamines.
The study found that patients receiving any of these drugs for sleep compared to non-users suffered “substantially elevated hazards of dying compared to those with equivalent comorbidity who took no hypnotics.” “Patients with prescriptions for hypnotics had approximately 4.6 times the hazard of dying over an average observation period of 2.5 years as compared to non-users,” according to the study. Nor was the risk limited to heavy or prolonged use. The study reported a 3.6 times greater mortality rate in patients prescribed 18 or fewer doses per year.
In addition to the increased death rate, there was “an overall cancer increase of 35% among those prescribed high doses.”
There are always problems in interpreting epidemiological studies, but the data seem valid. For example, higher doses were associated with both greater mortality and greater cancer risk. When an adverse effect can be shown to be dose-dependent it adds to the strength of the causal relationship. In addition, the findings were not marginal. The study group was large and the statistical associations were strong.
The authors drew no firm conclusions about how the medications cause increased mortality. Although not mentioned in their review, I believe the impairment of judgment caused by all sedating drugs may play a role in regard to taking proper care of oneself, including healthy living and avoiding accidents. Because of impaired judgment, these drugs often lead to unintentional overdose. This impaired judgment is an aspect of what I call “medication spellbinding.”
Sedative or hypnotic drugs also cause depression, which can lead to poor self-care and other problems. All of these drugs are central nervous system (CNS) depressants, so they will reduce and impair respirations, gag and cough reflexes and other functions during sleep. They also cause or worsen sleep apnea, which is associated with many health problems, including cardiovascular disease and accidents. All of the hypnotic drugs produce abnormal sleep cycles, which may reduce alertness while awake and produce other unknown health hazards. The newer ones like Ambien and Sonata are noteworthy for causing sleep walking, sleep eating, and even sleep driving and sleep climbing out of windows. The authors of the study point out that in controlled clinical trials individuals taking hypnotics have “more adverse medical events overall” than people taking the sugar pill as controls. All of them can be psychologically habit-forming, and all of them except the antihistamines can be easily abused and lead to addiction.
More and more, we are learning that we expose ourselves to grave risks when we use prescribed psychoactive substances as a solution to problems related to our emotional lives.
Sleep problems can come from many sources, including recent physical or emotional trauma, worries and anxieties, the resurfacing of past emotional problems and even childhood difficulties, excitement and stimulation in the face of new challenges, nighttime work schedules, hormonal changes, the discomforts of pregnancy, physical illnesses even before they otherwise become obvious, and physical pain. Many people feel plagued by loneliness, especially at night. Those who have been sexually abused often find that the mere thought of going to bed raises anxieties. Guilt and shame, often highly irrational, keep many awake. Creative people find themselves awakened by new thoughts and insights, whether they want them or not in the middle of the night.
Drugs or alcohol, when used frequently to bring about sleep, can actually disrupt sleep. The brain fights back again the sedating effects, eventually causing insomnia, as well as other emotional problems.
Sleep problems are complex, and no single approach fits all cases. Here are some suggestions.
If you remember when you were a child or if you’ve raised children, you may know that helping children fall asleep involves a number of important factors. First, there is loneliness, which is often handled by keeping the child company at bedtime. As an adult, don’t be afraid to tell your partner that you want to find a way to go to sleep together at night. Or make sure that your relationship is made peaceful as the time for sleep approaches, for example, by setting aside all arguments or over-stimulating topics two hours before bedtime, and instead focusing on enjoying yourself together. If you are alone, try to find folks you can call in the evening for a little company before bed or do some social networking. Or remind yourself of people you love or trust as bedtime approaches.
Second, there is the need for routine or ritual that nearly all children display around bedtime. Find comforting ways to bring your day to a close with your partner or by yourself. A special snack, a good book, a shower or bath, music, a relaxation tape, a white noise machine, a relaxing hobby, a pleasant or soothing radio program or TV show, or pleasant conversation — all can add to the sense of regularity that can help with sleep. People with sleep problems often become so anxious before sleep that they forget the routines that once made them feel safe and comfortable.
Third, again using children as our inspiration, children need reassurance about their fears before going to bed. Let yourself feel like a child and reassure yourself that your house is safe and that your other fears are just that — fears — that you can set aside at bedtime. If you can, share them with someone you trust. It helps to hear that other people often have no fear at all of the things we fear most. It proves that our fears are unnecessary and unrealistic. Or it can be comforting to know you are not alone in your fears.
Some other suggestions include keeping a notepad nearby to write down worries or realistic problems that need to be addressed in the morning. Then ritualistically close the notepad and go back to bed with the conviction you’ll deal with that stuff after a good night’s sleep.
Some people like to get up for a while to do something that brings comfort and satisfaction, or that’s boring enough to encourage sleepiness. When I was a young man, some of my first books were written in part during periods of difficulty sleeping at night. You may find you can make something useful out of your insomnia.
Don’t forget the spiritual aspect of going to bed and then going to sleep. If you believe in God, don’t hesitate to pray for a good night’s sleep, peace of mind, or the strength to put your problems aside. Or simply give up your worries to God for the night. If you believe in a higher power or greater meaning, however vaguely, let yourself take the time in bed to ask to be at one with it. And nothing is more powerful at night than expressing gratitude, perhaps aloud, for all that you have that’s good in your life.
Sometimes sleep difficulties represent serious underlying problems, and sometimes it’s a mistake to focus too much on the sleep problem and not enough on the underlying problem. Obsessive concerns about sleep often mask other issues. So if you are having a sleep problem, try to recall when it started, and then examine what’s been going on that may be stressing or distressing you, including at work, in the family, among your friends, or in the wider world. Medication-free counseling or therapy may be helpful, not only in overcoming the sleep problem, but also in helping you take that next giant leap you need toward improving your life.
In my experience as a psychiatrist, nearly everything we call a psychiatric symptom or problem, including insomnia, is in reality a signal that we have to face a new challenge in life. Having trouble sleeping? See what this problem teaches you about your life, your concerns, and what you may need to do to make your life as exciting, courageous, and satisfying as it can be.
Originally published in The Huffington Post.