When Counting Sheep Fails: The Latest Sleep Medications

Is the new generation of sleeping pills the answer for insomnia?

From the WebMD Archives

Insomnia has been around as long as sleep has. Some even believe that William Shakespeare was an insomniac, writing as vividly as he did about sleeplessness, tossing and turning, and sleepwalking in plays like Hamlet and Macbeth. Today, old Will has millions of fellow sufferers.

  • The 2007 Sleep in America Survey from the National Sleep Foundation found that 67% of women say they frequently experience a sleep problem.
  • The 2005 Sleep in America poll found that 35% of adults experience insomnia every night.

One option today's insomniacs have that Shakespeare didn't, of course, is the sleeping pill. Over the last 10 to 15 years, the market has been inundated with new and improved sleep medications -- ones that don’t come with the same degree of hangovers, side effects, and risk of dependency that previous sleep drugs did.

But that doesn’t mean they’re risk-free, or ideal for everyone who has problems getting a solid forty winks.

A Good Night's Sleep, Without the Hangover

The older classes of sleep medications, particularly the benzodiazepines -- think Valium and Xanax -- do more than just help you sleep. They affect how you sleep, altering your actual "sleep architecture," says Donna Arand, PhD, clinical director of the Kettering Sleep Disorders Center in Kettering, Ohio.

"They tend to decrease the amount of time spent in certain stages of sleep, particularly stages three and four (the deepest, most restful stages of sleep)," says Arand, who serves on the boards of the American Academy of Sleep Medicine and the American Insomnia Association. "People also complained of hangover effects from these medications." That's because they tend to have a longer "half-life," which is the length of time the drug stays in your body.

Non-benzodiazepine hypnotics like Ambien, Ambien CR, Rozerem, Sonata, and Lunesta, however, share key advantages over previous generations of sleep drugs:

  • They have a relatively short half-life, so you won't wake up groggy the next day. "There are minimal reports of 'hangover' effects with these new drugs," says Arand.
  • They are less likely than the older sleeping pills to cause addiction, withdrawal symptoms, or a buildup of tolerance (when you require more and more drug to have the same effect).

Why? The newer medications act only on specific receptors in your brain that are focused on sleep, while older groups of drugs have a more generalized effect on multiple brain receptors. "These new drugs are among the safest medications in medicine," says Thomas Roth, MD, Director of the Sleep Disorders and Research Center at Henry Ford Health System in Detroit.

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New Sleeping Pills Aren’t Right for Everyone

"If you have insomnia due to sleep-related breathing disorders [sleep apnea] or restless legs syndrome, for example, these drugs won't address your underlying problem," says Roth. Pregnant women, of course, shouldn't take these medications. And if you're "on call," frequently getting up in the middle of the night for work or for a child, they might not work for you.

They’ve also recently been linked to some unusual side effects. In March 2007, the FDA issued a warning that prescription sleep medications like Ambien and Lunesta can cause bizarre behaviors during sleep. Some people have reported that they drove cars and went on eating binges -- literally cleaning out the refrigerator with no awareness of taking a bite. The FDA has asked drugmakers to strengthen their product labels with warnings about these side effects. The FDA notes that severe allergic reactions and facial swelling have also been linked to these medications.

If your doctor prescribes one of these drugs for you, be aware that these side effects are a possibility. Consider asking your partner or other adults who live with you to keep an eye out for nocturnal disturbances.

A Tour of Today’s Sleep Aids

The array of prescription sleep medications available to today’s groggy insomniac can be truly bewildering. Which one might be right for you? The best person to answer that is your doctor, or a specialized sleep center if your struggles have left your doctor baffled. But to give you an idea of some questions to ask, here is a quick introduction to the medications now on the market:

Rozerem: If you’ve seen the “your dreams miss you” ads featuring a bedraggled insomniac talking to Abraham Lincoln and a chess-playing beaver, you’ve heard about Rozerem. Rozerem is the first in a new class of drugs designed to act on the body’s melatonin receptors. (Melatonin is a hormone that affects sleep by helping to regulate the body’s circadian rhythms.)

Rozerem is more specifically targeted than regular melatonin supplements, specifically affecting the sleep center of your brain. Its biggest plus: safety. Resesarch shows Rozerem has no side effects or withdrawal effects. “It’s a very safe drug to use, so particularly for people who are on other medications or who may have a concern about substance abuse, it’s a great drug,” says Arand. (But Rozerem is also included in the FDA’s list of drugs that should include a warning about unusual sleep behaviors.)

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Sonata: Of all the new sleeping pills, Sonata has shortest half-life, which is the amount of time it takes for half of the drug to be eliminated from your body. Its half-life ranges between 30 and 60 minutes. That means you can try to fall asleep on your own. Then, if you're still staring at the clock at 2 a.m., you can take it without feeling drowsy in the morning.

Ambien: The most commonly prescribed sleeping pill, Ambien has a moderate half-life of less than two-and-a-half hours. This means that Ambien is great for helping you get to sleep but, like Sonata, could be less helpful if your problem is waking up wide-eyed in the wee hours.

Ambien CR: Ambien CR, approved by the FDA in 2005, was designed to target both common sleep problems: difficulty falling asleep and difficulty staying that way.Think of it as a layer cake: one layer dissolves quickly to help you fall asleep, while the second layer dissolves more slowly to help you stay asleep. Clinical trials showed that Ambien CR decreased wake time after sleep onset for the first seven hours during the first two nights it was taken, and for the first five hours after two weeks of treatment.

Lunesta: Of all the newer sleeping pills approved so far, Lunesta has the longest half-life -- about six hours. This means you may feel groggy in the morning if you take it in the middle of the night, or at a time when you can't get a full night's sleep. On the other hand, this pill could help you if you tend to wake up in the middle of the night a lot. Lunesta is approved by the FDA for long-term use and has been found to help menopausal women sleep through the night.

Benzodiazepines: These older sleeping pills, which include drugs like Valium and Halcion, are useful when you want a drug that stays in your system longer. For instance, they have been effectively used to treat sleep problems such as sleepwalking and night terrors, says Arand. "The biggest problem with these is daytime sleepiness, although you also have to monitor them more closely for dependence as well," she says. (Dependence means that you always need the drug to go to sleep.)

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These drugs aren’t all created equal: Valium, for example, has a much longer half-life (about 6-8 hours) and therefore stays in your system a lot longer than Halcion, which has a 3-4 hour half-life.

Antidepressants: Insomnia is a common symptom of depression. Thus, some antidepressant drugs, such as Trazodone, are particularly effective in treating sleeplessness and anxiety that's caused by depression, even though they are not specifically approved by the FDA for the treatment of insomnia.

"In those cases, the antidepressant helps treat the sleep problem, but is really treating the underlying cause," says Arand. Could your insomnia be linked to depression? If you think you have other symptoms, talk to your doctor about this possibility.

Over-the-Counter Sleep Aids: Most of these sleeping pills, such as Sleep-Eze, are antihistamines. This means they're somewhat sedating and can cause some drowsiness the next day. They're safe enough to be sold without a prescription, but if you're taking other drugs that have similar effects -- like cold or allergy medications -- you could inadvertently take too much.

The American Academy of Sleep Medicine reviewed research on these sleep aids in 2006 and concluded that they may provide “modest, short-term benefits,” but “sufficient evidence does not exist to support over-the-counter sleep aids as an effective treatment for insomnia.”

Combining Medicine With Good Sleep Habits

Roth suggests that it's time to start thinking about insomnia as a chronic disorder -- which he notes that it is in at least 10% of the population -- and treating it that way. "For people who have high cholesterol, you don't just give them a drug to lower their cholesterol and that's the end of it," he says. "You also work with them on other factors in their life that may be elevating their cholesterol."

Similarly, he says, sleep medications for insomnia should not be used in isolation. "You want to use them in conjunction with good sleep practices, good behavioral therapies, and treating accompanying conditions," he says. That means, among other things, practicing "good sleep hygiene":

  • Use your bed only for sleeping, not for paying bills or working on your laptop.
  • Avoid caffeine, nicotine, and alcohol for four to six hours before going to bed, and don't exercise too late in the evening.
  • Make sure your bedroom is restful and quiet. Get a sleep mask or white noise machine if you can't block out light or noise from outside.
  • Get up and go to bed at the same time every day -- yes, even on weekends!

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Studies have also found that cognitive behavioral therapy (CBT) can be a very effective treatment for insomnia, making it easier to fall asleep more quickly and stay asleep longer.

"In fact, some research shows that medications aren't as effective in the long term as behavioral treatment of the insomnia problem," says Arand. "Changing behavior can have a greater impact and longer duration of effectiveness. But that doesn't mean you can't use these remedies in combination."

WebMD Feature Reviewed by Michael J. Breus, PhD on November 01, 2007

Sources

SOURCES: Donna Arand, clinical director, Kettering Sleep Disorders Center, Kettering, Ohio. Thomas Roth, MD, director, Sleep Disorders and Research Center, Henry Ford Health System, Detroit. National Sleep Foundation. FDA.

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