To Med or Not to Med

If you're in the sleep medication business, these are not bad times economically: sales of sleep meds are up. But if you're a person facing the question, to med or not to med, you may be confused. Advertising assures us that there's little danger from sleep meds, but the scare stories of Michael Jackson and Heath Ledger suggest otherwise. How to sort through the hype and hysteria? Is it better to tough it out without sleep or reach for a sleep med?

As the author of INSOMNIAC, a first person account of living with insomnia, I spent six years researching sleep meds and concluded that these are not demon drugs, but neither are they harmless. They require thought and attention. No sleep med on the market today is problem-free. None gives deep, natural sleep through the night and keeps on working indefinitely. All interfere with the structure of sleep, so that if we take them continuously, we may be robbing ourselves of the restorative benefits of sleep. Most have adverse effects on memory and coordination. Some may be addictive.

I'd say, turn to medications as a last resort, after you're tried everything else, a final line of action rather than a first. But since I find that living on the 2-4 hours that's my usual lot is just too grim, I do turn to them -- quite a bit.

If you decide to go this route, find a doctor who will work with you -- no mean feat, since doctors are caught in the same hype and hysteria that infects so much thinking about medications. There's the pill-happy doctor, on the one hand, who whips out a prescription pad before you've stopped talking, and sends you out of the office with a drug that may or may not be right for you; and there's the censorious doctor, at the other extreme, who makes you feel like a junkey for asking for a sleep aid. It may help to know that hypnotics, as FDA-approved sleep meds are called, are regulated in a way that makes many doctors shy away from them; if your doctor seems irritated with your request, it may have more to do with these regulations than with you. Hypnotics are regulated by the Controlled Substances Act, which categorizes substances according to their medical uses and potential for abuse and dependence. They're "schedule IV" drugs, which is less restricted than I, II, or III, but still, these are controlled substances, under the jurisdiction of the Justice Department and the Drug Enforcement Administration. FDA guidelines suggest limiting the use of most hypnotics to seven to ten days up to a maximum of a month, yet many of us take them for much longer. Prescribing them for more than a month may put the doctor at legal risk.

Antidepressants -- which include the older drugs like Elavil, Deseryl (trazodone), and the newer SSRIs, Paxil, Zoloft -- are not "controlled substances," which may be one reason they're so often prescribed for sleep. They don't work for me: they fog my brain, speed my heart, and don't help my sleep. But what doesn't work for me may work for you, since no two people react to a drug the same way -- even antihistamines, the staple of most over the counter sleep remedies and of cold medicines like Benedryl, are unpredictable, working like a soporific for some people and like speed for others. Someday, perhaps, a doctor will be able to take a blood test, assess your DNA, and with this information, be able to tailor a prescription precisely to you. But for now, no doctor can guess how a drug will work for you -- only you can be the judge of that. You have to be willing to come back and say, can I try something else? And for that, you need a doctor who's willing to trouble shoot.

Then, find out what you're putting in your body. Read the package insert, get on the web and find out all you can about it. Know what category of drugs the medication belongs to, the effects it's likely to have. (There are user-friendly, reliable Web sites that have information on drugs, listed below, and also sites like Sleepnet and TalkaboutSleep and Sleepstarved -my own site--where people talk about their experiences with drugs.)

The longer acting drugs, the benzodiazepines (Ativan, Valium, Restoril), are more likely to get you through the night, but may also leave you hungover the next day, since they hang around the system longer. They may also be more addictive--to some people, that is (again, everyone reacts differently). The shorter-acting, so-called non-benzodiazepines (Ambien, Lunesta, Sonata), may be out of your system so fast that they don't get you through the night. But at a low dose, these may help get you back to sleep when you wake up after a few hours. (That's how I use Ambien. But if you use a med in the middle of the night, be sure you've left time for the effect to wear off before you have to swing into action the next day.)

Then, if you continue taking a med for any length of time, keep tabs on yourself. Make sure it's not affecting your personality or mood. If you begin to feel not yourself, consider that it may be the med. Ambien, though it agrees with me, can have some pretty weird effects: people waking up to find candy bar wrappers and crumbs in their bed, having telephone conversations they don't remember, driving with no recollection of it. Sometimes this happens because they've taken too much of the drug, or have taken it over too long a time, or have mixed it with alcohol, or because they took it before they left the office or the party and drove home. (Never take a sleep med anywhere but in bed, when you are about to go to sleep!) Sometimes it happens simply because they have a bizarre reaction to this drug. "These drugs do things we do not understand," as Daniel Kripke says, whose website, The Dark Side of Sleeping Pills , may put you off them forever.

So try around to find out what works, then monitor yourself--then manage the drug. Take as little as you can to get by with, even if the bottle tells you to take more. The smallest dose is always the best dose. Drugs lose their effect over time, and if you start high, you'll habituate faster--and be more likely to become dependent. Try taking a break from the med; consider alternating it with another type of drug, say, a short-acting non-benzo with an antihistamine. Make sure the dose doesn't creep up. Be careful of creative combinations: that's what did in Jackson and Ledger.

The good news is that there's wider choice of drugs than there used to be -- the several kinds of antidepressants, the older and newer benzos and non-benzos, the over the counter antihistamines -- and this increases the likelihood of your finding something that works.. The bad news is that nobody knows what any of these meds do over time -- they haven't been tested over time. Only two FDA approved sleep meds, Lunesta and Rozerem, have been okayed for indefinite use, and even these have not been tested for anything like the duration many of us take them.

We're between a rock and a hard place, when it comes to meds. Lack of sleep is bad for mood, health, and memory; sleep meds may be bad for memory, health, and sometimes bad for mood. Only you can do the risk benefit calculations to decide whether the risk is worth the benefit to you. But if you're careful, and lucky, you may find some med that turns some wasted, wakeful hours into sleep.

Websites: www.webmd.com , www.pdrhealth.com/home/home.aspx , www.mayoclinic.com/index.cfm , www.medem.com , www.sleepstarved.org , www.sleepnet.com , www.talkaboutsleep.com
http://health.ucsd.edu/news/2002/FNbookPILL.pdf