Can long-term use of sleep medications be hazardous to your health?
Are Sleeping Pills Addictive?. Dozens of readers had questions for the Consults blog about the long-term effects of taking sleep medications. Here, Dr. Michael Thorpy and Shelby Freedman Harris of the Montefiore Medical Center Sleep Disorders Center respond.
Q. What are the risks of long-term use of prescription drugs to combat insomnia?Claudia, New York, N.Y.
A. Dr. Thorpy and Dr. Harris respond:
In our sleep center, we use several types of prescription medications to treat insomnia. The most well known are drugs like Ambien (zolpidem), Lunesta (escopiclone) and Sonata (zaleplon) — sometimes referred to as the “Z-drugs” or hypnotics. They all affect a brain structure called the GABA receptor, which is widely found throughout the brain and has many functions; their main effect is to dampen arousal, thereby allowing sleep to occur. There are also non-GABA sleep medications like Rozerem (ramelteon), which reduces arousal by affecting the receptor for the hormone melatonin.
Before using any of these medications, it is vital to understand the underlying cause of the insomnia, since other treatments may be more appropriate. If depression is the cause of poor sleep, for example, antidepressants or lifestyle changes may be the most appropriate course. Insomnia has now been shown to be associated with a range of underlying medical and psychological disorders, and it is therefore an important condition to treat. We usually use both behavioral and medication therapy, either alone or together, to get the best response. The aim is to have the patient come off the sleep medication completely when the insomnia resolves.
Some people, though, have chronic insomnia that is associated with a medical or psychiatric disorder and need to continue medication very long-term. They can do so without any untoward effects.
When used as prescribed, the sleep medications mentioned above are very safe — although, as with any prescription medication, they can have adverse effects in some people. For example, rarely, some of these drugs may actually cause an increase in arousal and prevent sleep. Ambien, surprisingly, has even been used to arouse people in a persistent vegetative state.
Still, sleeping pills are very widely used, and most people find them effective and do not suffer from adverse effects, even when used long-term. These medications have not been shown to produce a pharmacological or chemical addiction with withdrawal symptoms, unless they are taken in excessive doses.
These drugs can, however, be psychologically habit-forming. If the sleeping pill effectively promotes sleep but is stopped suddenly, for instance, some people may show signs of psychological dependence, with the desire to want to keep taking them. However, this is not an actual chemical addiction.
The sleeping pills mentioned above do not produce a worsening of insomnia — so-called rebound insomnia — when they are stopped. But insomnia can return, prompting the patient to want to continue with the medication. That is why we find that it is important to include behavioral treatments, such as good sleep hygiene or cognitive behavioral therapy, along with any medication treatment so that the patient can withdraw from the medication without a return of the insomnia. (See our earlier post, “Overcoming Insomnia Without Drugs.”)
When the medication is withdrawn, we always have the patient taper off the medication slowly, often over a period of weeks, to reduce any psychological dependence on the drug. So long as the insomnia is being actively treated behaviorally, the patient will not find a need to increase the dose of the hypnotic, and the patient will not develop a tolerance to the medication.
When a patient asks to increase a formerly effective dose of a medication, we usually find that something else has happened, usually additional stress or a lifestyle change. It does not mean the patient has developed a pharmacologic tolerance to the medication.
Sleeping pills should be taken only immediately before bedtime. It is not recommended they be taken in the middle of the night if you have to get up early the next morning. Some pills have a longer duration of effect than others and could cause daytime sedation. As with all prescription medications, sleeping pills need to be taken according to the physician’s recommendations. ( nytimes.com )
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