Johns Hopkins Health Alerts Healthy Living After 50 Sleeping pills and Insomnia
David Neubauer, M.D., Associate Director of the Johns Hopkins Sleep Disorders Center, talks about insomnia.
A good night’s rest can become a rare commodity as you age. This is because sleep patterns change as you get older: You spend more time in the lighter stages of sleep and less time in the deep, restorative stages. If you have trouble falling asleep or staying asleep more than three nights a week, or if lack of sleep leaves you exhausted, you probably have insomnia. David Neubauer, M.D., Associate Director of the Johns Hopkins Sleep Disorders Center and the author of Understanding Sleeplessness (Johns Hopkins University Press), explains his approach to insomnia and evaluates the new sleeping pills.
Q. A new Gallup survey finds that most people with sleep problems or insomnia never ask their doctors for help. What would you tell them?
A. People should have a low threshold for talking to their doctors about insomnia. Insomnia is not just one problem but is simply the end product of a lot of potential problems. Insomnia can occur in response to stressful events, but it may also be related to an underlying and/or undiagnosed medical condition such as depression or other psychiatric problems, chronic pain, Alzheimer’s disease, or digestive problems. People may think they have insomnia when what they have is sleep apnea (heavy snoring and interrupted breathing during sleep). The physician should work with the patient to discover the cause or causes of the insomnia. Underlying disorders can be treated. Evaluation at a sleep disorders center or clinic may also be appropriate.
Q. How effective are sleeping pills for treating insomnia?
A. They can help break the cycle of insomnia. For many years, the benzodiazepines—so-called tranquilizers, such as Valium (diazepam), Halcion (triazolam), Xanax (alprazolam), Restoril (temazepam), and others—have been prescribed for insomnia. Since they are available as generics, they are inexpensive. Because of their long-lasting effects, they may leave you groggy and/or disoriented the next day. Some research has suggested that such side effects as falls may actually outweigh the benefits for older people. These drugs tend to be habituating—that is, you may require larger doses over time. For that reason, they are only approved for short-term use of insomnia.
Q. Are newer drugs, such as Ambien (zolpidem), Sonata (zaleplon), Lunesta (eszopiclone), and Rozerem (ramelteon), better choices for insomnia treatment?
A. Ambien, Sonata, and Lunesta—the nonbenzodiazepines— more precisely target chemical receptors in the brain and have fewer side effects than the older drugs. These sleeping pills have been extensively studied for older people and found to be safe and effective. Rozerem, very recently approved, is different in its chemical action; it triggers the release of melatonin, a natural brain chemical that controls sleep.
Q. Which, if any, of these sleeping pills would you prescribe for insomnia?
A. Much depends on a patient’s specific problems. Having trouble falling asleep is one problem, having trouble staying asleep is another. Working out the proper dosage may take time. Some people can reestablish their sleep cycles fairly quickly on small doses. But if sleeping pills are needed for long-term use for insomnia, there’s no reason not to prescribe one of the newer sleeping pills. Lunesta, Roserem, and a new time-release formulation of Ambien CR (zolpidem) have been approved by the FDA for long-term use for insomnia. But they are very expensive. None comes as a generic. People taking sedatives for insomnia should keep in touch with their doctor for regular reevaluation of progress as well as side effects if they occur.
The New Sleeping Pills
- Ambien (Zolpidem) induces sleep quickly but causes grogginess if you sleep less than eight hours. It is not approved for long-term use. 30 tablets (5 mg) cost about $80. Ambien CR, a new time-release pill, is approved for long-term use. 30 tablets (6.25 mg) cost about $100.
- Sonata (Zaleplon) wears off in about four hours. It can be taken during the night if you have problems staying asleep. 30 tablets (5 mg) cost about $75.
- Lunesta (Eszopiclone) will help you fall asleep quickly but should only be used when you expect to get eight hours of sleep. Otherwise, temporary memory loss may result. Lunesta should not be taken right after a heavy meal. 30 tablets (1 mg) cost about $100. It is approved for long-term use.
- Rozerem (Ramelteon) is not a controlled substance, although manufacturers warn that its use increases the possibility of addiction or abuse. Rozerem helps with sleep-onset problems but is not recommended for restarting sleep if you wake up during the night. 30 tablets (8 mg) cost about $130.
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