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Were we to believe sleeping pill commercials, anyone with insomnia can toss back a pill and be whisked off into some beautiful, groggy isle where sleep comes easily, there are no consequences and floating Zzzs are as commong as cawing gulls.  The reality is far less cheery. Sleeping pills are some of the most addictive medications available. In 2013, nine million Americans admitted to using prescription sleep aids — a number that’s almost certainly risen in the years since. According to the Addiction Center, 30 percent of sleeping pill users are dependent.

Concerns over sleeping-pill use have become so pervasive that the American College of Physicians recently declared that the first line of defense against chronic insomnia should not be prescription sedatives like Ambien, but rather Cognitive Behavioral Therapy for insomnia (CBT-i). Sleeping pills can be addictive. Used sparingly or for short periods of time, these drugs can be helpful. But, when chronic insomniacs, or even generally troubled sleepers, find rest via pills, it can get tricky to fall asleep without them. And, with continued, longer-term use, people build tolerance to the medication, leaving them dependent on higher doses to achieve the same solemnifying effects. It’s not a slippery slope — it’s an unavoidable oil slick. But sleeping pills should in no way be outlawed. There have their place — just not as a first defense. 

To discuss the topic further, we spoke to Marc Leavey, MD, of Mercy Medical Center in Baltimore. 

For the uninformed, what are the dangers posed by sleeping pills?

One of the biggest problems with sleeping pills is the disruption of the normal sleep cycle. We need REM sleep. If you're using medications to simulate natural sleep, you may or may not have normal wake-sleep rhythms. Your body may be trying to catch up on what it's missing. Essentially, you'll be sleep-deprived. With sleep or dream deprivation comes increased daytime sleepiness, which could lead to falling asleep at the wheel. It's a big deal. You could also have trouble concentrating at work. Your boss may not like you dozing off in a meeting. Or if you work an assembly line, you could lose a finger.

No one reads the labels. They're intended for short-term use, not long-term use. With any drug, you should take the smallest effective dose for the shortest period of time.

And what about their addictive nature?

As far as dependency goes, going back to barbiturates, these were incredibly addictive. The new meds are supposedly better, but if you're using them for weeks or months, that’s not good. At a certain point you won't be able to fall asleep without them. Of course, with benzos (e.g., Xanax), you get used to them — you're addicted — so you'll have to bump up the dose to get the same effect, and then you have increased problems as time goes on.

How would you compare the risk of dependency with, say, pain pills?

The benzodiazepines are different from the opioid analgesics in that low-dose, or low-potency benzodiazepines can be used for prolonged periods of time without causing a physical addition, although there may be a psychological habituation. The stronger benzodiazepines are often used safely for short term therapy, but if used for a longer time can become physically addicting.  Thus, there is more of a therapeutic window, so to speak, with the use of benzodiazepines. With powerful effects on pain and endorphin levels, improving mood and a general sense of well being, the opioid analgesics quickly establish a need in sensitive individuals, that may be independent of the strength of the drug or length of the therapy.

Sleeping pills obviously have some nasty side effects.

As a class they are sedating, and the sedating effect lingers into the morning. There's carryover into the daytime. The hangover effect can be quite real. You have impaired judgment and slowed reflexes. There's also sleepwalking and sleepeating. You get up in the middle of the night, wake up, and forget what you've been doing. It's like amnesia. People take sleeping pills before boarding a flight. They sleep through the flight and wake up and don't know where they are and are very disoriented. 

Sleepeating is such an odd parasomnia. 

I had a patient with a cholesterol problem. Despite being good about what he ate, his cholesterol kept going up. One night his wife discovered him in the kitchen, eating half a gallon of ice cream every night. He had no memory of having done it — he was doing it in his sleep. Once he quit taking the sleeping pills his cholesterol went down because he wasn't binging at night. 

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What about the possibility of falling down?

There is impaired balance and diminished physical ability. When an older person wakes up at midnight to go to pee, when he gets out of bed he's still sedated. He'll fall down when he tries to stand up. His motor skills are dulled by the drug. That's why sleeping pills aren't recommended for older people. 

So why do you think people abuse sleeping pills?

No one reads the labels. They're intended for short-term use, not long-term use. With any drug, you should take the smallest effective dose for the shortest period of time. They're indicated for a week, ten days. If you have chronic insomnia, there are better things to use with fewer side-effects. These things are better than popping pills. 

Do you think Big Pharma is pushing doctors to prescribe sleep medications?

Now that there are mostly generic versions, they're not getting pushed. The commercials peaked and then went away. But maybe younger doctors still feel pressure to prescribe them after face-to-face meetings with pharmaceutical reps. 

With multiple studies indicating CBT-I being an effective and safe method for promoting healthy sleep, with no real side effects, drug interactions, or excessive cost, there should be little standing in the way of its use.

Would you classify sleeping pills as deadly?

I recently gave an interview about Prince's death, which was an apparent overdose of painkillers. People can take too much of these medications — they're being overused. There are other ways to deal with sleeplessness, like CBT-i (cognitive behavioral therapy for insomnia). This training is better than taking hypnotics and has no side effects. But it requires patience and hard work. Pills are a solution, but they're not the best solution for everybody. 

Your recommendation for CBT-i falls in line with the recent announcement from the American College of Phyisicians. 

Any drug or procedure in the spectrum of medical therapy should be evaluated with respect to indications, contraindications, adverse reactions and even cost. With multiple studies indicating CBT-I being an effective and safe method for promoting healthy sleep, with no real side effects, drug interactions or excessive cost, there should be little standing in the way of its use.  That is, except for the burden of having someone trained to teach it, and the time commitment to learn it, in this "take a pill and go to sleep" society that we live in.