You Probably Need More Sleep

Judging from the number of commercials about sleep disorders, it could be inferred that this is a very common problem. Actually, this inference would be correct. Most people, at one time or another experience difficulty falling asleep (onset insomnia), staying asleep, or with early awakening. These people know they suffer from a sleep problem, one or more of the forms of insomnia. They know they are not getting enough sleep, but even if you are getting the seven to eight hours that every commercial for sleep aids tells you is a good night's sleep, you probably need more. Research on sleep has consistently shown that people work better, feel better, and get more done if they average about nine hours of sleep instead of eight, and many people, perhaps most, get less than eight hours, even if they don't think they have sleep problems.

There is certainly no lack of companies that offer to sell solutions, mostly pills, for our epidemic of sleep disorders. In addition to drugs, we are offered types of sounds, smells and bedding, each of which, we are told, will allow us to gain an adequate amount of restful sleep. Let's look at some of the more common of these "cures" for our sleep ailments. This is not medical advice and I will not mention specific drugs but refer to classes and types, with one exception, an over the counter sleep aid. I have no financial interest in this, or any drug or program. This is solely for informational purposes.

Over the counter sleep aids:
These fall into several categories, the most common of which contain some form of anti-histamine, substances that block the cholinergic, specifically, histamine receptors in the central nervous system, one of the effects of which is sedation and hypnosis (sleepiness). They also have several other effects, such as drying up bodily secretions, which may not be desirable when all you want to do is go to sleep. Do these drugs work? In a way, yes, they do make you sleepy but they don't promote particularly good sleep in the sense of the normal progression through all of the stages of a sleep cycle. Moreover, they tend to have long periods of action which result in the groggy 'hangover' feeling in the morning.

Herbs
Recently, a plethora of herbal medicines (most of Asian origin) have appeared. Some of these have mild hypnotic effects. These are too numerous to go into any detail, but they all suffer from the same problems. For one thing, they are poorly standardized so that you don't know what, or how much, you are getting. Another problem is that the mechanism of action is poorly understood for virtually all of them. As the complete mechanisms of action of most of the drugs we take are not well understood, this is not quite as big a deal as it might sound, but even less is understood about most of them than is known about the prescription sleep aids.

Melatonin
I am putting this in a category by itself for several reasons. For one thing, its mechanism of action is reasonably well elucidated, it is well standardized, it works, and it is the most physiologic (natural) of all of the pharmacologic sleep aids available - period. More about this, later.

Prescription sleep aids
Prescription sleep aids come in a wide variety of types. First a quick word about three classes of drugs, hypnotics, sedatives, and tranquilizers. All of the drugs in these classes are behavioral depressants. The primary difference between sedatives and hypnotics is in degree. In theory, tranquilizers are a bit different in that they have more of an effect on certain behaviors (anxiety, anger, fear) than on general activity level. Whereas sedatives and hypnotics suppress all activity, tranquilizers are intended to reduce the negative activities while not affecting the positive ones, so that you maintain alertness. Unfortunately, there are few drugs that can actually have markedly different effects on the types of activity, but some come pretty close. True tranquilizers are not, properly, used as sleep aids. However, there are very few true, pure tranquilizers so that some drugs that are marketed in one dose as tranquilizers are marketed in a larger dose as hypnotics. More often, closely related drugs with essentially no significant difference in action are separated so that one of them is promoted as a sleep aid, and the other as a tranquilizer. The reasons are usually more fiscal than physiologic.
Over the years, there have been a wide variety of different drugs that have been used to induce or help sleep. From narcotics (after all morphine was named for "Morpheus," the Greek god of sleep) and barbiturates to an entire panoply of different compounds, all of which have some sedating effects. Prominent among the more recently used agents are a class of drugs that were designed and marketed as tranquilizers, that is, as having more effect on anxiety and generally negative behaviors than on overall activity level. These are known as the benzodiazepines.

The truth is, however, that they are, in fact, sedating and that all of them can be used for sleep. It only requires a higher dose than that which is generally used for anxiety. These have one advantage over many of the other agents. They are generally reasonably safe in overdose, so that the larger doses required to produce sleep, are not, in and of themselves, dangerous. There is an important catch to that, however. They have additive and interactive effects with many other drugs, including alcohol, so that mixing any of the benzodiazepines with other drugs, or drinking heavily while using them is actually dangerous. Also, they are addictive. It is not as easy to become addicted to these drugs as it is to narcotics and some other agents, but once you do, it is extremely hard to break the addiction, sometimes resulting in seizures.

Recently, there have been a plethora of new agents whose abuse and addiction potentials were supposed to be less than the benzodiazepines and most of the other older agents. As is usually the case with newly introduced drugs, the claims were generally premature, some of which the manufacturers undoubtedly knew when they were introduced. However, most of these have short half lives, meaning they leave the body fairly quickly and do not have a long effect. Many of the older drugs either stayed in the body longer, or have active metabolites (breakdown products) that stay in the body, causing drug "hangovers" and morning "grogginess." Not having difficulty arising in the morning is a good feature for a sleep agent.

Moreover, several of the new agents have very low physiologic addictive properties. Oh, you can get psychologically dependent, but that's not nearly as bad as being genuinely addicted to a drug so that stopping its use causes very uncomfortable and sometimes dangerous withdrawal symptoms. When discussing sleep aids with your physician, be sure to explain the length of time you can devote to sleep, and, whether you like it or not, be honest about any tendency to overuse or abuse drugs. However of most importance, be sure your physician is aware of every drug you take, including over the counter drugs of any sort as well as how much alcohol and caffeine you take in any form (coffee, tea, colas and other soft drinks contain caffeine or closely related drugs in the same class). Your physician will need to know this to choose the agent most likely to help, if any.

At least one of the new prescription agents has virtually no addictive potential, works fairly well, and has little or no hangover effect. The trade name for this drug is Rozeram, and it is essentially a "prodrug" that produces melatonin, mentioned above. It is, of course, much more expensive as the over the counter melatonin and, as far as I can tell, almost as good. (But melatonin is not a high profit item. Get the picture?)

As an editorial comment about profit and marketing, the intelligent consumer needs to watch for a common ploy. At about the time the patent is running out on a drug, a new, improved form of this drug will suddenly be released and heavily advertised by the original manufacturer. Often, this "improvement" is simply a slightly different delivery system. By adding a means of slowing the release of part of the active drug, and putting letters behind it, such as CR, for continuous release, ER, for extended release, or SR, for slow release, for example, the drug is advertised as a vastly improved product. What it really is is a vastly more expensive product that can then be awarded a new patent. Is it also an improvement?

Usually, no; occasionally, yes. Most of the time it's a new coat for an old drug that adds little, if anything, to its usefulness. For example, a very popular prescription sleep aid has recently exceeded its patent, meaning that other manufacturers can now sell it for a much lower price. Suddenly, a new form hit the market (and was granted a new patent). This pill, had a coating to "put you to sleep fast," and another layer to "keep you asleep." The fact is that the original formulation "put you to sleep" slightly faster, and kept you asleep about the same length of time. The half life and length of action of this drug was nearly ideal in the first place. The new, much more costly, form, did deliver a slightly smoother blood level but that provides little, if any advantage, except to the manufacturer. Given the massive promotion and advertising, with abundant samples provided (for a little while) to the physicians, it is prescribed and used a great deal, and the much cheaper, generic form has limited sales. And even if your insurance company pays for it, you pay for it in the end.

Some extended release preparations are quite rational. They can provide a smooth blood level when this is important (for example as with lithium) and/or they can reduce the number of pills the consumer has to take in a day, which is very good for compliance. However, many, as the one described above serve no purpose for anyone but the manufacturer. Why are these usually granted new patents? The answer is that our food and drug administration has plenty of money for a failed effort at controlling the flow of illegal drugs, but none for drug testing or even supporting tests by others. The net result of this is that they are dependent on outside studies, most of which are funded by the drug companies themselves, for their information on which to make judgments regarding the efficacy, safety, and necessity of new drugs marketed. To say they are handicapped by political decisions is to understate a very serious problem.

So, what should someone with a sleep problem do? First, the problem should be defined. How much sleep does the person get; how much does the person need; and what is causing the first to be less than the second. In other words, analyze the sleep pattern. Many sleep difficulties will yield to a simple examination of habits. There are several things that nearly all of us know about good sleep hygiene, but surprisingly don't always follow.

•Do not try to sleep immediately after vigorous exercise.

•Do not try to sleep immediately after a substantial meal.

•Obviously reduce extraneous light and noise.

•Sleep in a place that you do nothing else. (Well...maybe a little else.)

•Do not drink coffee, tea, or other stimulants within six hours of sleep.

•Do not drink alcohol heavily before sleep. Although this can make you sleepy, it will also disturb your sleep during the night in several ways.
There are several important points that are a little less obvious.

•As much as possible, arise at the same time every day and go to sleep at night when you feel sleepy. This works much better than picking a time to go to sleep and trying to force yourself to sleep at that time.

•Learn your own pattern about such things as reading or even television. Although they distract some people and interfere with sleep onset, some others find that a routine that involves watching a little T.V., listening to a little music, or, particularly, reading for a few minutes before sleep is a good way to relax.

•Sexual activity? Usually helpful before sleep; a possible exception to the exercise rule, but to each, his or her own.

One issue deserves a separate mention. If you are sleeping enough, or think you are, and still feeling tired, particularly when you arise, examine the possibility that you may be suffering from a serious sleep disorder such as sleep apnea. Sleep apnea, particularly the common, obstructive kind is much more frequent than people think and it is potentially very serious. If you snore, it would be a good idea to have someone observe your sleep for an interruption in your breathing. If there is any doubt, do not delay consulting a specialist and having a sleep study. In fact, if you institute good sleep habits, and still have trouble sleeping or feeling as though you have not had enough rest, consulting a sleep specialist is a very good idea, better than just asking your primary care physician for a drug. Some sleep specialists require a referral from a primary care physician. If this is the case, and you have a problem that is not easily solved, request your physician to make such a referral.
Have a good night.