I sat at my breakfast table a few weeks ago preparing to meet a new patient. I'll call him Mr. B. Admitted to the hospital overnight, he was to be transferred to my care when I arrived at work later that morning. I clicked through his chart ahead of time, reading eagerly about the heart disease that had perplexed a number of doctors from surrounding towns. I jotted a few important notes and headed to work to begin solving his case.
Unfortunately, I never got the chance. Arriving at the hospital, I found out from overnight staff that because of insomnia, Mr. B had received a customary dose of Ambien the night before. He had awoken confused, and after trying to get up to use the restroom, had fallen and struck his head. Rapid evaluation revealed a significant brain bleed, and he was quickly transferred to the intensive care unit for treatment.
While Mr. B's case is thankfully much more severe and dramatic than most, it highlights a recent swell in attention around sleep medications. In January, the FDA issued a statement about Ambien (the brand name for the drug zolpidem), one of the most popular insomnia medications in the U.S. The agency recommended using lower bedtime doses than we'd previously been prescribing, out of concern that current doses could leave people impaired the next morning. They recommend the cut even for patients who haven't ended up feeling groggy, and especially in women (who don't metabolize the medication as quickly as men). The recommendations also included a warning to insomnia medications in general:
As doctors debated the merits of these claims, Ambien made the news again last month when a national study reported that the number of emergency department (E.D.) visits related to adverse reactions from Ambien has risen by almost 220% in 5 years:
- The number of zolpidem-related E.D. visits involving adverse reactions increased nearly 220 percent from 2005 to 2010.
- Females accounted for two thirds of zolpidem-related E.D. visits involving adverse reactions in 2010. Patients over 65 represented one third.
- Half of visits involved patients who had combined other medications with zolpidem, including narcotics, anti-anxiety medications, and other insomnia meds.
The most common complaints in these cases were "daytime drowsiness, dizziness, hallucinations, agitation, sleep-walking and drowsiness while driving."
The ripple effects of these developments have continued through last few weeks. The FDA formally changed labels to specify lower Ambien dosing recommendations, and news of these findings were published this past week in the one the most widely read medical journals. Amid all of this, incidents like the one involving Mr. B, in which patients suffer harm after taking traditional doses of sleep medications -- have come under close scrutiny.
As a physician who treats adults suffering from insomnia, the fallout has been palpable. Dozens of patients have asked me recently about sleep medications during their clinic visits and hospital stays. Some carry printed-out news stories; others pull up bookmarked stories on mobile RSS feeds. Some want to try out the medications; others want to stop taking them. Ultimately, they all want to know the same thing: Are these sleep medications good or bad?
The reality, I've been quick to tell them, is not so simple. On one hand, sleep medications like Ambien can work, and work well. Insomnia can be debilitating. Many have used them safely and effectively, and some people swear by them. On the other hand, they can lead to dependence and worsen the mental clouding that many insomniacs already experience. More importantly, by limiting discussions to specific medications and their doses, we miss a fundamental issue in treating insomnia: sleep hygiene. By focusing on "hygienic" habits around sleep (avoiding napping, not eating or drinking caffeine or alcohol right before bed, establishing regular bedtime routines, exercising, using beds only for sleep, etc.) many people can achieve better sleep. Adopting those habits can often mean that medications can be used more sparingly, and at lower doses, if at all.
Instead of final judgments about drugs like Ambien, then, recent recommendations should encourage us to practice good sleep hygiene and then supplement that with as little medication as possible. Instead of simply labeling drugs as good or bad, recent developments remind us that judgments depend on when and how the sleep aid medications are used, and in whom.