The back of the alphabet is pushing for primacy.
The masked avenger Zorro appeared in 1919; the remarkably popular Z cars television crime series transfixed Britain in the 1960s.
Now is era of Z drugs. Zolpidem, zaleplon, and eszopiclone – respectively named for the commercially minded ambien, sonata and lunesta – are today’s wildly popular sleeping pills culled from the older and still very commonly used benzodiazepines. The Z drugs have done more than take over the sleep by pill industry; they are now the leading cause of psychiatric adverse drug reactions.
The numbers come from large scale surveys done by the Centers for Disease Control in the years 2009-2013, a nice review appears by Paula Span in the New York Times. Zolpidem (ambien) alone produced 11.5 percent of all ER adverse psychiatric drug visits—fully among the elderly.
Ambien is number one.
Last year Dan Kripke and colleagues reported these same Z drugs increased death rates in regular, daily users five fold. Scandinavian research puts the increased death rates as not quite as severe, but uniformly higher.
What’s up with the Zs? Why are “safe” sleeping pills producing such mortality and morbidity?
Let’s take a look.
How Do Zs Work?
The human information system possessed on its cell surfaces many benzodiazepine receptors. Two prominent forms are found in the central nervous system (brain and spinal cord) while one version is located on nerve cells everywhere else. Plug a drug into those three receptors like a key into a lock, and people often become sedated, relaxed, less agitated, mellow. Thus was spawned the famous benzodiazepines (BZs) of the 1960s—Valium, Librium, Ativan and their many cousins.
Looking for the perfect sleeping pill, industry logically looked for drugs that would hit one or two but not all three BZ receptors. In the Z drugs, they found ones that hit only one receptor in the brain, producing quick sedation. Many billions of dollars in profit followed. So did reports of bizarre behavior plus falls, accidents and deaths.
Why The Troubles?
There are probably many reasons. One is that hitting only one BZ receptor doesn’t appear to produce full, normal sleep. Some researchers describe the Z drugs’ effects as a sort of “pre-coma” which then allows the body to more easily shift into sleep.
It’s the “pre-coma” part that begins creating problems. If you take drugs like ambien and don’t immediately get into bed, the “in-between states" produced by these drugs—neither sleep nor wake —may cause very odd results.
My media favorite is the Calgary man who declared Ambien made him sleepwalk to his refrigerator where he downed a quart of vodka and promptly drove into several accidents. A more recent example comes from a lovely woman I treat—a strict vegetarian—who woke up with hamburger in her teeth, having devoured her carefully packed husband’s lunch in a middle of the night. She had no idea how that hamburger got there.
Visit a group of sleep labs and you’ll find many of their adult sleepwalking episodes are linked to Z drugs.
A further difficulty arises from the supposed advantage of these medications—their short duration of action.
With a half life of one to two hours, ambien should be “out of your system” well before you awake. It’s gone, so there’s no problem, right?
Wrong. A previous drug company incarnation of such a “safe” short acting sleeping agent was the drug triazolam, or halcion. Several European governments banned it after it caused numerous psychotic reactions, particularly among the elderly.
A further difficulty of these drugs is that they produce amnesia. People don’t know what they did “under the influence.” They can’t remember.
It’s also one of the reasons people feel they slept “well.” Drugs like ambien make people forget how often they woke up. So they feel as if they “slept through the night.”
How effective are they overall? Studies of sleeping pill studies argue they may add 11-14 minutes sleep for imsomniacs when first used.
Amazingly, despite the potential warning of short acting halcion, the FDA allowed a “smaller” dose of zolpidem/ambien to be marketed under the name “Intermezzo” for middle of the night insomnia.
If something provokes psychotic reactions, sleepwalking and higher death rates, taking a lower dose at 3 AM can’t be that bad, can it?
Why Are These Drugs Popular?
Sleep is a necessary part of normal human regeneration. It should be as natural as breathing.
In 21st century America, sleep is not so natural. Human sleep used to be consist of three phases— first sleep, after lights out; second sleep, with perhaps an hour of musing following first sleep, ending with “final” waking around dawn; and third sleep, or what we call naps.
Now we have the post-industrial American model of sleep, the “lie down and die” version.
Watch TV, throw off clothes, jump in bed. Immediately slumber, waking suddenly when the alarm goes off, fully refreshed.
That's a fantasy for almost all of us. But drug companies like selling fantasies. And they will sell you the pills to fulfill the fantasy.
But as most of us know, living on fantasies sometimes provokes tragedies. Humans are not machines. If we treat our bodies as machines, we face many perils.
One solution is much more interesting: getting people to use their wondrously regenerative bodies the way they’re actually built.
That means having a rhythm to the day, a time to move and a time to rest. To take the time and make the “effort” to rest before sleep. To not turn sleeping into a job. To recognize that sleep restores, refreshes, and literally rebuilds much of the body, beautifully and regeneratively.
You are partially reborn every morning you awake.
Sleeping certainly pills have their place, especially for brief use, for sleeplessness in times of storm and stress. But they don’t produce “normal” sleep. And the people who take them habitually, lured by the promise of “perfect sleep” should be carefully coaxed off of them, so that they can enjoy the astonishing merits of their normal regenerative activity.
It’s time to say goodbye to the equation pill=sleep. The public health costs, in money, emergency room visits, increased accidents and deaths, are too large.
And yes, there will be an apps for sleep—many apps. But the simplest trick is to rest before sleep.
That’s what regeneration is all about.