Mr. Sandman . . . : New Sleeping Pills Work Where Old-Fashioned Remedies Fail

INSOMNIA IS ONE of the most common complaints our patients have. By the time they come to our office, they usually have tried the common remedies--a glass of warm milk before bed, regular exercise, over-the-counter sleeping pills. What they want from us is something that will work, perhaps a prescription sleeping pill. What they probably will get is a lot of questions.

We first focus on figuring out why the patient can’t sleep. If someone tells us that he’s been sleeping poorly for several weeks, we look for an underlying condition, such as arthritis, heart disease or severe depression. In those cases, treating the underlying problem also treats the insomnia. Sometimes the culprit is a medicine the person is taking, and when the medicine is stopped, sleeping returns to normal.

Most often, though, people come to us because stress or bad habits have disturbed their usual sleeping patterns. Sometimes, the cause is easy to pinpoint: A woman had trouble falling asleep while her husband was in the hospital recovering from surgery. Students often sleep poorly around exam time. For insomnia caused by anxiety or stress, meditation or other relaxation techniques can help. We also suggest psychotherapy or other counseling. We are not averse to prescribing medication. There are certainly plenty of prescriptions being written for sleeping pills. California pharmacists fill an estimated 10 million prescriptions each year for benzodiazepines--a group of drugs that includes all 12 of the most common sleeping and anti-anxiety pills. (Halcion is a benzodiazepine, as are Valium and Xanax.) The problem is that all of the benzodiazepines pose certain risks. They will help you sleep, but most have the potential for abuse, some cause side effects such as daytime confusion or falling, and some can bring about a very unpleasant withdrawal syndrome.

Assemblywoman Jackie Speier, a Democrat from South San Francisco, believes the problems with these drugs are serious enough that prescriptions for them need tighter controls. New York state already has a controversial law that places benzodiazepines in the same class as narcotics, barbiturates and amphetamines and subjects them to the same controls.

Why would anyone take potentially risky sleeping drugs? Because insomnia can be extremely disturbing. Most people function poorly when they are deprived of sleep, and for some, just a few sleepless nights can start a vicious cycle: Worries about whether one will be able to sleep lead to a greater problem with insomnia. A 35-year-old man who experienced this anxiety described it as “freaking out.” “Without sleep, I know I won’t be able to perform well at work the next day, and thinking about that makes it even more difficult for me to fall asleep,” he says.

For those whose insomnia is exacerbated by worry about falling asleep, we suggest trying to improve what sleep experts call “sleep hygiene”: Try to wake up at the same time each morning. Avoid naps, drink less coffee and alcohol and smoke less. If unsuccessful after 20 minutes to 30 minutes of trying to sleep, heed the classic suggestion: Give up. Get out of bed and go to another place. Read, watch TV, listen to music--you pick the activity--and return to bed only when you feel drowsy.

Consider also keeping a “sleep diary” to record your activities before bedtime, the amount of time it takes you to fall asleep, and the number of times you awaken during the night. The diary will let you know how many hours you are actually sleeping, and it can be of great help to a doctor looking for clues to the cause of your insomnia.

If all that fails, we recommend a pill. Over-the-counter sleeping pills are not generally very effective. But diphenhydramine (Benadryl), an antihistamine that recently has been made available without a prescription, works well for some people. One or two 25-milligram tablets may make you drowsy enough to sleep. Benadryl does not pose the risks of benzodiazepines, though it is not entirely risk-free. If you are on other medication, be sure to ask your doctor before adding Benadryl, since it could interact. If benzodiazepines are prescribed, you should select a drug carefully with your doctor. Ask about the different drugs, how they work and what the side effects are. The choice of a particular drug at a given dosage is crucial. Some guidelines for taking sleeping pills safely:

Avoid taking them nightly, because these pills can be addictive. If you do take a benzodiazepine every night for more than that, do not stop taking it suddenly; that can cause withdrawal. Instead, ask your doctor how to taper off the drug.

If you need a pill for more than a week, we recommend taking a drug, such as Restoril, Serax or Ativan, that won’t accumulate in the body. Take these an hour or so before you plan to go to bed because they won’t take effect immediately. Don’t be fooled into taking an extra pill to get it to work faster. If you need a pill that works faster, you’ll need another drug.

Valium and Dalmane work more swiftly, but after a few days they do begin to accumulate, causing daytime drowsiness, impaired mental functioning, even confusion.

Halcion and Xanax are popular and effective, but we prescribe them only if other drugs fail. One problem with Halcion is that it causes short-term memory loss. In one famous story, a man took the drug so that he could sleep on a plane. When he arrived at his destination, he could not remember why he was there. At higher doses, Halcion also has been associated with a syndrome known as “rebound insomnia,” in which a person who takes the drug for a week or more becomes unable to fall asleep without it. Xanax, marketed to treat depression, anxiety and sleeplessness, causes a difficult withdrawal syndrome in some people. They feel as if they are in a state of continuous panic over which they have no control. Therefore, it can be more difficult to stop taking Xanax than the other drugs in its class.

As people age, their bodies become more sensitive to the side-effects of medication. Elderly people should avoid most sleeping pills because they are at considerable risk for memory loss, confusion, hallucinations, even physical instability, leading to serious falls and fractures. Elderly people who need a benzodiazepine may try Serax, Ativan or Restoril, being sure to limit themselves to the lowest dose.