This article is a transcribed edited summary of a video Bob and Brad recorded in February of 2021. For the original video go to https://www.youtube.com/watch?v=zbAmE7HIxLQ
Bob: Welcome, my friends. I’m joined by Chris, the pharmacist, smartest guy I know. Or at least in the top 5. I’ll give you that. Today we’re going to talk about the truth about sleeping pills, Ambien, Lunesta, Sonata. We might even talk about another one. Are they dangerous? We are going to get into this. Now these are called "Z-drugs."
Chris: "Z-drugs," primarily just because they have the names, the z’s.
Bob: The "Z" is the other name they have.
Chris: Yep, zolpidem, eszopiclone, and zaleplon.
Bob: So, they all have the Z’s in them.
Chris: Yes, that’s why.
Bob: I, unfortunately, have some experience with this. I was always a great sleeper. Like the best sleeper ever. Then I ran into some problems with sleeping and I didn’t have any coping mechanisms. I was already doing all the things that we recommend you try first, all the natural ways that can help you get to sleep. I know the most important suggestion is that you go to sleep at the same time every night.
Chris: Yes, they talk about sleep hygiene. Let’s talk about these numbers, you’re talking about 50-70 million Americans at some point or regularly have difficulty sleeping. That’s a large amount of people in our population.
Bob: And it affects your health greatly.
Chris: Yes, top to bottom, there are so many things that sleep is restorative. When a lot of people that you see approach a pharmacy or talk to your doctor, 70-80% of those problems can be corrected with good sleep hygiene.
Bob: Keeping the room cool, keep it dark.
Chris: Same time every night, easing into the evening, relaxing activities.
Bob: Turning your lights down at a certain time.
Chris: Exactly. Darkness, it starts to bring those melatonin levels up. It’s really important for that. We are a busy society as a whole. As Americans, we are runnin' and gunnin' pretty much from the moment we wake up, running the kids to school, working on a project, working on a business project, I mean, we are just a busy society. Unfortunately, insomnia can encroach on that and a lot of times, sleep hygiene goes out the window. That’s the first place to attack it. So, if you can ease into your night, minimize caffeine, minimize alcohol, leading to your evening.
Bob: Caffeine, it can stay in your system for quite a while. So really probably no caffeine after lunch, right?
Chris: I mean, well lunch, or not much later than 3 or 4 in the afternoon. Some people have incredible tolerance to caffeine so it kind of depends on the person. We have to tailor it to the patient because it depends on their patterns and what they do. If you’re having a cup of coffee at 8pm, probably not going to help with the sleep scenario. Same thing with alcohol which is kind of interesting. If you’re like, “I’ll take a beer before bed and I’ll fall right to sleep.” Well, there’s a paradoxical excitation that can occur with a beer or a glass of wine, which you think is relaxing, but it’s actually stimulating. Then it affects your REM sleep, which is rapid eye movement which is that part of the sleep which is so important to us because it resets our brains.
Bob: It restores us.
Chris: Then we miss out on a lot of that. So that sleep hygiene is critical and watching out for certain drugs that can impact sleep. So, those are some of the non-drug things we can do before resorting to drugs. You do want to see your doctor too. Say you’re going thirty days in a row and you’re not sleeping well, that’s kind of the medical criteria. I tend to be, somewhat impatient. If you haven’t slept in like 2 weeks, you’re probably affecting your immune system. You’re definitely going to be affecting your work life, your social skills, because this can cause you to be short tempered. There’s a lot of things that absolutely affect you. So, we want to be super duper careful. What if it’s a thyroid issues that's not controlled? What if there’s something going on with your adrenal glands? What if there’s something else that’s triggering these types of things? As a pharmacist, there’s no way on earth I could possibly know and that’s why we have to go to the doctor so they can ask the certain questions and run the certain tests. To see if there’s maybe something else out there that’s maybe creating the problem that you just didn’t even know when you’re falling asleep, getting frustrated, beating your head against the wall because, “I can’t sleep.” It is such a frustrating scenario for patients all across the board. It’s awful.
Bob: Right, because you can’t will it. The more you think about it, the worse it gets.
Bob: One of the problems that I have, that a lot of people have, if you go on vacation or a conference, and one time I had trouble sleeping because there was road noise. I didn’t sleep all night, and then I had to go to a conference. I want to make sure that it’s well known here that we are not advocates of drugs. If we can, we try to go off prescriptions, we try to go natural ways, that’s the Bob and Brad Way. But there’s times where you may need to use them for a short period of time or maybe just when you go on vacation or a conference.
Chris: Yeah, the whole invention of this "Z-drugs" in general, was based off of benzodiazepines. The benzos came into effect in the fifties and we thought they were a great drug so then, over time, we realized that there was tolerance and addiction, so in came the nineties. The first "Z-drug "on the market was Ambien or Zolpidem. Early in my career, 25 years ago, you mays well have put it in the water, as far as the prescribing habits at that time. It was so proper because it worked great and really the distinct advantage of the "Z-drugs" that they have over benzodiazepines and the false impression that they get, they are safer but there’s a caveat to that. Long term, whether it’s a benzo or if it’s a "Z-drug," they’re not designed for long term use. Yet, I’ve got patients that have been on it forever. There are newer studies that suggest that it could be affecting your memory.
Bob: Dementia, right?
Chris: Yes dementia, and some of those studies are conflicting too. It’s kind of tough. There’s an interesting doctor that had talked about a discussion that he had with a patient to try and get her off of one of her sleeping medication. It was met with a lot of animosity and it’s tough because when we don’t get our sleep, it’s kind of like taking away your best friend. It’s like, gosh, you can’t take that away from me because how am I going to get rest?
Bob: If I don’t sleep well, the day is not going to go well. I mean, it can ruin vacations.
Chris: Well yeah, it can ruin performance. You have to be focused at work or even just with family and friends. Having proper sleep fixes a lot of other ills. It’s restorative, it’s helpful to your immune system. It’s critical to get that sleep. It’s such a hard challenge and that’s why your doctor is so incredibly important in trying to find the right mix for you to keep you safe.
Bob: Along with the end goal of trying to get off of them. It’s a temporary fix.
Chris: If you look at like, you take Kaiser Permanente, which is a West Coast health system, which is about 12 million members strong, their optimum goal is to have everybody no matter what they are on, only two weeks of consistent use before we want them to either taper or discontinue. Going forward and then used only intermittently, like that occasional night where, “oh, I had a crazy day and I just can’t unwind.” Then it’s very appropriate to use. Within the three drugs, whether it’s Ambien, Lunesta or Sonata, which again would be the zolpidem, the eszopiclone, or the zaleplon, in that order for the generic names: the doctor’s going to be very critical about selecting which ones the right one for your particular situation. With the Ambien, it has an extended-release formulation, and Lunesta has a longer action. So, we have to be careful.
Bob: Ambien has both forms right?
Chris: It’s an interesting drug. It’s pretty cool. It works for four hours and then you get a burst four hours later that keeps you to sleep. It’s for people that actually can wake up. That’s the problem. We will pick on Ambien. When people use drugs, like this one, on a regular basis, over and over again, actually loses its effectiveness.
Bob: That’s what I found, because I was on Ambien. It worked fantastic, ½ pill is what I’d take, and it took the hour to fall asleep. Then it went to the point where it only would work for three hours.
Chris: Yep. You develop a tolerance to all these medications relatively quickly. The Sonata, or the Ziaplon, is interesting because it really only works for about an hour. It’s designed for people that just can’t fall asleep. Within the dosing guidelines for the FDA and actually the manufacturer says if you wake up within four hours and you have at least four hours more you have to sleep; you can repeat that dose. It’s so short acting but it’s interesting that all these "Z-drugs" can get this weird amnesia effects. When you take this drug, you want to go to bed right away. That is absolutely critical.
Bob: You can feel it working. I could not sleep, and it put me to sleep.
Chris: Absolutely. The thing is it can put you into a hypnotic state. Basically, you can sleep-eat, you can sleep-walk and say, “Man, I want to go to McDonald’s and get a shake,” and all of a sudden, you’re sleep driving and you drove through somebody’s front yard.
Bob: They call that ambient zombie or "Z-drug" zombies.
Chris: Yeah, it’s a powerful, powerful drug. So, when you take it, you go to bed right away.
Bob: Yeah, people were found binge eating, cleaning their house, driving a car, having sex.
Chris: Yeah, lots of strange things but also getting really weird things that show up from Amazon the next day. You’re like, “Oh my gosh, I got a $10,000 blender”. I mean, we can laugh about it, and it is kind of funny, but it’s not because you can not fight these drugs. They are very powerful.
Bob: Roseanne Barr made that racist remark, she blamed it on Ambien, and the Ambien manufacturer.
Chris: They backtracked it.
Bob: They said no, they said racism is not a known side effect of Ambien.
Chris: In today’s society, that’s not an excuse and that’s why she was fired. Rightfully so. Social exceptions, that’s not there, but the drugs do have these very powerful effects. We have to respect them. We have to use them effectively. It’s very, very critical for that.
Bob: The thing I found out, Chris, as I started weaning off of it, the fact that it was just there; helped. Like, I’m going to go to sleep and if I can’t get to sleep then I can just take this and that calmed me down and it stopped my mind from spinning.
Chris: Yeah, just knowing that it’s there, there’s a psychological aspect to it and there’s a physical aspect to it. Like I said before that tolerance does develop. I had a conversation with one of my patients yesterday, she said she tried everything, did the counseling, and so there’s still millions and millions upon Americans that these are a very requisite and very appropriate portion of their lives. Yes, we want people to use it as minimally as possible, but sometimes there’s just times for whatever reason, brain chemistry, psychological chemistry, history, I mean, there’s a lot of other things that are going on underneath the surface that the doctor needs to get to. They work exclusive with the patient to ensure that we are getting the best possible care and try and keep them safe as possible. But yeah, just have that psychological factor that just knowing that you can just go to that. Some people say, I can go three days and kind of wing it. But that fourth day, I’m going to have to take that medication. Sometimes that’s enough. That’s when we get you back in, we get you reset and you’re good to go. Exercise, minimizing caffeine, sleep hygiene. We put it all together in a complete package and then hey, we have a better quality of life.
Bob: With the Ambien ER, obviously you can’t cut that in half.
Chris: No, you cannot split that because what will happen, you’ll get a bolus dose, your stomach acid is going to degrade that. And it’s basically going to launch all that Ambien into your system.
Bob: How would that be if you only took half of it?
Chris: Well, you’re just going to churn through it. You’re going to take half the drug but you’re going to get all the drug that’s in that half table and it’s just going to elute out into your system. If it’s a compression matrix tablet, it’s actually kind of interesting. The manufacturer’s quite genius when they did this. Basically, they just found a way to get it around your stomach acid, get it into your gut. So, it has two parts. You have your immediate release and then, four hours later, boom, it’s absorbing again but it’s absorbing in the intestines rather than, well they all absorb in your intestines, but the first round passes the stomach acid that helps to get it going, gets in the intestines, absorbs in your system and then makes you tired. And it works within 20 minutes.
Bob: So, I tried the Lunesta too. That seemed to keep me asleep longer. That was eight hours.
Chris: Yes, it does. You have to give yourself, especially that constantly point for pharmacists is, you want eight hours and even realistically, probably 10 hours out of your system because if you’re driving and all of a sudden you get into a car accident. You say, “I took my Lunesta last night.” Well, that’s operating while intoxicated so that is a risk. That’s something that we have to be careful with. As we age, that’s another big risk because unfortunately as we age, our metabolisms slow down, drug stays in the system higher and longer.
Bob: Also, when you age, sleep becomes more difficult for a lot of people.
Chris: It does, for a lot of different reasons. We talk about our sleep cycles. It’s very important as we age. Like, a newborn, they sleep 16 hours a day. If you’re a new parent, five minutes at a time.
Bob: As a teenager, I could sleep 12 hours.
Chris: Yeah, but you had a lot of growth changes going on. I think we all could. It’s interesting, sleep cycles themselves, by the time a child is 5 years old, it mimics an adult. It’s just a longer period of time in the four phases of sleep. It’s kind of interesting when you look at it from that response. More importantly, with respect to these medications, and you use the example of Ambien ER, and also your Lunesta. You want to make sure that you have that 8-hour gap, minimum, before you consider thinking about things that require more thought or focus like work or business or driving. If you’re going to do a workout, it could actually affect your coordination.
Bob: We were going to mention this too, Chris. I actually had a fall and what had happened, one, I didn’t have the lights on in the room. But I got up and it’s in the middle of the night and I was on Ambien and I was trying to get to the bathroom, and I was all over the place. I was tired.
Chris: It absolutely messes with you. From a coordination standpoint and again, as we age, that’s why the importance of these things is we have to be exceedingly careful with the prescribing of them. You’re a very coordinated person and it took you for a loop. As we age or maybe some of our muscles aren’t firing the way we want it to, let’s say we’re 75 years old. You take that fall, you hit your head on the counter, you could break a hip.
Bob: You could kill yourself even. It can be a downward slide after that.
Chris: It’s that serious. That’s why we have to be cautious with that. We don’t need as much sleep as we age but that’s not to say that you still need sleep. It’s very, very critical. It’s funny when you look at different species. Like a giraffe only sleeps 30 minutes a day. Which I thought was really kind of interesting. It’s funny.
Bob: Humans are the only ones that are not following the sleep cycle of sunlight, because we can artificially create light so we can work longer hours, a bad thing for humans actually.
Chris: Yeah, you know or shift work makes it very challenging; people that travel for a living. Like you said, you have trouble in hotels. I mean, there’s a lot of appropriate uses for these "Z-drugs," but you know, again, you want to use it with a level of caution.
Bob: Now, what would you recommend as far as length of time?
Chris: Well, the guidelines that are kind of being placed in now, currently, they really say two weeks of consecutive use and then to taper and/or try and find another mechanism. And even when you’re using the "Z-drugs," asleep hygiene still has to be a mainstay of everything that we do. It’s getting actually adequate sunlight during the day if we can, which, if we work at a 9-5 position, we’re in the Northern Hemisphere for us here, sun’s gone by the time we get out of work. It doesn’t always work to our advantage. If we can though, we’d like to get some outdoor activity, if it’s at all possible, even though it’s cold. Because daylight is important so hopefully there’s a window or something that we can at least get some of that. The reality of it is, you still want to fall into that sleep hygiene pattern. Try it and use it.
Bob: I want to warn against this, and I’m sure you’ll back me up on this 100%. Taking melatonin and if you keep taking it, your body stops manufacturing it, am I correct?
Chris: Yeah, some of the studies suggest if we repeatedly take the over-the-counter supplement melatonin, that it can actually shut down our natural system. Basically, when it gets dark out, melatonin goes up, makes us tired, and when it’s light out, it drops, and we wake up. That’s our circadian rhythm. It’s critical for our functioning and you know, we have so many people now that work third shifts. There are physicians, there’s nurses, there’s manufacturers, there’s just people that are night owls. It’s still so critical for us to make sure we get that adequate amount of sleep. When we use these drugs longer than that, the studies actually show that if beyond two weeks, you actually revert back to the same sleep patterns you had pre-drug. So, you really want to use it for a short period of time, get your body caught up so that you’re functioning cognitively and feeling well, because sleep also affects our immune systems, the way we feel, our behavior, I mean, it’s everything. Once we can get reset, we want to try and rely on our own natural methods to try and sleep. Then for the occasional use or difficulty sleeping, it’s there for you. For some people, though, I mean, you have people that have PTSD and a lot of other things that are out there and there’s a multitude of other medications that the doctors will certainly try and/or encourage. Sometimes it just doesn’t work that way.
Bob: You might be someone that’s having difficulty with pain too and having trouble sleeping because of that.
Chris: There’s a multitude of reasons why doctors have people on these things long-term. The guidelines are one thing, but each situation is individual. We’ve got, what, 340 million Americans? So, there’s, you know, we’ll call 70 million Americans that have each individual different sleep issues on a given day. And so, we have to treat them each as individuals and what’s best for them. What works for Bob might not work well for Chris. It just kind of depends on the person and what we can do to try and keep ourselves going forward in the healthiest way possible.
Bob: I’m really happy that I’m completely off it now. And you only get by on what, 4 hours a sleep a night?
Chris: I’ve got problems, ha-ha.
Bob: Thanks everybody and check us out on all our channels.
Chris: Thanks everyone!
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