Sleeping Pills - the downside

The most popular prescription drugs for insomnia these days are Ambien, Lunesta and Sonata. Many people also use pills called benzodiazepines, such as Valium, Restoril, Ativan, and Xanax. While effective, such pills have side effects and can be habit forming if used continuously. Sleep apnea can become worse with these powerful sleeping pills. In some people, Ambien is associated with sleepwalking, and eating when asleep without conscious awareness. Driving under the influence is hazardous. Elderly users of these medications have an increased risk of heart failure, falls and cognitive side effects.

The most problematic aspect of these prescription drugs is found in an article published in the British Medical Journal on February 27th, 2012. Entitled Hypnotics’ association with mortality or cancer: a matched cohort study, this article concludes that people who received prescriptions for sleeping pills had an increased risk of death or a cancer diagnosis, when followed for 2.5 years between 2002 and 2007. The word ‘hypnotic’ refers to a medication causing sleep. The study was done at Scripps Health in San Diego. The authors searched the electronic medical records of a large health system in rural Pennsylvania, and matched 10,529 patients who received sleeping pill prescriptions with 23,676 matched controls who did not. The average age was 54 years. Patients prescribed any sleeping pill (Ambien, Lunesta, Sonata, benzodiazepines, barbiturates and sedative antihistamines) had an elevated risk of death, with a dose-response association. Even people taking 18 pills a year or less showed some increased risk. Sleeping pill use in the upper third of the cohort was associated with a small but significant elevation of a cancer diagnosis. The researchers did not think that the death or cancer hazards were associated with pre-existing conditions. The authors stated that 24 previous studies have shown an association between use of prescription sleeping pills and mortality. No studies have shown that the use of such pills prolongs life or prevents cancer!

The mechanisms involved in these associations have yet to be worked out. The authors state that sleeping pills can increase depression, and when used with alcohol can lead to accidental death. Suicide may be a factor in some cases. Ambien can lead to ‘heartburn’ - regurgitation of food mixed with stomach acid that can injure the esophagus or lead to respiratory infections. Laboratory studies with rodents show that sleeping pills can cause chromosomal damage. This finding could be related to the rise in cancer.

Here are some conclusions I draw from this disturbing study. If you have been given prescription sleeping pills in the hospital, or at a very difficult time in your life, don’t worry. The use of such pills for people who are dying is absolutely justified. However, for most of us it is better not to take prescription sleeping pills. If you have been using them nightly for more than two weeks, you should decrease the dose very gradually; you may want to talk to your doctor or nurse-practitioner about a schedule to help you get off them.

What should we do to fall sleep and stay asleep more naturally? Sleep researchers say we should maximize our own output of melatonin – the sleep hormone. Melatonin is secreted by the pineal gland in our brains as darkness falls. It makes us sleepy and reduces our body temperature. When we turn on the lights and stay up late working or playing, this reduces the time we are in darkness. Less melatonin is put out, and sleep can become elusive. We may fall asleep, but not stay asleep – a common complaint of older people, who secrete less melatonin with advancing age.

Instead of deploring the genius of Thomas Edison, we can be grateful for current researchers who have found out how we can live with the advantages of light and still sleep. Studies have shown that it is the blue component in light that causes the most melatonin suppression; it is possible to block blue light by wearing goggles that filter out over 90% of the blue light. By putting on these yellow-orange goggles for 1-2 hours before bedtime, melatonin will flow out and sleep will improve. You can find these goggles, which can be worn over reading glasses, at LowBlueLights.com, with a lot of interesting commentary on why they are effective. A less expensive version of the goggles is found at BluBlocker.com. Wearing these goggles, you can easily read, work on the computer, watch television, etc.

Daily exercise is a way to increase your natural melatonin secretion. A 2005 Canadian paper showed a positive correlation between the duration of exercise and the amount of melatonin produced in overnight urine.

There is compelling evidence from shift workers that disruption of melatonin secretion can be a problem. Dr. Eva Schernhammer at Harvard has studied the effects of night light on cancer risk through the melatonin pathway. She found that nurses who had worked for more than 15 years on rotating night shifts had a 35% higher risk of breast cancer than those who never worked rotating shifts. Shift workers have disrupted melatonin output. She also found that women with invasive breast cancer had less of a melatonin metabolite in their overnight urine. She found that women who were totally blind had a lower rate of breast cancer than blind women who still respond to light. Dr. Schernhammer concluded in a 2009 paper that melatonin is able to fight breast and other cancers by being a powerful antioxidant that can destroy damaged DNA before it can initiate cancer, by preventing cell mobility that causes metastasis, and preventing blood vessel growth that may nourish cancer cells.
A Japanese study in 2006 found that men who worked rotating shifts had a significant increased risk of prostate cancer over those who worked non-rotating shifts.

Daniel Kripke, the lead author on the Scripps paper, suggests the following for better sleep - keep the light out in your bedroom, try meditation or prayer, and learn progressive muscle relaxation or self-hypnosis. He also suggests taking melatonin tablets if you are a night owl, to reset your sleep-wake rhythms. He suggests talking to your doctor about an appropriate low dose of melatonin to try at bedtime. My advice is – start with 0.5 mg, and go up to 1-3 mg as needed. The kind that dissolves under the tongue goes most directly into your bloodstream. But – get those blue-blocking glasses, for the most natural sleep!
Sadja Greenwood, MD, MPH

Restorative Sleep

The lights we depend on after dark – to work, read, use the computer, and get around - the huge advantages of electric light - have a downside. They upset our natural sleep-wake cycle. The pineal gland, located midbrain, behind the eyes, secretes a hormone called melatonin, synthesized from the amino acid tryptophan. Melatonin comes out as the day gets dark, making us sleepy and lowering our body temperature. When we turn on the lights and stay up late working or playing, this reduces the time we are in darkness. Less melatonin is put out, and sleep can become elusive. We may fall asleep, but not stay asleep – a common complaint of older people, who secrete less melatonin with advancing age. Instead of deploring the genius of Thomas Edison, we can be grateful for current researchers who have found out how we can live with the advantages of light and still sleep. Studies have shown that it is the blue component in light that causes the most melatonin suppression; it is possible to block blue light by wearing goggles that filter out over 90% of the blue light. By putting on these yellow-orange goggles for 1-2 hours before bedtime, melatonin will flow out and sleep will improve. To apply this research to your own sleep patterns, go to LowBlueLights.com. Meet Richard Hansler, at the Lighting Innovations Institute at John Carroll University in Cleveland. Hansler, now 87, is a physicist who has pushed the development of lighting that does not disrupt melatonin outflow. At this website they sell blue blocking glasses, as well as special lights low on the blue part of the light spectrum, both incandescent and fluorescent. Their glasses, which can be worn over reading glasses if needed, cost from $68 to $80. I have used these glasses for over 2 years and find them very effective. Much less expensive blue blocking glasses can be found elsewhere on the internet – read customers’ comments carefully to find out if they are effective.

Eva Schernhammer at Harvard has studied the effects of night light on cancer risk through the melatonin pathway. She found that nurses who had worked for more than 15 years on rotating night shifts had a 35% higher risk of breast cancer than those who never worked rotating shifts. Shift workers have disrupted melatonin output. She also found that women with invasive breast cancer had less of a melatonin metabolite in their overnight urine. She found that women who were totally blind had a lower rate of breast cancer than blind women who still respond to light. Dr. Schernhammer concluded in a 2009 paper that melatonin is able to fight breast and other cancers by being a powerful antioxidant that can destroy damaged DNA before it can initiate cancer, by preventing cell mobility that causes metastasis, and preventing blood vessel growth that may nourish cancer cells.

A Japanese study in 2006 found that men who worked rotating shifts had a significant increased risk of prostate cancer over those who worked non-rotating shifts.

A 2005 Canadian paper showed a positive correlation between the duration of exercise and the amount of melatonin produced in overnight urine. This is suggested as a mechanism by which exercise reduces the risk of breast cancer.

Here’s my take-home lesson from the research on melatonin. Investigate blue-blocking glasses - and try using them 1-2 hours before your regular bedtime. Increase the duration of your daily exercise if you have trouble sleeping, or staying asleep. And – if you do wake at night and can’t fall back to sleep, get up and have a small snack of food, especially one containing milk. Milk contains enough tryptophan to promote sleep. Something sweet, like a piece of banana, will stimulate insulin which helps transport tryptophan across the blood-brain barrier.

In my next column I will write about new data on the potential dangers of prescription sleeping pills, and more natural alternatives. Also – there is new data on the importance of sleep in the prevention of diabetes and dementia. Stay tuned!

Sadja Greenwood, MD, MPH back issues on this blog

Sleep is the best meditation – the Dalai Lama