Thursday, March 8, 2012

Maybe Sleeping Pills aren't all just innocent clouds of blissful sleep...

Can I just tell you that I am slightly frustrated by the fact that I know A LOT about sleep, and not afraid to say it. I studied it exclusively for a year at Duke as a Fellow (after my 4 years of medical school and after my four years of Neurology residency and Neurology certification) to be "Fellowship Trained" in Sleep Medicine and delaying entering the final medical work force by a year just so I could understand sleep that much better. I lecture on it, write articles on it, get consulted about it from fellow physicians.....

AND then my referring docs and patients just want to slap on some wine before bed, or Ambien before bed, or Lunesta before bed, etc. Or they google-read that Dr. Velpo's Magic Supplement (just made that up) will cure their sleep issues.

In they end, they are just masking the real problems... and I care about the real problem, not the sleep. The sleep issue is just a consequence.

95% or more of humanity needs no help sleeping if you treat the underlying problem. Which means 95% or more of the patients I see on one of the hypnotics could come off if we addressed the problem they are trying (and always failing) to mask with the medication.

Okay, stepping off my soapbox, what are the hypnotics:
They are used to make you sleep, whether it be deep enough to cut out an appendix or deep enough to sleep through your husband's snoring.
The list is too long to type here, but I'll mention some of the common ones I see (by their generic names since the drug pharmacy brand names changes from time-to-time):

There are MANY reasons to come of these medications if used just for sleep, such as changes in the quality of your sleep with long-term use, change in the sleep stages you get with long-term use, next-day affects on thinking and mood because they change the way your brain tries to rest itself while you sleep, interaction with other medications (usually subtle and under appreciated), unnecessary extra costs, masking the real underlying problem which may be very unhealthy or even deadly if left untreated.... etc.

This study just added to that concern. You can read below the line for more details.

But in summary, they sifted through 10,531 patients from a large U.S. health system who WERE taking a hypnotic (presciption: alcohol, marijuana, etc didn't count) to help them sleep and compared them to 23,674 patients who were NOT taking a hypnotic between the years of 2002 and 2006 to help them sleep. They followed them for 2 and a half years.

Of the people taking sleep agents, 6.1% died.
Of the group not taking anything, 1.2% died.

The more pills one took, the higher their chance of dying.
They even stratified it to amount of use:

HR 3.60 for 0.4 to <18 pills
HR 4.43 for 18 to 132 pills
HR 5.32 for >132 pills

What the above says is that if you take 18 pills a year to help you sleep.... you are 3.6 times more likely to die than if you didn't need the medication.
If you need it more than 18 times but less than 132 times a year, you are 4.43 times more likely to die than if you didn't need the medication.
If you need a sleeping pill more than 132 times a year, you are 5.32 times more likely to die than if you didn't need the medication.

Now, they didn't tell why all these people died, or if the medication was responsible directly (unable to prove) nor how it might be indirectly responsible. This was just a study to note the trend. I think the trend is more trustworthy given the huge numbers of patients involved in the study. The more people in the study, the more the "odd" or "unique" cases become less relevant and even out in the wash.

Take home message: Stop masking the problem. Let's get it straightened out.
HR 3.60 for 0.4 to <18 pills
HR 4.43 for 18 to 132 pills
HR 5.32 for >132 pills