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Insomnia: A Medical Indication in Need of a Drug
Once upon a time, drug companies promoted drugs to treat disease. Now it is often just the opposite.
They promote diseases to fit their drugs.
— Marcia Angell, MD, former editor in chief of the New England Journal of Medicine and author of The Truth about Drug Companies
We live in a "take a pill and go to sleep" era. Like Pavlov's dogs, insomnia-plagued Americans have been trained to pop a pill to reap a sleep reward, expecting to immediately fall asleep and stay asleep, with little or no effort. It is the path of least resistance, giving us an easy-way-out option, rather than confronting the root cause of our insomnia. Just "set it and forget it" so we can discretely walk away from our responsibility to identify our own underlying issues. Knowing this, it should come as no surprise that 25 percent of Americans take insomnia medications every year. Twenty years ago, Ambien (zolpidem) was introduced to the market — hailed as the supposed solution to all of our sleep complaints. Ambien belongs to a category of sleep agents called Z-drugs, originally promising to provide us with a safer alternative to benzodiazepines without a hangover effect or overdose potential. Z-drugs quickly became widely overused, and many consumers fell victim to the increased risk of addiction. Yes, you and I got hooked; according to a 2013 analysis published by the Addiction Center, over nine million Americans routinely use sleeping pills and 30 percent are dependent. With up to seventy million Americans using sleeping pills today, the CDC (Centers for Disease Control and Prevention) has even deemed insufficient sleep as a public health epidemic.
The situation seems to have gotten out of hand, allowing the thief of sleep to prevail by effectively stealing our precious rest and forcing us to install a drug-based security system. When did synthetic chemicals become the primary chosen defense? The story gets far more interesting. From 1993 to 2007, the United States witnessed a sevenfold increase in new insomnia cases, corresponding with an astounding thirtyfold increase in Z-drug prescriptions. From 1999 to 2010, office visits for sleep-related complaints increased by 30 percent, demonstrating that Americans were being plagued by an insomnia epidemic. To keep up with the feverish pace of new insomnia diagnoses, new sleeping pill prescriptions exploded in volume from 5.3 million in 1999 to 20.8 million in 2010 — an increase of 290 percent over ten years, dominated by a mind-boggling 350 percent increase in Z-drugs alone. Coincidentally, or maybe not, a pharma- driven, aggressive insomnia awareness campaign strategically paralleled Z-drug market launches, beginning with zolpidem (Ambien) in 1993. Over a fifteen-year span, Z-drug prescriptions were being dispensed twenty-one times more rapidly than verified diagnoses related to sleeplessness and five times more rapidly than insomnia diagnoses. Basically, physicians became vending machines for sleep candy. It is blatantly clear, excessive Z-drug prescriptions were being written daily without corresponding documented medical indications. Something smells rotten — is it genius marketing or mastery in the art of manipulation?
After dedicating years of my life to clinical pharmacy practice, I realized that an insomnia epidemic didn't suddenly appear out of thin air. It was created by a pharmaceutical industry-spawned marketing tactic called "disease mongering." Disease mongering extends the boundaries of treatable illness and expands the market for new products. In essence, sickness is sold to boost the booming business of drugs and devices. But exposed to the light of day, this is really nothing more than creating drugs that are in search of an indication. Pharma convinces healthy people that they are unwell and the slightly unwell to think they are gravely ill and then persuades them that everyone requires drug treatment. For instance, shyness is now "social phobia"; kids simply being normal, energetic kids now have "attention deficit hyperactivity disorder (ADHD)"; and 10 percent of the population is now affected by restless leg syndrome (RLS), a "disease" warranting, yes, yet another drug.
Even before officially launching Z-drugs, pharma masterminded an ambitious insomnia educational campaign intending to prime the medical community. Under the guises of public service awareness, practitioners, including myself, and consumers were shrewdly targeted to begin questioning personal sleep habits and overall sleep quality and quantity. Once the stage was set for a groundbreaking unmet need, pharma sold the promise that a mere little pill could guarantee a good night of restful sleep, followed by a productive day. After questioning individual sleep needs, enticing ads followed with, "Sleep the night and seize the day ... A better tomorrow begins tonight," and, "Does your restless mind keep you from sleeping?" Like a fairy godmother granting wishes and dangling glass slippers, pharma offered a magical solution — one Americans eagerly believed and, thus, quickly bought what drug companies were selling. Even with years of medical education and drug expertise, I had the wool effectively pulled over my eyes — I bought what they were selling. I allowed the power of influence to dupe me into believing my ailments required pharmaceutical intervention.
Today, the odds of achieving blockbuster drug status are rare, requiring over $1 billion in annual sales. As a practicing pharmacist, I personally witnessed when pharma struck gold in 2006, achieving blockbuster status with Z-drugs and earning manufacturers $3 billion in combined drug sales for zolpidem and eszopiclone. To hit the mark, pharma invested heavily in direct-to-consumer (DTC) marketing, spending $850 million in 2006 and another $500 million in 2007, yielding an additional four million prescriptions. New insomniacs continued to be diagnosed in America, and the sleeping pill trend steadily increased by 60 percent from 2000 to 2010, with over 4 percent of adults taking sleep aids at least once a month. Much Z-drug marketing has since halted due to patent expirations and sales being dominated by generics. However, newer sleep agents are generating a resurgence of ads, once more attempting to appeal to your emotions.
Do you question whether you've been unfairly influenced by pharma advertising? A cause and effect phenomena can be postulated, whereby disease mongering effectively generated a paradigm shift in insomnia treatment. Unfortunately, the pendulum swung in the wrong direction. Prior to the inception of pharmaceutical sleep agents, we relied on herbs and food as primary treatment for sleep issues. Agents like melatonin and chamomile were widely utilized, along with relaxation techniques. Recently, pharma entered the natural medicine marketplace by introducing a prescription-only version of melatonin, a supplement backed by a proven safety and efficacy track record for over a hundred years. Was pharma driven by fear of competition or desperation or even impressive profit margins when it tapped into the nutraceutical arena? We may never know the true reason.
Insomnia awareness and strategic pharma education has vastly contributed to overprescribing and overutilization of drugs as first-line treatment. Rather than calming wandering monkey minds with more cost-effective or free resourceful practices, like meditation or prayer, a trained response favors inducing a semicomatose state with the easy pill fix, designed to help you forget your worries, and then you sleep. It doesn't have to be this way. You hold the key to your personal health destiny, and every informed decision you make can bring you one step closer to improved health and increased vitality. If you want to hop on board the health train, you will need to become undrugged.CHAPTER 2
Sleepless in America
When you have insomnia, you are never really asleep, and you are never really awake.
— Fight Club
I was plagued by insomnia for years. A typical night would play out much like this: I lie awake staring blankly into the darkness knowing my sleep thief has returned. My monkey mind wildly ping-pongs as I count one sheep, two sheep, three little sheep, please let me sleep. In fifteen minutes, my husband's breathing slows to a rumbling snore as he blissfully succumbs to sleep. How does he do that? I attempt to calm myself and resume my scattered counting, one sheep, two turtledoves, three French hens, Little Bo Peep, Bye Bye Blackbird. The clock mocks me at midnight, and anxiety percolates. Now infuriated with my snoozing husband, I give him a jarring shove. I hear a moment of silence, followed by a snort and resumption of the agonizing vibrato. The clock continues taunting me as I silently recite prayers, meditations, and mind-calming exercises. My body finally surrenders from exhaustion and frustration several hours later. Unfortunately, my alarm jolts me awake after only an hour, and my cheery and refreshed husband leaps out of bed. Hitting snooze, I roll over, remaining lifeless, struggling to open my eyes, disoriented, groggy, and grumpy. Unfortunately, I get to look forward to suffering brain fog and another unproductive day while I begin to prematurely dread tonight's encore. This is insomnia.
Sleepless in America is not a Meg Ryan and Tom Hanks movie. This is real-life drama fueled by performance anxiety keeping you up all night worrying about being up all night. If you battle nightly dream stealers, you are one of the fifty to seventy million American adults with chronic sleep disorders. If a more persistent pattern develops, forcing you to seek medical attention, you join 10 percent of Americans with clinically diagnosed insomnia. Insomnia follows acute or chronic patterns of sleepless nights with difficulty falling asleep, returning to sleep, staying asleep, or any combination of these. Acute insomnia is linked to stressful or devastating life events and resolves soon after the stressor is removed, usually without medical treatment. On the other hand, chronic insomnia often prompts medical intervention, exceeds three episodes a week for more than three months, and in many cases persists for two or more years.
Prolonged sleep deprivation may force you into an active nocturnal existence, binging on late-night exercise or cooking infomercials and marathons of Beverly Hillbillies and Green Acres. Combine this with highly charged emotions like desperation and frustration and added undesirable ill health effects, and you will find yourself primed for easy enticement by the flood of drug ads promising a simple pill solution. If you cave in, you are now one of over eight million Americans using sleeping pills to maintain a good night's rest. For many, effortlessly popping a pill beats adjusting sabotaging habits in order to eliminate the sleep thief. If you are part of the sleeping-pill nation, as I was, or are searching for ways to avoid joining this group, this book is for you.
Sleep Is a Luxury, Not a Priority
Optimal daytime functioning requires rejuvenating sleep, but somehow society has shifted sleep from a priority to a luxury. American's total sleep time has decreased 20 percent over the last one hundred years. This substantial sleep loss originates to a literal light bulb moment that happened on December 31, 1879. On this date, Thomas Edison unleashed the long-lasting incandescent light bulb on the world, and it quickly became the most sleep-disruptive invention ever. By 1914, Edison identified sleep as a "bad habit," officially declaring sleep as optional and chiding that, without forced darkness, there is no reason to sleep at all. Today, with light available twenty-four hours a day plus compact, techy gadgets and gizmos entertaining us in bed, together with a barrage of self-inflicted scheduling obligations, we've morphed into busybodies too distracted to succumb to primal sleep needs.
Constant sources of mental stimulation create a never-ending pursuit of ways to energize and fuel our bodies with more caffeine, nicotine, and sugar so we can work harder, faster, and more effectively to create bigger, better, and more fulfilling lives. For many on a quest to achieve their personal best and running tandem with Edison's reprimanding sleep remarks, sleep takes backseat to a millionaire-guru mind-set of "I can sleep when I'm dead." A high-strung, stressed-out, fast-paced life effectively depletes an already dismal sleep budget. Skimping on sleep carries a lofty price tag payable in exorbitant health-burden costs. Eventually, it will catch up with you. Maya Angelo said it best: "When you know better, you do better." I am certain this is the reason why many opt for the sure-thing drug solution to counteract known poor habits and excessive daytime stimulation.
Burning-the-candle-at-both-ends, stressful lifestyles hail as the chief cause of insomnia. Pinpointing the source of the sleep disruption, whether environmental, lifestyle-induced, or even related to a medical condition, will provide valuable information. If you enlist a skilled sleep disorder practitioner to evaluate emotional or physical causes who won't automatically scribble a script for a sleeping pill, you will discover underlying physical dysfunctions that are not obvious. For instance, nighttime spasms and sporadic leg movements may be restless leg syndrome (RLS). Of course, pharma now has a drug for that, but RLS doesn't always require drug treatment. Natural RLS solutions are effective if the condition is caused by nutrient deficiencies, electrolyte imbalances, or even drug reactions. For some, slumber interruption stems from a physically active parasomnic dream state allowing one to kick, talk, or scream. This reaction is similar to a puppy whimpering, yipping, or even chasing rabbits in his sleep. That's all adorable and nonthreatening. However, in the human world, some spouses have been punched, smacked, slapped, or seriously injured while the agitated sleeper defends him or herself from a dream attacker. Some sleep disruptions are caused by the sensation of choking, gasping for breath, or even dreaming that you are drowning or being smothered. You may have stopped breathing due to obstructive sleep apnea (OSA), which contributes to sleep fragmentation and excessive daytime drowsiness. Other sleep disrupting medical conditions include chronic pain, Alzheimer's and dementia, benign prostatic hypertrophy (BPH), hormonal issues like menopause, heart disease and arrhythmias, diabetes, lung diseases like COPD and asthma, digestive issues like acid reflux (GERD) and irritable bowel, depression, attention deficit disorder, anxiety, panic disorder, and substance abuse.
Sleep Deprivation Is Disastrous
Sleep deprivation is highly dangerous. It can lead to devastating consequences and has been implicated in numerous horrific public disasters. For instance, operator fatigue due to lack of sleep was responsible for grounding the Exxon Valdez and for the nuclear meltdown at Three Mile Island, in addition to an estimated one hundred thousand motor vehicle accidents related to driver fatigue and excessive drowsiness, according to the US National Highway Traffic Safety Administration. These tragic incidents demonstrate the massive toll long-term sleep deprivation takes on your mind, body, and daily functioning.
Skimping on sleep mimics an immune response similar to stress or disease, explaining why you often feel physically sick after a restless night. This launches a zombie-like walking dead chain reaction that has you dragging yourself through the day sluggish, fatigued, drowsy, disoriented, and anxious. Your brain may be plagued by a fog, adversely affecting your memory, cognition, concentration, problem-solving ability, and mood. Piggyback everything with indigestion, headaches, and pain. Imposing these adverse effects on yourself will have you wishing you could crawl back into bed for a do over.
A continued insomnia pattern will set the stage for a perfect storm with a tsunami of symptoms that throw your body into full-blown fight- or-flight crisis mode. The harmonious hormonal symphony responsible for controlling stress, appetite, and rejuvenation is now compromised. Elevated stress hormones, like cortisol and adrenalin, encourage the body to store fat, thereby promoting obesity, heart disease, and diabetes. Unbalanced appetite-controlling hormones such as leptin and ghrelin intensify fat and carbohydrate cravings, leading to snack attacks and late-night binge eating. Finally, crucial restorative hormones responsible for cellular renewal and regeneration, like growth hormone and melatonin, are severely depleted, placing you on a road to accelerated aging. Sleep is fundamental to rejuvenate, repair, and remain youthful, so reject the pharmaceutical Kool-Aid and advice from any guru who preaches, "You can sleep when you're dead." In the quest to be my personal best, I have been guilty of following an entrepreneur's mind-set, which creates massive results by overextending working hours and, subsequently, robs time that should be reserved for sleep. Heeding misguided advice and de-prioritizing sleep in order to accomplish other tasks may just make you a sacrificial lamb; you'll never enjoy the rewards of your sacrifices if you are buried six feet under.(Continues…)
Excerpted from "Undrugged: Sleep"
Copyright © 2018 Dr. Lori Arnold, PharmD..
Excerpted by permission of Balboa Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Section 1 Are Sleep Drugs Worsening Your Insomnia?,
Chapter 1 Insomnia: A Medical Indication in Need of a Drug, 3,
Chapter 2 Sleepless in America, 7,
Chapter 3 Trouble Sleeping? We Have a Drug for That, 12,
Chapter 4 The Truth About Z-Drugs: A Pharmacist's Synopsis, 17,
Chapter 5 Side Effects and Complications: Is the Benefit Worth the Risk?, 30,
Chapter 6 Complex Sleep-Related Disorders, Parasomnias, and "Zolpidem Zombies", 37,
Chapter 7 Lawsuits and Legal Woes: The "Zolpidem Defense", 47,
Chapter 8 Unvitamin Effect: Nutrient Depletions, 49,
Section 2 From Insomnia to Un-somnia: Undrugged Solutions to Naturally Promote Sleep,
Chapter 9 The Undrugged Method, 53,
Chapter 10 Readjust: Adopt Better Sleep Habits, 63,
Chapter 11 Drug-Induced Disease: Drugs, Herbs, and Supplements That Can Cause Insomnia, 78,
Chapter 12 Replenish and Restore: Drug Alternatives, 83,
Chapter 13 Refresh: Healing with Food, 100,