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Episode 50

 

What should I know about sleep medication risks?

What are the risks in the non-benzodiazepine class of medications?

What is the addiction potential of those medications?

 

The desperation that comes from trying to sleep causes people to make choices they might not normally make. They may take far more medication than they should. They may mix depressants in an effort to overcome the anxiety that keeps them awake. They may buy medications from someone else’s prescription even though it’s illegal.

Sleep medications can be a miracle for some while holding a number of risks that should be on our radar.  In this episode we talk about the three most popular medications used in the non-benzodiazepine class.  We’ll discuss the risks inherent in these medications as well as the risk of addiction. 

Transcript

You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 50. It feels weird to be talking about the 50th episode already. I’m not sure what it feels like in terms of how many I’ve done so far, but 50 seems like kind of a lot. I’m really grateful to all of my listeners and hope that you’re finding the podcasts helpful.

I’ve been doing some work behind the scenes and the most recent thing that come out is that I’ve updated the treatment planning tool. I made it fillable so that you can fill out the treatment planning tool on a computer, save it as, and be able to have it for each client that you use it for. I’ve also added some more information to the appendix at the end, along with links to episodes that relate to each drug.

Even if you’ve already downloaded it, you can go and download it again. Or you can send me an email at betsy@betsybyler.com and I’d be happy to send you another copy. I’m also working on an assessment tool that’ll walk people through doing a substance abuse assessment. It’ll be a little while before that one comes out, but I’ll be sure to let you know.

I hope you all had a chance to listen to last week’s episode on sleep medications. Last week, we talked about the different classes of medications that are used to treat. We have benzodiazepines, we have the benzodiazepine, receptor agonists, or Zdrugs. We have the sedating antidepressants. We have the other prescription medications, such as things like Seroquel and Zyprexa. And then we have the newer class that is orexin receptor agonists that blocks the receptor that produces the chemical that causes wakefulness. This week we’re going to talk about the abuse  and sleep medication risks. 

Over this podcast series, we’ve talked about medications and how they can become habit forming and how people have gotten addicted. A lot of times we think about things like opiates, because that’s kind of the most common class that we hear people getting addicted. And while that’s true, people also are getting addicted to things like Adderall and Ritalin, as well as sleep medications. Of all of the sleep medications listed, probably the most numerous in quantity are the benzodiazepines.

Sleep Medication Risk: Benzodiazepines

So things like temazepam, trade name Restoril.  Triazolam, which is Halcion and things like Xanax and ativan also get used in that category. The issue with benzodiazepines is of course the tolerance that requires people to use more and more as well as the incredibly long withdrawal that can happen as well as the danger in withdrawal.

I won’t go over all the benzodiazepine information today because there are two episodes that I did previously on benzodiazepines that you can listen to if you want to know more information. For today. I’ll just say that the seizure risk in withdrawal of benzodiazepines is very serious and can be life-threatening.

Sleep Medication Risk: Less Risky classes

So outside of the benzodiazepine class, there are a couple of classes that aren’t really ones that people abused because they’re not necessarily something that’s going to get them high. 

There are two reasons, typically that people are abusing sleep medications. One is because they’re trying to sleep and they feel like either what they’ve been taking isn’t working or that they need to take more of that thing without being directed by a doctor or people are taking them straight up just to get high. In order to do that, of course they could take them orally or they could crush them up and snort them. They could shoot them up, but I haven’t heard a lot of people doing that. 

So the other medications that are not really abusable are the orexin receptor agonists and that medication Belsomra is one that’s kind of new and works in a different way. Rather than blocking histamines or slowing down brain activity this will work on the orexin receptors. It’s kind of a neat idea to go with that angle  rather than the other. 

There are histamine blockers and that’s typically what people use over the counter. So things like Benadryl or the active chemical that’s in things like Z Quill. But there is a prescription of a histamine blocker called Silenor that is used sometimes.

Rozerem is another medication that is melatonin based that is recommended for use in a lot of cases. The side effect profile comparatively is quite low and also doesn’t have the dependence risk that the benzodiazepines and then the Z drugs have. 

Sleep Medication Risk:  Z-Drug Invention

So the Z drug, remember these are the benzodiazepine receptor agonists. They are non benzodiazepines, but they are sedative hypnotics and anytime you get something that has a sedative effect, it has the potential to be abused. They’re called Z drugs because they either start with the letter Z or the letter Z appears in the name itself. 

Z drugs were hailed as the innovative hypnotic of the new millennium. These medications were supposed to be an improvement on previous benzodiazepine sleep medications. Z drugs have significant hypnotic effects.  The rapid peak level is to help with sleep latency or sleep onset.  The other aspect is that they apparently have a short half-life and faster clearance in the body. Benzodiazepines, even short ones have like an eight to 10 hour clearance.

The ideal insomnia treatment would be a medication that is a potent sedative overnight, but clears without residual effects during the day.  Benzodiazepines  were used as the primary form of insomnia treatment for many years  until the late eighties and early nineties when research was turning towards trying to find an alternative that wouldn’t have some of the same risks as benzodiazepines. 

Part of the problem with benzodiazepines is that they changed sleep architecture. Reducing deep sleep, meaning stages three and four while leading to dependence tolerance and withdrawal. The Z drug class are non benzodiazepines that have a somewhat lower risk level. 

My issue with that statement is that it depends on what risk we’re talking about. Certainly benzodiazepines are a hundred percent addictive. Absolutely cause a tolerance withdrawal and the detox and withdrawal from them can actually be fatal. So for sure, we have clear reasons to see why use of benzos to sleep long-term is not advisable.

When they created the class of Z drugs what they found is that they affect the same receptors as benzodiazepines. However, they have a shorter duration of action and half-life, do not disturb overall sleep architecture and cause less residual effects during daytime hours. Initially the research was all looking really good for Z drugs being a much better alternative. While it is true that they seem to be a better alternative than benzodiazepines. Over the years, since this class of drugs was created, there have been increasing reports of issues related to behaviors while on the Z drugs.

Sleep Medication Risk: Ambien

The most common and the most popular is the first one we’re going to cover and that’s Ambien. The generic name is Zolpidem. It’s FDA approved for use in the short term treatment of insomnia.

It’s typically aimed at people who have difficulty initiating sleep. So sleep latency or sleep onset. It also has some efficacy in helping with sleep duration, which has to do with the number of times someone wakes up and in treating chronic insomnia. It can also act as a minor muscle relaxant Ambien was approved for use  in the United States in 1992, the generic became available in 2007.

It’s considered a schedule four drug and in 2018, it was reported that there were over 12 million prescriptions for Ambien written that year. Some research has also shown that it is rapid and effective in restoring brain function in patients who are in a vegetative state, following brain injury. The drug apparently has the potential to completely or partially reverse the abnormal metabolism of damaged brain cells. This is in patients who have a non brain stem injury. 

Ambien is rapidly absorbed in the gastrointestinal tract and generally has a generally short half-life in healthy patients. It’s often formulated in a tablet or as an extended release tablet, but it also has an oral spray, which is sprayed into the mouth over the tongue. And there’s a sublingual tablet as well. 

Generally it’s five to 10 milligrams per tablet or per dose, depending on the patient’s sleep quality. Generally they advise you not to take it after you’ve eaten, because it can slow down the absorption of the drug. And generally you’re taking it at the time you’d like to start. 

It’s typically only prescribed to adults with older adults having a lower dosage. As there have been some complications, there was some research that pediatric patients were experiencing hallucinations. Although that percentage was pretty small. 

Ambien has of course the side effect of sleepiness because after all, that’s what it was created for. There are some other adverse effects that are listed as risks. Things such as changes in behavior withdrawal and central nervous system depression. In rare situations, there have been some reports of tongue larynx  or glottis swelling in the form of angioedema. As well as reported shortness of breath, airway closure, nausea, and vomiting.

 All of those side effects with one exception sound like the kind of  side effect warnings that we find on a lot of medications. Certainly anyone could have an allergic reaction, go into anaphylactic shock or in other ways have other bad reactions. It’s the changed behavior and abnormal thinking that catches my attention. In the articles about these behaviors. It also mentions that there have been people showing aggression and extroversion that is abnormal for the person who’s taking it.

The prescribing instructions always talk about it being used for short term relief of insomnia. This is not how I’ve seen it used in the population I work with. That’s not to say that it’s not being used  in a short-term way in other places. It’s just not my experience that it’s only a short-term thing like seven to 10 days. I’ve seen people on it for years.

The issues with Ambien started popping up with reports of strange behaviors for people who were on Ambien. These strange behaviors are called parasomnias.

Sleep Medication Risk: Parasomnia

Parasomnias are described as abnormal and undesirable behaviors during sleep that are thought to be due to the sleep state instability.  Some are really not a big deal while some of them point to a possible underlying  neurodegenerative process. Parasomnias have a broad spectrum of events, including abnormal motor behavior and sensory experiences. Excessive motor activity and abnormal motor behaviors adversely affect the patient or the bed partner resulting in fragmented sleep, psychosocial effects and even injuries. 

In general, parasomnias tend to affect children and become less prevalent as they get older. Generally they categorize parasomnias based on which sleep state they’re in when the behavior is observed. There are parasomnias that are  sleep state independent.

They list three states of human behavior as wakefulness NREM and REM sleep. The NREM sleep is divided into three stages N1, N2 and N3. Transitions from one state to another is not quick, but involves a reorganization and transition of various neural centers before a specific state manifests itself.

Most of these parasomnias appear to occur during the N3 and REM sleep state. The common feature of these parasomnias is recurrent episodes of incomplete waking and amnesia for what it was that woke them up

Primarily when it comes to parasomnias, we’re generally talking about sleepwalking. This is the most common form of parasomnia. The behaviors can go from aimless wandering to more complex  and prolonged behaviors and people doing things like driving while sleeping.

So sleep terrors are also considered a parasomnia. They describe as episodes of intense fear, accompanied by loud piercing screams, or loud crying during which the patient appears terrified. Typically these almost always, according to the literature resolved by late childhood.

Talking while sleeping, they call a confusion arousal. It’s generally from an NREM sleep state that  results in disorientation and occasionally automatic behavior like vocalizations and motor activity.

There is a parasomnia called sleep-related eating disorder (SRED). This parasomnia is more common in women and is characterized by episodes of binge eating after being partially awakened from an end REM sleep state. These episodes typically favor high carbohydrate foods, and some other inedible items like raw meat or pet food.

This parasomnia is closely related to and thought to be a variant of sleepwalking. Patients are totally unaware that this is happening and the adverse consequences could be weight gain worsening of diabetes that kind of thing. This is different from nocturnal eating disorder though, where the person is eating at night, but they are aware of their eating behaviors. Ambien is actually the most likely to cause this to happen. Sometimes there are medications use to treat sleep-related eating disorder that include dopamine agonists like Topamax. 

Another parasomnia is sexsomnia. This is sleep related abnormal sexual behaviors. It’s classified as a subtype of N REM parasomnia disorders. Typically these emerge from partial awakening during slow wave sleep. It’s more common  in younger males.  There’s a wide range of behaviors like having sex, attempting to have sex, masturbating, assaultive  sexual behavior or sexual vocalizations.

The REM parasomnias are a different class than the NREM parasomnias that we’ve been talking about. The REM sleep, which is what we all typically hear about is characterized by rapid eye movements. Dreaming during REM sleep tends to be vivid and really detailed compared to the vague dream content of non REM sleep. In this category there are nightmares rather than night terrors. Additionally, this is where sleep paralysis shows up as a parasomnia. And something called REM sleep behavior disorder or RBD.

RBD is where muscle tone is kept during REM sleep. This isn’t the same thing as sleep paralysis as the person can’t move. But more that their body is still retaining all of the muscle tone in action.

There are what’s called quote, other parasomnias. Think of this, like we have our other or not otherwise specified categories. It’s kind of the same thing as that. In this category is sleep enuresis, which is bedwetting, sleep-related hallucinations.

There can be sleep hallucinations that occur at sleep onset and those that are  happening on a weakening. These are two different kinds, and sometimes it can be really difficult to know whether the person is dreaming or not as the person may not be able to recall what they were dreaming about.

The parasomnia risk does not go away just because you’ve been taking a medication and haven’t had it yet. It’s clear from the literature having parasomnia effects  or impairment during the day could happen after the first night or the 50th.

So as this relates to Ambien, when all of these parasomnias started popping up, this is when science started looking at what about the Z drug class  is causing these episodes. There have been multiple reports across different countries, different age groups, different medical profiles of people experiencing parasomnias. The one that makes the news the most often tends to be asleep driving. 

There are reports of people getting in their cars, driving to a store, buying something and coming home.  As you can imagine, people have gotten injured and even killed because of sleep driving incidents.

It’s not just while they’re sleeping though that there is a risk. Part of this is because of drowsy driving, where they talk about the person getting up after taking Ambien or one of these other Z drugs and still being groggy, but not realizing it. 

We can imagine how that would be possible. There are plenty of times I’ve driven to work and having long blinks because I hadn’t been awake quite yet and that was on taking nothing for sleep. Now, generally the half-life on this one is really short. It’s like 2.6 hours. Now that goes up depending on your dosage. And the 2.6 hours is about five milligrams of Ambien. 

There is a risk of overdose with Ambien, just like many of the other drugs. It is a depressant meaning that it slows down the central nervous system and therefore could cause respiratory depression. Especially when taken with other kinds of depressants and the most common of course is alcohol. The combined effect is the problem here. As we’ve talked about in most episodes I’ve done on depressants.

An interesting fact about Ambien is that in 2013, the Food and Drug Administration in the United States ordered the parent company who manufacturers Ambien to change their dosage recommendations. This was  in response to at the time over 700 reports of Ambien related driving accidents; both sleep driving and drowsy driving.

The long lasting forms of Ambien tend to be associated with the daytime problems. Part of the reason they came out with extended release of course, is because they wanted people to be able to stay asleep longer. The trouble is, is that depending on metabolism, we don’t know how long that’s going to take. They recommend that you don’t take Ambien if you have less than seven or eight hours before you have to be active again.

The liver enzymes that are responsible for metabolizing, Ambien are higher and  are more active in men than in women.. The literature suggests that women are more susceptible to the effects of Ambien due to the slower metabolization of that medication.

Initially, of course, they thought it wouldn’t have any addiction potential. However, with moderate to high doses of Ambien for long periods of time, there is medication withdrawal symptoms that can include shaking, stomach cramps, vomiting, nervousness, and panic attacks.

Sleep Medication Risk: Lunesta

The second medication we’re going to cover in this Z class of drugs is called eszopiclone or Lunesta. There appears to be some difference between a zopiclone, starting with an E and Zopiclone starting with the Z. Zopiclone is the active ingredient in Lunesta, but the generic form of Lunesta is called eszopiclone.

Lunesta was approved in 2004 for the treatment of insomnia. Other than sleepiness common side effects include headache, dry mouth, nausea, and dizziness. There are  some severe side effects, including angioedema, which we talked about with Ambien, hallucinations, and even some worsening of suicidal thoughts. It’s also a non benzodiazepine sedative hypnotic.  As a sedative hypnotic it has the same risks as Ambien, where we talked about respiratory depression and any kind of compounded effect from another depressant being placed on top of it.

Again, it’s for short-term use, although this one says about six months rather than seven to 10 days, although I saw dosage recommendations vary in different areas. So that’s kind of confusing.

In 2014, the Food and Drug Administration warned about Lunesta causing next day impairment of driving and other activities.  They lowered the recommended dose from three milligrams to one milligram. Lunesta is a schedule four drug under the Controlled Substances Act.

There are risks about physical and psychological dependence in taking Lunesta. Lunesta is generally very similar to both Ambien and Sonata. It has basically some of the same profiles and the same risks. It’s very similar when it comes  to the peak of where it hits as well as the half-life as Ambien.

Sleep Medication Risk:  Sonata

The last medication in this class is called Zaleplon or Sonata. Sonata was approved for use in 1999.  It also has a quick onset of action and the elimination half-life of approximately one hour. It said to improve sleep without producing the rebound effects in patients with insomnia. It has been shown to improve sleep latency through multiple studies.

It is also a schedule four drug like the other two. It’s dosing is a little more like Ambien whereas in five to 10 milligram tablet. It also has the warning of not taking it, unless there’s at least seven or eight hours before you have to become active again.

Similarly, it is metabolized mostly by the liver, which has implications for how quickly the medication can be metabolized in women versus men, as well as in the elderly population where the literature talks about needing to be extra careful in prescribing sleep medications.

Adverse effects, other than drowsiness of course, dizziness, diarrhea, grogginess, and decreased ability to cocentrate. Additionally, there are the abnormal thoughts and behavior, including aggressive behavior, confusion, agitation, hallucinations,  worsening of mood issues, including worsening of depression, suicidal thoughts, memory loss and there have been of course some severe allergic reactions. On most of the medications that we’ve talked about there have been people who have severe allergic reactions. So if I don’t mention it know that it’s always a possibility

Sonata is apparently less susceptible to causing the parasomnias than Ambien or Lunesta.  Sonata appears to be less likely than Ambien and Lunesta to cause anterograde amnesia. Remember that’s amnesia of things happening post taking the medication rather than amnesia of not being able to remember previous events.

Sonata was also shown to have less ability to affect  word recall and recognition six hours after administration. It didn’t show that effect even at higher doses. Sonata in general still has those warnings about the parasomnias and the next day impairment, but it doesn’t seem to be quite as pronounced as the half-life is shorter and the recovery time isn’t as great.

So for instance, these medications are sometimes used with the military and in people who are in aviation to help them be “mission ready”. So to speak. There are guidelines for each of these medications about how long the person has to be awake before they’re able to engage in their mission or in their flight. Ambien, and Lunesta both have longer recovery periods than Sonata.   

Those are the three main medications used in the Z class category. I think it’s clear that they are preferable above benzodiazepines. Benzodiazepines have a number of other issues with them that can cause problems. They’re not without risk though. The parasomnias are very serious, can be and have been life-threatening. They’re not necessarily common though. They’re common enough that we see them in the news, but it’s not something that happens in a large percentage of people, which is why the medications are still able to be prescribed .

The tolerance, dependence and withdrawal is concerning. I think the trouble here is that when people can’t sleep, they get really desperate. I have had clients who have taken Ambien and they feel like it stops working after a while and so they want to take more.   The problem is then they have to get up the next morning and maybe they’ve only taken it five hours before their alarm goes off. 

I specifically remember a client who was taking it and worked in a factory on a line, working on machine parts. This is a particularly dangerous job at times and there was some next day impairment. 

One of the problems with insomnia appears to be  that it’s not just the body’s physical response, but that it’s the psychological response. Last week, when we talked about sleep disorders, I talked about the psychophysiological form of insomnia that has to do with the cycle of the body, not getting the message about sleep. And then basically the brain getting in the way and telling the body that it’s not going to sleep anyway. 

Lots of places when I was looking at different articles  had conflicting views on the addictive potential. I saw people using the phrase psychologically addicting. Now I have to tell you that psychologically addicting usually makes my eye twitch just a little bit. And part of that is because it’s been used by people who are smoking weed, forever, talking about it being psychologically and not physically addicting.  Which is not true. It’s absolutely physically addicting. It’s just the withdrawal isn’t as bad as other drugs.  I do think that psychological dependence may actually be applicable in this case.

We all know how quickly anxiety can cause issues for a person. A thought gets in their head and it goes around and around and it seems like they can’t dislodge it. All of a sudden it’s becoming true. The same thing happens when someone’s trying to sleep. If they have a belief that their medication or that something’s going to keep them from sleeping, it can be very hard to get around that.

Sleep Medication Risk: Difficulty quitting

One of the things that is really hard about these medications is getting off of them. Everything I read talked about that these medications should be used in the short term, even if short term in this case is six months. Taking them for years and years isn’t recommended and is apparently associated with a dose increase or less effectiveness over time.

This is a problem when you get to the point of getting to a max dose and not being able to take more. Getting off of these medications can be really hard because of the psychological impact of knowing that you’re going to be going off of them. It can be hard because your brain is telling you that you should panic, and you’re not going to be able to sleep.

For people who have had sleep deprivation because of insomnia the idea of not being able to sleep is very scary and often they will do just about anything to avoid that happening again. Especially when they’ve had a period of time where they were sleeping and finally felt okay. Insomnia is so difficult. I’m certain that pretty much all of us have had clients talk about their trouble with sleep and the things that get in the way.

These medications are useful. We may have clients that are taking them. When you have a client that’s taking one of these medications what I would suggest is to be really clear about what the dosage is, what they’re taking and how often they take more if at all.

The thoughts about not sleeping are part of the problem that keeps people from being able to initiate sleep. This is where the CBT-I comes in, that we talked about in the last episode.  There is a protocol for cognitive behavioral therapy to treat insomnia. It’s said to be fairly effective. I personally have not been trained in it, but have a colleague who uses it and has seen really great results from using it.

Sleep Medication Risk: Over-the-counter medications

Clients that have trouble sleeping will often have tried a number of things on their own. There are things  like Nytol or Z Quill or Unisom or Benadryl. People use different medications that have things like diphenhydramine  or Doxylamine succinate in it, which act as sedative. These are histamine blockers, which cause sedation.

Part of the reason that experts don’t recommend using these for sleep onset is  because of the anticholinergic properties. Acetylcholine is a neurotransmitter that plays a role in a lot of brain functions, including short term memory and thinking. Anticholinergic medications can produce cognitive impairment that persists even after you stopped taking them. 

In research done in 2015, the researchers found that there was an increased risk for Alzheimer’s and dementia for people who were taking these medications long-term. I imagine that there might be some people thinking, “but people take Benadryl all the time for allergies. Isn’t that going to be a problem?”

Well, yes,  if they aren’t taking Benadryl on a consistent basis, but I think what people find and that’s backed up by literature is that the effect of Benadryl or these other medications is short lived. Initially it can work really well and you have some relief from either the allergy or it helps you sleep. However, that doesn’t last very long and so the effect, isn’t something that’s going to continue.

When people have allergies that need more than just Benadryl they usually go to the doctor and get a prescription that doesn’t have the same kind of properties and risks as using diphenhydramine on a regular basis.

The implications for us have to do with people’s lack of sleep and their mood. Yes. The parasomnias are something that are a danger.  Having someone drive, have sex with, attempt to have sex with, sleepwalk or engage in aggressive behavior, even towards themselves all without remembering it is a huge risk. I’m less concerned about that, although absolutely I’m paying attention anytime I have someone who’s taking one of these medications. 

What I’m concerned about is how much they’re taking, if it’s effective and what impact that has on their mood. Sleep deprivation or a sleep deficit is a huge problem in pretty much everyone I see when it comes to anxiety, PTSD and depression. Of course, with depression, we think about people sleeping for long periods of time. But I haven’t found that that’s the majority of my clients.

When I have someone  who’s in the depressive portion of a bipolar disorder, then yeah they sleep for generally a long period of time.  But lack of quality sleep is generally more the problem that I find with people.

There are tons of studies about how this impacts our body and our mind and memory. It is actually one of the first things that I focus on when I’m meeting with someone. If they aren’t sleeping well, I’m pretty sure we’re not going to have a lot of success in a lot of areas, mood, memory, concentration, feelings of hope for the future even. And so this is the thing that I tend to go after first,

I talk to them about sleep hygiene and I asked them really specific questions about what’s happening when they’re trying to sleep. Is there a fan? What’s the light like? How does your body respond to sunlight and a host of other things.

I find that when people are able to get more consistently good sleep, that their general outlook improves. I would want them to go see their primary care doctor and possibly be referred to sleep medicine in order to find out what’s happening. I’d like to work on their sleep hygiene before I send them to their primary care doctor, because that’s going to be the very first thing that the doctor talks about.

Sleep Medication Risk:  Impact of addiction

The last part I want to talk about is where people are using these things to get high. It is a sedative. There are some reports about hallucinations and abnormal thoughts. There is some muscle relaxant quality to these medications as well. So it’s going to be sought after. Ambien is something that is sold on the street. Lunesta and Sonata just aren’t prescribed quite as often, but certainly they could be sold as well.

The combination of putting one depressant with another is extremely dangerous. I don’t know that people think about it being problematic to drop alcohol on top of Ambien. We’ve all seen those warnings and wonder if they’re actually really accurate. Someone who’s abusing substances. Isn’t necessarily going to care about that warning.

A really big issue in the addiction world is that people who have used substances other substances in this case have impaired sleep, the drugs and the withdrawal actually impair the sleep cycle for that person. Each drug has a unique effect on the person’s ability to sleep.

For our purposes in dealing with addiction. There are a few things I want to bring up about people when they’re coming off of drugs. Insomnia is one of the main withdrawal symptoms for pretty much every substance I can think of.

One of the main chemicals affected in drug use is of course, dopamine. Dopamine is a feel-good chemical, but it also has implications in the sleep wake cycle and alertness. When someone’s using drugs, they’re jacking up their dopamine levels and messing with the receptors.

When they come off of those drugs, there’s naturally going to be a drop in the dopamine that the person’s getting. This is going to lead to some problems with sleep in general, not to mention the problems that are associated with specific drugs.  For an example, let’s take marijuana.

Sleep Medication Risk: Combining the med risk with the effect of the previous drug use

Marijuana interacts with the endocannabinoid system, by binding to the cannabinoid receptors in the body. That system, and those receptors are involved in regulating the sleep wake cycle, among other things. Trouble sleeping is the number one symptom of someone coming off marijuana and generally the thing that ends up drawing them back.

When it comes to opioid drugs, of course, those can cause sleepiness. However, there is a much bigger problem with people who are using opioids and heroin. There was a study in 2018 done by UCLA. They were studying brain tissue and found that this particular brain had far more orexin receptors than other brain tissue. Remember that orexin  is the chemical in the body that has to do with wakefulness. 

What they found  was that the brain tissue was from a person who had  been a heroin user. This led them to look at other brain samples and they found the same thing. In the sample of brain tissues from people who had been using heroin, they found that they had 54% more orexin receptors than an average brain. That is a huge amount. And what it tells us is that the drugs that people are using are causing far more changes than just dealing with their impulse to use and the body seeking more rewards.

If you want to know more about the brain science of addiction, be sure to check out episode seven on the brain science, where I talk about this. It’s more than just the cycle of addiction. It’s what happens to the system in the body.  Sleep of course is a huge problem during early recovery and withdrawal. Being awake is difficult when you feel like shit and people want to sleep just to get through the day. The more days they put together, the better they’ll feel. 

If they feel shitty and still can’t sleep, that’s going to make things even harder. Not being able to sleep is actually a huge reason for relapse. At least with the people I’ve seen over the years and what I’ve heard them say about why a relapse happened.

 A lot of times it has to do with the fact that they just needed some relief. Because sleep is so important in healing and helping our body repair itself the lack of it also can draw withdrawal out.

The implications for us are just increased I guess. We already talk with people about sleep. Sleep’s hugely important in people’s mental health and their outlook on life. When someone is abusing substances, we know that their sleep is going to be impacted even more.

My encouragement is to do a continual assessment, not necessarily every week, but be checking in on these different things to see how they’re doing. Whenever one of my clients is having a rough week or a rough couple of weeks, I always ask them about sleep because I’m wondering what is happening and a lot of times sleep is one of the first places I see problems pop up.

Sometimes I’ll ask clients to talk to their bed partner and ask them questions about how they sleep at night. If it’s not super disruptive, the partner may not really say anything, but our bed partners have a lot of information. 

People do use these medications to get high. That is definitely something that’s happening.  It is for some people, their drug of choice. It starts out as being something for sleep, but they end up finding that they need a little more and a little more, and they’re using it also to escape life, to just get to the point where they’re like, you know what? I can’t do this day anymore. I just need to sleep. It is something that we want to pay attention to. 

All of the things I’ve talked about with sleep, the takeaway is sleep medications are supposed to be short term. The experts talk about sleep hygiene and cognitive behavioral therapy for insomnia. As we are assessing our clients for sleep issues, as it relates to mental health, we also need to be checking in about what they’re using to help them sleep.

So many people, I know, use alcohol to help them sleep as part of their, a couple drinks a night kind of thing.  We will need to be able to address the underlying cause of the sleep issue.  It’s going to be really hard for people to get off of a substance or stop using something if they think they’re going to be awake at night and not able to function during the day, this has to be approached slowly because the anxiety that gets produced from that sleeping seems to kick up really, really fast.

As always, there are links in the show notes to all sorts of things about sleep medications  and studies. You can find that on the website at betsybyler.com/podcast. 

Next week is the first week of the month, which means it’s interview week. I had the privilege of interviewing a woman named Vanessa. She’s a physician turned recovery coach from the Chicago-land area who found her way into recovery. It is an inspiring story of hope from a truly wonderful person. I hope you’ll join me for that podcast. And until then have a great week.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know.  Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

Helpful Links

Treatment Options for Insomnia – American Family Physician

Pharmacological Treatment of Insomnia

https://aasm.org/clinical-resources/practice-standards/practice-guidelines/

https://aasm.org/

Sleeping Pills: Types, Side Effects & Treatment

Insomnia Medication: Sedative-Hypnotics, Antidepressants, TCAs, Antidepressants, Other

Sleep Aids: How to Use Them to Treat Insomnia | Sleep Foundation

Are Sleeping Pills Safe? Here’s What Research Says | Time

Learn the risks of sleep aids – Harvard Health

Focus: Addiction: Prescription Sedative Misuse and Abuse

Antihistamines for Sleep: Is It Safe?

Treating Insomnia: Which Sleeping Pill Is Right for You? – GoodRx

Taking Z-drugs for Insomnia? Know the Risks | FDA

Here’s Why You Shouldn’t Take a Sleeping Pill Every Night | Time

Sleeping Pill Brands and Types: The Pros and Cons

Connections between Sleep and Substance Use Disorders | National Institute on Drug Abuse (NIDA)

Using medication: What can help when trying to stop taking sleeping pills and sedatives? – InformedHealth.org – NCBI Bookshelf

Side Effects of Sleeping Pills: Common and Potentially Harmful Side Effects

The Health Risks of Abusing Sleeping Drugs

How to Use Sleep Medications Safely | Sleep Foundation

Sleep and Addiction | Primary Care Collaborative

Drugs, sleep, and the addicted brain | Neuropsychopharmacology

Can You Get Hooked on Over-the-Counter Sleep Aids? – Consumer Reports

Ambien: Is dependence a concern? – Mayo Clinic

Causes and Emergency Treatment of a Sedative Overdose

Sleep abnormalities associated with alcohol, cannabis, cocaine, and opiate use: a comprehensive review | Addiction Science & Clinical Practice | Full Text

Insomnia: Pharmacologic Therapy – American Family Physician

The Very Real Dangers of Taking Sleeping Pills

Americans Are Getting Worse at Taking Sleeping Pills – The Atlantic

The DAWN Report: Emergency Department Visits for Adverse Reactions Involving the Insomnia Medication Zolpidem | CBHSQ Data

What Substances Can Cause Sleep Behaviors?

Prescription Sleeping Pills Guide: Strength, Names & More | hims

Prescription Sleep Aids for the Treatment of Insomnia

Are drugstore sleep aids safe? – Harvard Health

Sedatives – Side Effects, Dependence & Addiction | Everyday Health

Ramelteon: A Novel Hypnotic Lacking Abuse Liability and Sedative Adverse Effects | Anesthesiology | JAMA Psychiatry | JAMA Network

Mika: This therapy is helping me triumph over my 20-year addiction to sleep medicine

Zopiclone: a sleeping pill used to treat bouts of insomnia – NHS

Trazodone: Antidepressant, Sleeping Pill or Both? | Hazelden Betty Ford

FDA Approves New Sleep Drug With Claims Of Less Risk Of Unpleasant Side Effects

5 Drug Classes for Sleep Disorders

Sleepwalking Disorder | Dual Diagnosis

Frontiers | Sleep Medication and Athletic Performance—The Evidence for Practitioners and Future Research Directions | Physiology

Weekly Dose: quetiapine, the antipsychotic ‘sleeping pill’ linked to overdoses

Column: Marilyn Monroe and the prescription drugs that killed her | PBS NewsHour

Column: Sleeping pills: A risk of car crashes, gunshot wounds and Jason Bourne amnesia – Los Angeles Times

Ambien Uses, Dosage, Side Effects & Warnings – Drugs.com

Ambien (Zolpidem) Uses, Side Effects, Dosage, Overdose, Interactions

Sonata: Uses, Dosage, Side Effects, Warnings – Drugs.com

Sonata (Zaleplon): Uses, Dosage, Side Effects, Interactions, Warning

Lunesta: Uses, Dosage, Side Effects – Drugs.com

Lunesta (Eszopiclone): Uses, Dosage, Side Effects, Interactions, Warning

FDA Drug Safety Communication: FDA warns of next-day impairment with sleep aid Lunesta (eszopiclone) and lowers recommended dose | FDA

Zolpidem – StatPearls – NCBI Bookshelf

Lemborexant Article

Don’t Sleep On It: 10 Things You Didn’t Know About Ambien

FDA: Here Are The New Warnings About Sleeping Pills Like Ambien, Lunesta, Sonata

Evidence Brief: Effectiveness of Stellate Ganglion Block for Treatment of Posttraumatic Stress Disorder (PTSD) – VA Evidence Synthesis Program Evidence Briefs – NCBI Bookshelf

Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research

The Clinical and Forensic Toxicology of Z-drugs

Zolpidem dependence, abuse and withdrawal: A case report

By the way, doctor: Are sleeping pills addictive? – Harvard Health

Sleep Medicine: Parasomnias

Parasomnias: Causes, Symptoms, Types & Management

FDA adds Boxed Warning for risk of serious injuries caused by sleepwalking with certain prescription insomnia medicines | FDA