Smart use of sleeping pills

By J. Steven Poceta, MD

Many people find it challenging to get a good night’s sleep either because they have problems falling asleep or staying asleep through the night. While many effective medications on the market to promote sleep might seem like a dream come true, misuse of such medication — whether accidental or intentional — can have nightmarish consequences.

In my medical practice and as a legal consultant for patients being prosecuted for driving under the influence, I have encountered numerous situations in which the sleep medication zolpidem (also known as Ambien or Ambien CR) has triggered abnormal and sometimes dangerous behaviors known as parasomnias. The most common of these sleep-related behaviors include night terrors, sleep walking, and sleep eating, as well as the less common sleep driving. Usually, a sleep walking episode would end when the person bumps into a wall and awakens, but if a sleeping pill is involved, the episode might continue. In this case, the person would be in a drug-induced state without conscious awareness of his or her actions. For example, one of my patients filled the bathtub in her sleep and flooded her home. Another who had unexplained weight gain discovered that he ate nightly in his sleep.

Sleep driving is probably the most dangerous parasomnia that has been associated with sleeping pill use. I have evaluated several defendants who were charged with driving under the influence (DUI) while taking zolpidem. Like alcohol, zolpidem is a sedative, and these defendants exhibited symptoms similar to intoxicated drivers.

While parasomnias can occur even without sleep medication, zolpidem appears to possibly make them more likely or more severe—and also can produce a related daytime behavior known as an automatism. This unusual, rare abnormal behavior is characterized by poor muscular control and confusion; certain types of epileptic seizures are probably the most commonly recognized automatism. Like being on autopilot, people in an automatic state have no recollection of their behavior even though they appear to consciously interact with their environment.

Does this mean you should avoid zolpidem? Not necessarily. The key is being smart about how you use it. If you have been prescribed zolpidem (or any sleep medication), there are steps you can take to maximize its effectiveness and safety.

Tell your bed partner or housemates when you start to take a sleeping pill. This gives them a “heads up” to be on the alert for any unusual behavior. Let your prescribing doctor know if you live alone, as he or she may decide to use a lower dosage or different medication.

Make sure your physician knows if you are taking any other medications, including prescription and over-the-counter medications, as well as herbal or natural supplements. Especially avoid combining alcohol with your sleep medication.

When you begin taking a sleeping pill, take it at the lowest recommended dose so you can see how you react. Do not take additional doses during the same night. If your physician approves increasing the dose, do so gradually and monitor your reactions.

Take sleeping medication at your normal sleep time and go to bed. A sleeping pill is not like flipping a switch — you have to be ready to go to sleep. Many patients I have worked with were taking their sleep medication at odd times. For example, a patient who’d had a bad day at work and just wanted to get some sleep took a sleeping pill at 6 p.m.; however, his usual bedtime was 11 p.m. Shortly thereafter the pill kicked in, but because his body wasn’t ready for sleep, he was basically in a drugged state similar to being inebriated. He ended up driving his car and being arrested. In another case, a woman was taking zolpidem every afternoon to help her headaches. She would be clumsy and unsteady during the evening, and have no recollection of her activities the following morning.

When used wisely, zolpidem can be a valuable sleep aid. However, it is particularly important to follow your physician’s instructions exactly, and to report as soon as possible any concerns or problems that might occur.

J. Steven Poceta, MD, is a consultant in Neurology and Sleep Disorders at Scripps Clinic in La Jolla, California.