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Sleep Medications:

The Good, the Bad and the


Ugly
By Nancy Nadolski
Sleep Expert, Nurse Practitioner, Author, Speaker

Sleep School Online LLC


Copyright 2014

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Sleep Medications: The Good, the Bad and the Ugly


By Nancy Nadolski
www.mysleepschool.com
Sleeping pills. Sleep meds. Tranquilizers. Sedatives.
It seems like there are millions of medications available to help people who aren't getting
enough sleep. The reality is that millions of people just like you suffer from the dreaded wideawake nights.
If you lay awake at night trying to fall asleepa little pharmaceutical first aid may seem like a
good idea.
If you wake up in the wee hours and can't get back to sleep before the alarm goes offyou may
be willing to try almost anything that the drugstore is dispensing.
We live in a quick-fix society, perfectly primed for popping a pill to solve every problem. And
insomnia is a big problem.
But before you take any sleep medication, please keep reading and then phone your health care
provider. Whether we are talking about over-the-counter sleeping aids, natural or herbal sleep
aids or a sleep prescription this free article is important information that you should have on your
nightstand.
To understand the good, the bad and the ugly of sleep medication lets start at the beginning.
Sleep Problems date back a very long time
Life moves fast, and problems and stress-factors seem enormous today. Many a sleepless night is
spent worrying. But the problem of insomnia is not a new one. Centuries ago, opium was one of
the first recorded sleep aids. The powerful drug was being used to help the early insomniacs and
it is documented as early as 1500 B.C.
A reading of the bible also tells us that alcohol was used to create sedation and sleep for Noah.

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As a matter of fact, in the past 2 centuries humans have used everything from chloral hydrate to
barbiturates to mommys little helpers to get the elusive good nights sleep.
The Good, the Bad and the Ugly
Sleep Medication: The Good, the Bad and the Uglywhy do I say that? Simply because sleep
medication is all of those things. When it comes to sleep medication you cant have the good
without the bad and the ugly.
My name is Nancy Nadolski and I am a medical professional specializing in the treatment of
sleep disorders.
As one of the licensed sleep practitioners who treats insomnia every day; we always aim for the
right dose, at the right time, for the right problem. Done correctly, taking a sleep medication at
the proper dose for the appropriate amount of time can be good. But many sleep medication is
dispensed over-the-counter, without any medical supervision and that can be bad. And even
more serious things occur when people start taking more medication than is safe, or combining
drugs that were never meant to be taken in combination with anything else. This can be ugly.
Very ugly.
Sleep medication can be ugly.
Sleeping medication can be simple, small, innocuous looking little pills. But ugly things can
come in small packages. Look at it this way; what do you think the following list of names all
have in common?

Heath Ledger.
Marilyn Monroe.
Elvis Presley.
Michael Jackson.
Anna Nicole Smith.

The commonality (besides fame and fortune) is that every one of those people had problems
sleeping. They each relied on medications to get to sleep and stay asleep. The autopsy reports of
Heath, Marilyn, Elvis, Michael and Anna Nicole all showed some type of sleeping medications
in their system at the time of their death. This represents the ugliest of the ugly about sleep meds;
they have shown up in autopsy reports of those who have died way too young.

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Starting with the death of Marilyn Monroe, sleeping meds have been linked to addiction, self
prescribed overdosing, accidental overdose, really poor judgment and sadly enough, suicide.
The ugly side of sleep medication happens because we expect a lot from sleep medication. For
that matter, we expect a lot from all medication. When meds dont perform we are
disappointedand then we execute our own polypharmacy by combining sleep medication
and/or by taking sleep medication in higher than recommended doses because we are determined
to get a good nights sleep.
Sleep medication can be bad.
This brings us to the bad portion of sleep medication.
Sleep medications can be bad because while in the short term they have rescued many an
insomniac, they also create the belief that sleep will only follow a dose of sleep medication. That
belief is wrong and the outcome is often bad.
Is there anything good about sleep medication?
Yes, because sleep medication does work. Sleep medication has been shown to be safe and
effective when used appropriately.
The current sleep medications have been engineered to work effectively to initiate and maintain
sleep without interfering with the necessary stages of healthy sleep. More on that when you sign
up for Sleep School.
Right now you should know that for short term use, there are medications that can help you get
to sleep and stay asleep. These medications come without the risk of rebound insomnia, next day
hangover, or seizure activity when they are stopped.
Is all sleep medication the same?
No. Not even close. In my practice I find that there is confusion about the 2 classes of
medications often prescribed for sleep; sedatives and hypnotics.
Sedatives can sometimes help create sleep because they have a calming function. At low doses
sedatives have minimal effect on motor and mental function. At higher doses sedatives can
create sleep and also some of the same effects as alcohol.
Examples of sedatives most prescribed would be:
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Xanax or alprazolam
Klonopin or clonazepam
Valium or diazepam

These do not have any FDA approval for sleep but sometimes clinical judgment calls for them to
be used for sleep that is in the company of anxiety.
Sedatives are typically prescribed for:

Panic disorders and anxiety due to their calming effects


In surgery (out-patient and in-patient) to help initiate anesthesia
Muscle relaxants

Conversely, hypnotics are designed to induce drowsiness and facilitate sleep onset and sleep
maintenance.
Specific hypnotics FDA has approved for sleep:

Ambien or generic zolpidem for sleep onset


Ambien CR or generic zolpidem CR for sleep maintenance
Lunesta or generic eszopiclone for sleep onset and maintenance
Sonata or generic zaloplon for sleep onset
Intermezzo or zolpidem for sleep maintenance

When prescribing hypnotics a medical professional hopes to:

Get you to sleep


Keep you asleep
Increase total sleep time
Make sure you can function well the next day without any drug hangover effects.

How do sleep medications work? For that matter, how does sleep work?
Im glad you asked! When the brain is getting ready to sleep there is a specific combination of
ingredients that show up in just the right doses, at just the right time. I call that sleep soup.
One of the ingredients that turns on the sleep switch in your brain is gamma amino butyric acid,
aka GABA.

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Getting good, healthy sleep means your brain needs GABA in the system at just the right time
for initiating and maintaining sleep.
Unfortunately the sleep medications dont always play nicely and they think they can go
anywhere they please in the GABA system. This is where we get side effects that make the good
sleep medications go bad and ugly.
Confused?
Its simple, really. The GABA receptors are the most dominant receptors for slowing things
down in the brain and the body. The medical term is called inhibitory. In fact, medications that
control and stop chaotic brain activity called seizures operate in this same neighborhood. Antiseizure medications disrupt the chaos by slowing electrical signals down in the brain.
The medications we have now are more particular in finding the part of the GABA system
specific for sleep. The sleep medications are targeted to the GABA-A receptors. In contrast,
alcohol and sedatives are like a garden hose spraying everywhere in the GABA system.
Medications like the brand name Intermezzo (zolpidem) is designed to confine itself to the
GABA-A receptor.
The GABA-A receptor specific medications have no use for treating seizures, anxiety or muscle
spasms. They are specific for starting sleep and keeping it going through the sleep period.
There are other ingredients in the brains sleep soup
There are a number of other chemicals present in your brain and they all have long, complicated
sounding names like; Acetycholine, Monoamines, Dopamine, Norepinephrine, Histamines,
Hyprocretin, and Orexin. These chemicals are present in very specific amounts during your 24/7
sleeping - waking circadian cycle. In other words, there is a specific shift in the chemicals when
it comes to initiating and maintaining sleep.
Over the counter medications these all impact the neurotransmitter histamine.
As the sleep soup continues to simmer in the brain, there are other neurotransmitters that need to
be present or absent in just the right amounts.
Histamine is a neurotransmitter that has many receptors and functions throughout the body. One
of those receptors lives in the part of the brain responsible for helping us wake up. Simply put,
giving ANTI-histamine makes you sleepy.
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Walk in any pharmacy and you will find a row of sleep aids. Most of these have an
antihistamine called either doxolamine or diphenhydramine. These are antihistamines that cross
the blood brain barrier and can make you sleepy.
Back to the Good, the Bad and the Ugly
Products with a combination of antihistamines and acetaminophen or ibuprofen are very modern
and popular sleep aides. Examples of these are Tylenol PM or Advil PM. They can be good
because they treat acute or chronic pain as well as sedate and initiate and maintain sleep.
They can be bad because they stay in the system a long time and can create a next day hangover.
Remember, the perfect sleep medication not only does its job, but also knows when to stop.
Can Herbal and Dietary Supplements be used as Hypnotics/Sleep Aids?
The answer? Maybe.
Two of the most widely marketed and popular sleep aid supplements are melatonin and valerian
root.
Melatonin is a hormone secreted by the pineal gland of the brain. It also occurs naturally in
plants and microbes. Varying levels of melatonin coordinate the body cycles and rhythm.
Melatonin receptors in the brain and other parts of the body are activated when melatonin is
released.
Melatonin is the only hormone available for sale over the counter in the United States. Most is
sold in a synthetic form that has the same properties as the natural occurring hormone. Melatonin
has been found in plant products where it is sensing light/dark and controls how the plant
changes in the seasons. Feverfew and St. Johns Wart are plants that have melatonin. And
smaller amounts are found in cherries, bananas, grapes, rice, olive oil, wine and beer.
In mammals, melatonin is secreted into the blood by the pineal gland. This gland is in the center
of the brain and secretes melatonin in the dark. Thats why it is called the hormone of
darkness. When light enters the eye this melatonin secretion and production is closed down. The
melatonin signal is just one part of the sleep-wake cycle switch. Melatonin levels rise in the
evening as the night draws near and plummet when the sun comes up in the morning.
Although several studies have shown effectiveness with melatonin and jet lag the truth is we
dont know enough about melatonin supplements to determine the right dose, at the right time.
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There is no current data that shows effective treatment for insomnia with melatonin. That being
said, some people will swear that it is the only thing that works for them. To them I say; if it
aint broke dont fix itbut stay with the same dose and with the same brand.
If you are considering melatonin you should know too that the timing of melatonin seems to be
the key to its individual effectiveness. A study in 2000s journal Sleep reported about the varying
effects of melatonin when given at different times.
The authors concluded that an 11:30pm dosing of melatonin had no clinical effect on sleep in
healthy volunteers. But when melatonin was given at 8:00 PM it showed the same effect as a
sleep aid (20 mg of temazepam) on the subjects in helping them sleep.
The other widely known sleep supplement is valerian root. Valerian has been used as a medicinal
herb since the time of ancient Greece and Rome.
Through history it has been reported to be used as a sedative. Some people believe that valerian
root operates in the GABA neurotransmitter receptor system. Truth is we really dont know how
it works or how to dose it.
We do know that studies done have been quite small and for very short periods of time.
One such study about valerian root was reported in Pharmacopsychiatry in 2000. It looked at a 2
week period. The study showed a significant improvement in both initiating sleep and
maintaining sleep when taking 450 mg of valerian root at bedtime. Stage 3 or delta sleep was
more pronounced the longer the subjects took valerian root.
The good news with valerian root is there were no identified or reported side effects.
In a second study we learned more about a reduction and discontinuation of sedatives and a
relationship to valerian root. Subjects tapering off of and discontinuing a sedative reported much
better sleep maintenance when they combined the tapering with valerian root. This study only
had 19 participants and only lasted 15 days but it gives hope to those interested in exploring
more long term evidence.
There have been no other herbal supplements studied well enough to suggest effectiveness and
safety as a hypnotic. Melatonin and valerian root have been studied the most yet there are no
long term safety studies and appropriate dosage has never been consistently identified. Valerian
root shows the most promise with little adverse effects.

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The good, bad and ugly also includes no FDA regulation for formulations and production. That
means unless you do your own research, the product you buy may not have the ingredients you
are looking for.
And all the other sleep medication
You are most likely familiar with many of the sleep medications and terms. You may not know
though that one of the first steps for a prescribing clinician to treat insomnia is to give a
medication that has a high safety and low abuse potential profile. The bottom line is that even
though the medication has not received the FDA indication or approval for sleep, a wise clinician
knows the pharmacology and uses her clinical judgment to prescribe.
Antidepressants with a strong antihistamine component have been prescribed and generally work
well. These include:

Deseryl (usually the first one the primary care clinician reaches for) or the generic
trazodone
Elavil or the generic amitriptyline
Remeron or the generic mirtazapine
Silenor or the generic doxepin

These medications stay in the body for a long time because they were originally approved to treat
depression and anxiety on a 24 hour basis. So the timing for these medications is very important
to minimize the risk of driving drowsy and next day hangover.
Another risk with these medications (as with all medication) is developing a tolerance.
Developing a tolerance means the starting dose is no longer as effective so the dose is increased
to get the same response. Higher dosing for the desired response also means more side effects
and most likely the next day hangover.
Let me reiterate that before you take or change any sleep medication you need to speak with your
medical provider. Be it over-the-counter sleeping aids, natural or herbal sleep aids or a sleep
prescription. Any med used incorrectly is very serious business.
I know that you have an interest in a better, healthy, restful nights sleep so Id also like to
suggest one more thing;
Sleep School. Yes. Sleep School.

2012 Sleep School Online LLC

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The problem of insomnia is not a new one. Sleep School is the perfect new e-solution to this age
old problem. Sleep School is a unique blend of licensed medical care, years of clinician success
with sleepless patients and the latest and greatest that technology can provide.
One of the reasons Im so jazzed about my new Sleep School is that technology can either be
one more thing that keeps you awake at night or be the thing that finally helps you get the
sleep you crave. From your initial download of the sleep diary through six weeks of healthy
homework you will be more rested, more refreshed, more everything.
And because Sleep School is already a proven success, Im making an unheard of money back
guarantee. If you arent completely satisfied after 60 days of sleep school we will happily refund
your investment in full, no questions asked.
My name is Nancy Nadolski and I am a medical professional specializing in the treatment of
sleep disorders. Click here to get started with my Sleep School. And remember, good sleep is
good medicine!

2012 Sleep School Online LLC

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