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Sunday, December 8, 2013
Sleep Aids: Melatonin, Ambien, Advil PM
I have some questions about sleep aids: Melatonin, Ambien, Advil PM. Can any of these medicines become habit forming? If so, which of the three is one least likely to become dependent upon? How much Melatonin is safe to take on a nightly basis? If there are side effects, which one of the three is least likely to produce them? In your opinion, which one of the three would you recommend for a female with a chronic sleeping problem?
Insomnia is a very common in modern society with an estimated 1/3 of Americans suffering from insomnia at any one point in time. Fortunately, the majority of cases are short-term and resolve within weeks, rarely requiring prolonged therapy. However, up to 20 million Americans complain of problems with chronic insomnia that may significantly effects their life, so you are not alone.
Insomnia has multiple underlying causes. Identifying the underlying factors that are contributing to insomnia is extremely important to ensure appropriate treatment. The workup of insomnia requires a detailed evaluation to help sort out the important underlying factors that may need to be addressed. Most cases of chronic insomnia can be managed without the use of sleep-inducing medications. If a specific cause of the insomnia can be identified, then treatment should be directed at that issue. Often times, behavioral therapy can be very effective for patients whose insomnia is the result of a poor sleep environment, poor sleep habits or psychological conditions. Some of the techniques used for behavioral treatment of insomnia include stimulus control therapy and sleep restriction. If interested, you should discuss these techniques with your physician. Improving “Sleep Hygiene” can make a dramatic impact in some cases (see the “Steps You Can Take to Improve Your Sleep” on the website).
Drug therapy is required to manage insomnia for some individuals, though caution should be exercised with long-term use of most medications. Of the medications you listed (ambien, melatonin and advil PM), each has it’s own uses and potential problems. I’ll answer your questions first, then talk a little about each medication class.
1. Can any of these medicines become habit forming? Ambien is the only of these medications that can be somewhat habit forming, though this effect is relatively mild compared to the older traditional sleeping pills. Still, in some individuals it may be difficult to stop if used repeatedly over a long period of time.
2. How much Melatonin is safe to take on a nightly basis? Melatonin is a naturally occurring hormone in the body and thus is safe for long term use. The major problem with melatonin from a safety standpoint is that this drug is not regulated by the FDA. As such, users need to be aware of the possibility of impurities and lack of melatonin in this “health food supplement.”
3. If there are side effects, which one of the three is least likely to produce them? They all have potential side effects, though are in general fairly well-tolerated. I recommend you check a pharmacy web-site for details on side effects, though will mention that all can cause potential daytime sleepiness and headaches. It’s impossible to predict if a given individual will have a side effect to any or all of the medications. Usually trial and error is the only way to tell.
4. In your opinion, which one of the three would you recommend for a female with a chronic sleeping problem? Without obtaining additional information regarding the specifics of your sleep problems, your history, other medical problems and other medications used, I could not possibly recommend a specific sleep aid.
The newer sleep-inducing medications such as zolpidem (Ambien), zaleplon (Sonata), or eszopiclone (Lunesta) seem to work well for short-term insomnia, though chronic long-term use (more than 6-12 months) of these agents has not been well-studied.
Melatonin, a naturally occurring sleep-inducing substance, has been found to be variably effective for treating insomnia as it tends not to be as powerful a sleep aid as some of the other medications. It may play a role in treating some individuals who have insomnia and are lacking normal melatonin secretion, but this does not appear to be common. It is probably most effective in treating those who have problems related to their underlying biologic or circadian rhythms, as melatonin will help to regulate these. Usually a dose of 1 mg at bedtime is adequate. Users of melatonin should be aware that this drug is not regulated by the FDA. Recently, a new melatonin-like substance, ramelteon (Rozerem), was approved for the treatment of insomnia. This medication appears to be fairly well-tolerated and is the first uncontrolled medication (as opposed to a controlled substance) approved by the FDA for the treatment of insomnia.
Advil PM is basically an over-the-counter medication billed as a sleep aid, primarily because it contains the antihistamine diphenhydramine (more commonly known by one of its trade names, Benedryl). The older antihistamines like diphenhydramine have sedation as one of their side effects and so have been used as sleep aids. Diphenhydramine is very good for bringing about sleepiness if taken at a time when we expect to be awake (such as during the daytime). Its use to promote falling asleep more quickly at night has not been well-studied and it’s effectiveness for this is probably overestimated. In addition, antihistamines can cause frequent awakenings and interruptions from sleep, so its usefulness as a sleep aid has been questioned by some authorities. Aside from sedation, antihistamines at prescribed doses can cause confusion, constipation, dry mouth and trouble urinating in some individuals. Elderly persons may be at a higher risk of running into these side effects. Advil PM also contains ibuprofen. While at a low dose in Advil PM, this medication, when used chronically, may increase the risk of cardiovascular disease and thus should not be used daily for indefinitely.
To learn more about insomnia or other sleep disorders, please visit the American Academy of Sleep Medicine website. In addition to information, the website contains a list of Sleep Centers across the country so that you may locate one near you. Good luck and here's to good sleep!
Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University