Most insomnia medication effective for short-term use

About 60 million Americans a year experience insomnia often, or for extended periods of time, leading to problems in job performance and other activities. Insomnia affects about 40% of women and 30% of men.

For short-term insomnia, doctors often prescribe benzodiazepine sleeping pills. These medications generally act as hypnotics in high doses and as sedatives in low doses. The effect of a given dosage may vary. The benzodiazepines include Ativan (lorazepam), Dalmane (flurazepam), Doral (quazepam), Halcion (triazolam), Klonopin (clonazepam), ProSom (estazolam), Restoril (temazepam), Serax (oxazepam), and Valium (diazepam).

"All the drugs available for treatment of insomnia have some drawbacks, especially with prolonged use," says Mark Abramowicz, MD, editor of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs. "Short-term use of a short-acting NBRA is generally effective and safe, but it is not clear that NBRAs are more effective or safer than benzodiazepines, which cost much less."

These medications vary in their effects on next-day driving skills. Lunesta, with its longer duration of action, could impair driving in the morning, even when taken at bedtime. Sonata, which is shorter acting, has not been shown to affect next-day driving skills, even when taken in the middle of the night. Ambien CR, with its intermediate duration, could impair driving skills the following morning, especially when taken in the middle of the night.

Another medication for insomnia, Rozerem (ramelteon) works by a different mechanism, acting on the brain's melatonin receptors. Unlike the benzodiazepines and NBRAs, it is not a controlled substance, and problems with rebound insomnia or withdrawal effects have not been observed. "We use quite a bit of Rozerem and it's nice because it's not addicting. It's not even habituating," says Robert G. Hooper, MD, medical director of the Scottsdale Sleep Center.

"Comparative studies with other hypnotics are lacking, and it's not clear whether this medication is as effective as the benzodiazepines and NBRAs," says Dr. Abramowicz.

For many patients, non-pharmacological treatments such as changing sleep habits, relaxation training and cognitive therapy may be more effective and durable than treatment with drugs. "Almost everyone I see for difficulties with sleep initiation or sleep maintenance has some psychologically-based contributing features or habitual patterns," says Dr. Hooper. "It could be some food or drink they're using, without realizing it can interfere with sleep."

A National Institutes of Health (NIH) consensus development panel on managing chronic insomnia issued a statement in June 2005 calling for increased reliance on cognitive methods. "Behavioral and cognitive-behavioral therapies have demonstrated efficacy in moderate to high-quality randomized controlled trials," the NIH panel said. "Cognitive-behavioral methods have been found to be as effective as prescription medications for short-term treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of cognitive-behavioral therapies, in contrast to those produced by medications, may last well beyond the termination of active treatment."

AN OVERLOOKED PROBLEM

Insomnia and sleep deprivation account for an estimated $16 billion in medical costs each year, while the indirect costs from lost productivity are much greater.

"Insomnia is an increasing problem," says Sean Sullivan, JD, president and CEO of the Institute for Health and Productivity Management. "I've become convinced that sleep disorders are perhaps the most overlooked, ignored, underrated cause of health and performance problems in the workplace."

This article is based on information supplied by The Medical Letter, ( http://www.medicalletter.org/), a non-profit organization that publishes newsletters offering critical appraisals of new drugs and comparative reviews of older drugs. The Medical Letter is completely independent of the pharmaceutical industry. It is supported entirely by subscription sales and accepts no advertising, grants or donations. Institutional site license inquiries can be sent to info@medicalletter.org.

Elaine Zablocki has been reporting on healthcare for more than a dozen years. She can be reached atinfo@medicalletter.org