Waking up to Insomnia: A Review of Causes, Treatments, and Misuse

Introduction

As a college student, I’ve experienced sleep deprivation first-hand. However, I’m not alone. Approximately 33-50% of the US adult population has symptoms of insomnia. 

Insomnia is more than a significant public health burden. It affects work absenteeism and health care costs across the country. In order to remain happy and healthy, sleep is vital to human lives. By knowing the causes, analyzing the best treatments, and understanding misuse of certain medications, the consequences of insomnia can be remedied and sleep can cease to be a struggle. 

Causes

The list of causes and risk factors for insomnia is extensive -- understandable considering its prevalence. 

The risk of insomnia is greater for certain groups: 

• Women

• Individuals over the age of 60

• Those with a mental or physical health disorder such as anxiety, depression, PTSD, chronic pain, and heart disease

• Individuals with high levels of stress

• Individuals with a lack of a regular sleep schedule

Non-Pharmacological Treatments

Doctors have proposed several management therapies for those struggling with sleep. Some of the most popular treatments that do not involve pharmacological treatment include:

1. Sleep Restriction Therapy limits the number of sleeping hours to improve the homeostatic sleep drive, promoting a more consolidated sleep. 

2. Stimulus Control Therapy involves the restricting of poor late-night habits like eating, reading, or using technology in bed. 

3. Relaxation Therapy uses different exercises to reduce pre-sleep arousal including meditation and yoga. 

4. Cognitive Behavior Therapy (CBT) has been promising to the medical community as it has shown significant improvement in sleep onset latency (the amount of time spent falling asleep), wakefulness after sleep onset, and total sleep time. CBT is the first line of treatment for insomnia, but the lack of therapists and high costs can make it impractical for many patients.

Many patients use a combination of these therapies to help their insomnia. However, in many cases, therapeutic treatments are not enough.

Pharmacological Treatment

Another popular treatment for insomnia is pharmaceutical treatment. The most common pharmaceutical treatments are drugs that act on proteins involved with sleep. Drugs like benzodiazepines (BZDs) and Z-drugs create sedative and hypnotic effects on patients. However, two of the biggest risks with these drugs are the risks of abuse and dependence. 

BZDs and Z-drugs are both associated with cognitive and memory impairment, the rapid development of tolerance, and the risk of abuse. One of the most common pieces of evidence of this is motor vehicle accidents. Case control studies found that these drugs approximately double the risk of being involved in motor accidents. These problems have led clinicians to search for other treatments that are less harmful.

Thus, researchers have looked for drugs acting on other physiological aspects such as melatonin receptors. Melatonin is a hormone that is important for regulating the human body’s circadian rhythm (internal clock responsible for sleep). The FDA recommends a dosage of 8 mg of melatonin for the management of sleep onset insomnia. The possible side effects of this treatment are fatigue, drowsiness, and dizziness.

Overall, many pharmacological treatments have side effects. If any of these treatments are used, it is best that they are paired with overall good sleep hygiene and awareness of poor sleep habits.

Misuse

One study published by Michael F. Weaver, a doctor from the Department of Psychiatry and Behavioral Sciences at the University of Texas Medical School at Houston, illustrates real patient cases about the abuse of sedative medication. Up to 33% of elderly patients in North America are prescribed benzodiazepines or Z-drugs for sleep problems. These drugs are prescribed under specific conditions - symptoms of a sleep disorder. Most problems arise when patients have underlying mental conditions that make them more likely to abuse the prescribed drugs for self-medication purposes. Termed “chemical coping,” patients who use their prescriptions in order to self-medicate often find themselves building a higher tolerance to the therapeutic effects of the drug that were meant to help with sleep. 

In the first case of this study, a patient described to have depression and anxiety self-medicates using a short-acting benzodiazepine. However, over time her symptoms do not improve, and she even experiences physical consequences of her misuse. Despite her desire to increase her prescription dosage due to her newfound tolerance, it is clear that this drug is not the most helpful or efficient for her set of conditions.

In the second patient case, the patient has a history of drug and alcohol addiction and begins using a BZD drug after obtaining it from a non-medical source. After repetitive abuse, he begins to have physical symptoms, such as tremors from withdrawal, that affect his daily life. Here it can be seen that the previous substance abuse showed a tendency for this patient to rely on self-medicating, leading to physical harm. A history of previous addiction is one of the biggest predictors of potential abuse of prescription drugs.

The biggest measure to prevent this misuse and addiction is the act of prescribing safely. First, physicians should have a comprehensive understanding of an individual’s past supplements and prescriptions, problems with medication management, and health problems in order to properly assess each patient. 

Certain other factors have also shown a trend for medication abuse:

• Young age

• Experiences of childhood sexual abuse

• Experiences of legal problems

• A history of lost/stolen prescriptions

The Prescription Drug Monitoring Program (PDMP) is a helpful resource for any physician looking to write a prescription. This electronic database collects information on the rates of usage of certain medications in each state and potentially certain patients. Moreover, Weaver states that this resource is recommended in order to “raise awareness for a need for caution when prescribing.”

In The Future

Insomnia is an important health concern, affecting a significant amount of the US population. Several treatments are popular, such as natural and pharmaceutical therapies. However, certain risks to prescription medications should be taken into account when physicians are giving treatment for insomnia (and similar conditions). As researchers continue to learn more about insomnia, it is vital to educate physicians and strive to find better alternatives to sedative drugs. In order to promote a healthy, well-rested society, it is important that more studies and general education are done on the nature of sleep disorders and their consequences. 

Resources

Addiction Information: https://www.addictionresource.net/sleeping-pills/

For more information on sleep disorders: https://sleepeducation.org

The National Sleep Foundation: https://www.thensf.org