The Roseanne saga took an unexpected turn this week as the actress returned to Twitter to explain that the tweet that led to the cancellation of her show was sent out while she was on Ambien. Sanofi, the pharmaceutical company that makes the drug, fired back a tweet of their own. “People of all races, religions and nationalities work at Sanofi every day to improve the lives of people around the world,” the company said. “While all pharmaceutical treatments have side effects, racism is not a known side effect of any Sanofi medication.” By mid-day, #Ambien was one of the top trends on Twitter.
It may be true that racism isn’t a side effect, but that doesn’t mean there aren’t many, many other side effects to the drug. In fairness, it would have required quite an epic Twitter thread for the company to list them all. In my book The Sleep Revolution, I spent the better part of a chapter writing about so-called sleep aids (just because you’re not awake doesn’t mean you’re asleep) and the very real dangers they pose, which will outlive the current twitter feud. So whether or not you have some time suddenly freed up by the cancellation of the Roseanne reboot, here’s an abridged version of that chapter.
SLEEPLESSNESS AND SLEEPING PILLS: A MATCH MADE IN BURNOUT HEAVEN
An entire industry has arisen to facilitate our attempts to get more sleep. In the United States, more than 55 million prescriptions for sleeping pills were written just in 2014, with sales topping $1 billion. A 2013 Centers for Disease Control report stated that 9 million Americans—4 percent of all adults—use prescription sleeping pills. It also found that women are bigger users of sleeping pills than men; that sleeping-pill consumption increases with age and education; and that white adults consume more than any other racial group.
I asked several sleep experts what they thought of the 4 percent number from the CDC, and the general conclusion was that the survey number involved significant underreporting. A National Sleep Foundation poll found startlingly high rates of sleep-aid usage among women, with 29 percent reporting that they use a sleep aid of some kind at least a few nights each week. A survey by Parade magazine of more than fifteen thousand people found that 23 percent of respondents took sleeping pills once a week and 14 percent took them every night. The problem is global: in 2014, people around the world spent a staggering $58 billion on sleep-aid products, a figure projected to rise to $76.7 billion by 2019. Not surprisingly, the use of sleeping pills is highest among those who regularly get less than five hours of sleep a night.
For the drug industry that stands to profit from today’s sleep crisis, business is good and the future looks bright. But the strength of this market is just a reflection of the depth of the problem. And although marketers use the soothing term “sleep aids,” burnout is the necessary condition that feeds the sleep-aid market.
“In twenty years, people will look back on the sleeping- pill era as we now look back on the acceptance of cigarette smoking,” Jerome Siegel, director of UCLA’s Center for Sleep Research, told me. “Movies and TV glamorized smoking. Advertisements, often with doctors or actors posing as doctors, were used to sell cigarettes.” Only after many years and many studies linking cigarettes to lung cancer and other diseases did the government step in to regulate tobacco advertising. So we may have moved beyond the era of Joe Camel and advertisements proclaiming “More doctors smoke Camels than any other cigarette!” and “Give your throat a vacation . . . Smoke a fresh cigarette,” but as Siegel put it, “history appears to be repeating itself. The chronic use of sleeping pills is an ongoing public health disaster.”
Sleep difficulties can turn into serious medical problems, as I discuss in the Sleep Disorders chapter. For the vast majority of us, however, sleep difficulties are a lifestyle problem. Yet we tend to treat all our sleep-related woes the same way: with a pill. This is hubris on the scale of Greek mythology. We expect, as if by magic, to wrestle sleep into submission. This isn’t accidental. Combine the marketing power of the modern pharmaceutical industry with a client market that includes, potentially, every fatigued and burned-out worker—which is to say nearly every worker—and you’ve got the makings of the juggernaut that is the modern sleep-aid industry. As Matthew Wolf-Meyer put it in The Slumbering Masses, by “empowering medical practitioners, pharmaceuticals, and caffeine as mediators in individuals’ relationships with sleep,” we have created a world where “rather than a gentle sovereign, sleep has become demonized and rendered an object of medical and scientific control.”
As so many of us burn out in our efforts to keep up in today’s high-pressure, always-on world, we’ve made it easier and easier for the pharmaceutical industry to tighten its grip on us and expand its reach. Instead of questioning how we live our lives, we fall prey to sophisticated marketing that promises us health, happiness, sleep, and energy. And who wants to be the naysayer, the Luddite who rejects such progress? A great deal of ingenious and insidious brainpower, along with billions of dollars, goes into selling us a solution that doesn’t actually solve our problems but only disguises and prolongs them.
The most common pharmaceutical weapon we use to knock ourselves out is the drug zolpidem, which you probably know as Ambien. It accounts for more than two-thirds of the sleeping pills sold in the United States. It is also sold under the soothing names Intermezzo, Sublinox, Zolfresh, and Hypnogen. That last one is especially apt, since zolpidem is part of a class of drugs known as hypnotics, which work to induce and lengthen the duration of sleep. Of the 55 million prescriptions written for sleeping pills in the United States in 2014, 38 million were for zolpidem, accounting for sales of more than $320 million. Lunesta, another hypnotic, marketed with a seductive green butterfly logo, had more than $350 million in sales in the United States in 2014, and that figure does not include the generic version, eszopiclone, which generated another $43 million.
When you hear the stories of people who have become dependent on sleeping pills, you realize that they actually shouldn’t be called sleeping pills at all. Because we now know that simply not being awake doesn’t necessarily mean you’re actually asleep. It’s not the clean, binary, zero-sum game the drug manufacturers would have us believe. Which is why sleeping pills aren’t the solution to our sleep-deprivation crisis—they’re another crisis masquerading as a solution, offering a false promise that takes us further from the benefits of real, restorative sleep.
Harvard Medical School professor Patrick Fuller explained to me the difference between natural sleep and drug-induced sleep. Sleeping pills typically target only one of the many different chemical systems used by the brain as part of the sleep process, which “necessarily produces an imbalance in the chemical signaling by which the brain achieves normal sleep and may limit restorative slow-wave sleep. The newer drugs like Ambien produce more naturalistic sleep but can have side effects, albeit rarely, like sleep eating and sleepwalking, which by definition are not a part of normal sleep behavior.”
This limbo state, when we are not really awake but not really asleep, can result in behaviors ranging from the harmless and humorous to the disturbing and dangerous. And part of the danger is that you will more than likely have no memory of whatever you do.
The Today show’s Julia Sommerfeld was a regular user of Ambien until what she describes as her “wake-up call.” Her credit card company called to report suspicious activity on her account—nearly $3,000 charged to the store Anthropologie at 2 a.m. Her initial reaction—fraud!—was quickly disproven, in the form of an e-receipt at the top of her in-box: she had been the perpetrator of an Ambien-induced online shopping spree. On other occasions, while on Ambien, she had also consumed large quantities of brown sugar right out of the bag, devoured two of her sons’ decorated Easter eggs, and written an embarrassing email to her boss. What finally got her to kick the hypnotic habit was her husband invoking their toddler son. “How can you be sure you’d never hurt Jude?” he asked. “What if you decided to put him in the car?” In fact, in a University of Washington study, people who took generics of Ambien, Desyrel, or Restoril were nearly two times more at risk of being involved in a driving accident.
In response to growing concerns, the FDA in 2013 cut the recommended dose of zolpidem in half—in half!—for women and began requiring stronger warning labels highlighting the dangers of driving a motor vehicle after taking extended-release versions of the drug. It was a significant step forward—as well as a dramatic, unequivocal acknowledgment of how the drug manufacturers have been allowed to profit from a sleep-deprived public for so long.
Ambien has also been used as a defense in criminal trials—a pharmaceutical version of the “Twinkie defense.” On The Fix, a site about recovery and addiction, Allison McCabe told the story of Lindsey Schweigert, a thirty- one-year-old working for a defense contractor. Returning from a business trip exhausted, she took one dose of generic Ambien. Several hours later, when she emerged from her zombie state, she was in police custody. She’d gotten out of bed, filled the bathtub and left the water running, taken her dog out, climbed into her car, and, while driving, collided with another car. She failed a sobriety test after falling three times when asked to walk a straight line. The police charged her with driving under the influence. Prosecutors sought a sentence of six months, but Schweigert’s lawyer pointed to the warning label on the Ambien she took and argued that she belonged in the hospital, not jail. The label read:
After taking Ambien, you may get up out of bed while not being fully awake and do an activity that you do not know you are doing. The next morning, you may not remember that you did anything during the night. . . . Reported activities include: driving a car (“sleep-driving”), making and eating food, talking on the phone, having sex, sleep-walking.
Put aside for a moment the absurdity of this label and the fact that it exists. Or file it under: Warning Labels Apparently Written by The Onion. The charges were dropped, though Schweigert was left with a suspended license and nearly $10,000 in lawyers’ fees. The more of these stories I hear, the more shocked I am at the number of people who walk away from such incidents with similar consequences—a suspended license, a financial burden, but ultimately nothing more.
Because of the FDA warning, the consequences of Ambien use are treated as a side effect, not as a crime. I asked Ted Olson, a former US solicitor general, to explain why something that would be a crime in one context is not in another. “Criminal laws are not well-suited for prosecutions in these kinds of cases,” he explained, “because of the difficulty in articulating standards for impairment from various types of medication and, for that matter, for driving while tired, sleep-deprived, emotionally distracted, et cetera. And there are probably not adequate tests or articulated standards as there are with alcohol impairment. One drug might affect one person quite differently than another. On the other hand, civil cases might be easier and present less in- surmountable obstacles of proof and standards for liability.”
There are, of course, times in our lives—a traumatic experience, the death of a loved one—when we might need some temporary help getting to sleep. But it’s important to make a distinction between turning to sleep aids at such moments and turning to them—as ads suggest we should—as an everyday, long-term cure for sleeplessness.
There’s no shortage of stories of lives derailed or destroyed in ways that could never be contained in the pharmaceutical-industry parlance of “side effects.” And in many instances the people involved took the drug exactly as directed.
Shortly before her death, my friend Nora Ephron told me about taking Ambien one night in Paris. She woke up in the morning disoriented, with wet hair. It turned out that she’d gotten up during the night, filled the bathtub with water, and gotten in. She recounted it to her friends as a funny anecdote—Nora could make anything funny—but it’s a story that easily could have had a very different ending.
Sleeping pills carry major health risks even for occasional users. One study from the Scripps Research Institute led by Dr. Daniel Kripke compared data from a sample group of more than 10,000 people taking sleeping pills, including zolpidem (Ambien) and temazepam (Restoril), with a control group of more than 23,000 not taking sleeping pills. Researchers found that those prescribed as few as 18 doses of sleeping pills a year had a three-times-higher risk of death during the study’s two-and-a-half-year follow-up period than their counterparts in the control group, “with greater mortality associated with greater dosage prescribed.” Further- more, those taking the highest dosage of sleeping pills (more than 132 doses per year) had a 35 percent increased risk of cancer—including lung, lymphoma, prostate, and colon cancers. This association between sleeping pills, cancer rates, and death remained strong even after controlling for health conditions such as obesity, heart disease, and diabetes.
Yet we hear little about these increased risks, even as other, much smaller risks get tons of airtime. I have many friends, for example, who obsess about organic produce, organic diapers, organic dish soap, and organic shampoo but pop sleeping pills as though they’re candy. It’s sort of like taking great care to eat a nutritious breakfast and then think nothing of smoking a pack a day.
In 2015, Kripke, in an effort to protect consumers and hold the sleeping-pill industry more accountable, submitted a citizen petition to the FDA requesting a complete overhaul to the distribution, labeling, and regulation of sleeping pills. His proposals included requiring drug manufacturers to perform more studies on the risks of taking sleeping pills, helping doctors educate their patients about those risks, and requiring drug labels to include the mortality hazards.
Given these major dangers, what do sleeping pills actually do for us? In 2015, Consumer Reports found that Ambien and Lunesta put people to sleep only about twenty minutes faster on average than a placebo and added only three to thirty-four minutes of total sleep time: “Their effectiveness is so limited that as of late 2014 they were no longer considered a first-choice treatment for chronic insomnia by the American Academy of Sleep Medicine.”