Friday, September 23, 2011

Sleeping with Big Pharma

     In the last blog, The Insomnia Epidemic, I spoke about how our natural sleep patterns differ from the "cultural norm" of one 6-8 hour block at night and suggested that this causes many folks sleep problems.
Sleep experts believe that our 24/7 culture has created such pervasive sleep deprivation that abnormal sleepiness is the norm. Unfortunately, there is no adapting to getting less sleep than we need. What happens is we adjust to a sleep-deprived state in which our judgement, memory, reaction time, and many other functions are impaired. Studies also document how our subjective assessment of performance with sleep deprivation is way off. We consistently think we're doing fine, until we really can't function. The experts say that if you feel drowsy during the day, even when bored, you haven't had enough sleep. Similarly, falling asleep within 5 minutes of lying down in bed suggests severe sleep deprivation. So there's no question, the public is hungry for more (or better) sleep. And a smorgasbord of medications are on offer everywhere you look, in magazines, on television, and on the internet.

     According to Medco Health Solutions, a prescription drug benefit program manager, the number of adults ages 20 - 44 using sleeping pills doubled from 2000 to 2004.  Children apparently have not been spared. Usage increased 85% in 10-19 year olds during the same period. And the trend has continued. In 2008 the sale of prescription sleep aids totaled $3 billion. The number of prescriptions written for sleep meds exceeded 59 million in 2009, an increase of approximately 4 million scrips from the previous year.  In 2010 the pharmaceutical industry took in $5 billion from the sale of sleep medications.

     How do we explain this astronomical rise in sleep medication usage? There are only a few possibilities.  It's hard to imagine that this population's sleep deteriorated so dramatically in these 4 years it accounts for this trend. Some might suggest that the sleep impaired were always out there but hadn't been diagnosed and treated until the recent focus on insomnia. While this may have some truth, it hardly explains the rate of increased usage of these meds. After all, insomnia is not a sexually transmitted disease. There is not a stigma attached to sleep disorders that would make it difficult for patients to report their concerns. Has the cultural environment changed significantly? Has this time period witnessed big changes in our use of mobil devices, lap tops, etc.? Did we become even more 24/7 since the turn of the century? Yes, to some extent we have.

    But I believe it's none of the above. So what happened?

     The combined effect of changes in three areas, medicine, advertising, and our psyche, created the perfect climate for these medications. Let's take them one at a time.

     Over the past two decades the practice of medicine has been transformed (some would say ruined). The average patient visit is 10 minutes. There is no time to discuss the patient's home life, work situation, social or financial stressors. There is no continuity of care. Patients bounce around to specialists without anyone overseeing the whole person. So if people complain of difficulty sleeping, there will not be an exploration of what's going on in their life. That takes way too much time.  Physicians continue to want to help. They want to respond to the patient's complaint.  In this context, the prescription is the best they've got.
     In addition, physicians diminishing control of the field of medicine (now run by government and insurers) and decreased remuneration has made them more susceptible to dubious practices such as responding to patient requests for specific medications.
     These forces have catalyzed the "medicalization" of sleep, a process where a formerly normal behavior is reframed as a medical problem. In fact, analysis of data over a 15 year period shows the new generation nonbenzodiazepine sleep med prescriptions grew 21 times more rapidly than did sleeplessness complaints and 5 times more rapidly than did insomnia diagnoses.  The inappropriate use of medical solutions to treat problems of living fits neatly into the changes in the American psyche that I discuss below.

     In the early 1980's the pharmaceutical industry began marketing prescription drugs directly to the public. The FDA questioned this practice and imposed a moratorium in 1983, but lifted it in 1985. Not surprisingly, there is a striking correlation between the amount of money spent on advertising for a drug and that drug's sales. The 4 million sleep scrip increase from 2008 to 2009 coincided with a direct-to-consumer 2008 ad budget of $500 million for Ambien CR and Lunesta, the most prescribed sleep meds that year.

Our Psyche:
     The funny thing about sleep medications is they don't change your sleep very much. If you look at efficacy studies you realize that people are not sleeping much better on these sleep medications that are selling like hot cakes. The studies show that on average, subjects fall asleep about 12 minutes faster and increase their total sleep time by about 15 minutes compared to placebo. And yet these very same subjects report that they slept well. So what gives?

     Well, it so happens that a side effect of these medications is something called anterograde amnesia, a state in which you cannot form new memories. In other words, you don't remember how you slept. (In fact you may not remember all sorts of things that went on during the night, like driving around, sending emails, or eating more than you thought humanly possible. But that's another story.) These agents also have an anti-anxiety effect. Not only might this help you fall asleep, but it also minimizes the impact of not doing so.    

     One Lunesta advert has a mellifluous women's voice cooing sympathetically "Does you restless mind keep you from sleeping?" That is a bullseye.  The American mind has reason to be restless. A decade ago, 9/11 presented the greatest shock in this country's history. What initially seemed to have the potential to unite the population and create common purpose quickly deteriorated. The country became polarized into red and blue, antagonistic camps speaking different tongues, accusing the other of being unpatriotic, unamerican.  For the past 10 years we have engaged in the "War on Terror", an amorphous conflict without boundaries, a means for assessing how we're doing, or consensus. We do not feel safer. 
Iraq and Afghanistan have not been transformed, but we have. Our belief in American ability and fair play has been compromised. Historically, national traumas have provided a fulcrum from which we have forced positive changes. None of the past decade's national nightmares, Hurricane Katrina, mortgage defaults, stock bubbles, a collapsing economy, or unemployment have been able to provide the stimulus for a gathering of transformative momentum.

     Why are sleep medications so popular? Because in the quiet darkness of our bedrooms with nothing to distract us, the mind struggles to empty itself of haunting anxieties. To swallow these pills is to change our state of consciousness. We forget. Then we sleep.



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