Episode 35: Sleeping Pills

What are the common sleeping pills used for insomnia? When should they be used and what should you look out for when using sleeping pills? We address these questions and more with the help of Prof Wallace Mendelsen who also discusses the history of using substances to help with sleep, which puts current practice in perspective.

Dr Moira Junge (Health Psychologist) and Dr David Cunnington (Sleep Physician) host the monthly podcast, Sleep Talk, talking all things sleep.

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Audio Timeline / Chapters:

  • 00:00 – 02:29 Introduction
  • 02:29 – 31:03 Theme – Sleeping Pills
  • 31:03 – 32:33 Clinical tip
  • 32:33 – 35:33 Pick of the month
  • 35:33 – 36:45 What’s coming up in sleep?

Next episode: Napping

Links mentioned in the podcast: 

Presenters:

Guest interviews:

Wallace MendelsonProf Wallace Mendelson has more than forty years of experience in sleep research and clinical care. He is retired professor of psychiatry and clinical pharmacology and former director of the Sleep Research Laboratory at the University of Chicago, and former president of the Sleep Research Society. Among his honors is the William C. Dement Academic Achievement Award from the American Sleep Disorders Association/American Academy of Sleep Medicine as well as a Special Award in Sleep and Psychiatry from the National Sleep Foundation, and he is a distinguished fellow of the American Psychiatric Association. Dr. Mendelson has authored or co-authored four books related to sleep, co-edited another, and published over 190 peer-reviewed papers on various aspects of sleep research. His website, describing his interests, a blog devoted to literature, as well as a downloadable curriculum vitae, can be found here.

Regular hosts:

Dr Moira JungeDr Moira Junge is a health psychologist working in the sleep field, who has considerable experience working with people with sleeping difficulties in a multidisciplinary practice using a team-based approach. Moira has consulted at Melbourne Sleep Disorders Centre since 2008, and is actively involved with the Australasian Sleep Association (ASA). She has presented numerous workshops for psychologists wanting to learn more about sleep disorders, and is involved with Monash University with teaching and supervision commitments, as well as clinical involvement with the Monash University Healthy Sleep Clinic. She is one of the clinic directors at Yarraville Health Group which was established in 1998. In addition to her expertise in sleep disorders, her other areas of interest and expertise include smoking cessation, psychological adjustment to chronic illness, and grief and loss issues.

Dr David CunningtonDr David Cunnington is a sleep physician and director of Melbourne Sleep Disorders Centre, and co-founder and contributor to SleepHub. David trained in sleep medicine both in Australia and in the United States, at Harvard Medical School, and is certified as both an International Sleep Medicine Specialist and International Behavioural Sleep Medicine Specialist. David’s clinical practice covers all areas of sleep medicine and he is actively involved in training health professionals in sleep. David is a regular media commentator on sleep, both in traditional media and social media, and blogs for the Huffington Post on sleep. David’s recent research has been in the area of non-drug, psychologically-based treatments such as cognitive behavioral therapy and mindfulness in managing insomnia, restless legs syndrome and other sleep disorders.

Connect with David on Twitter or Facebook.

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Transcript:

Dr. David Cunnington:Welcome to episode 35 of Sleep Talk, the podcast talking all things sleep and welcome to my co-host Moira.

Dr. Moira Junge:Hello Dave. Hello everyone.

Dr. David Cunnington:So this episode, the theme is sleeping pills. We’re going to talk about medications and the use for helping insomnia. One of the reasons for doing that is it’s something that’s really commonly done. So not necessarily just prescription medications but think of that as what people are taking as over-the-counter medications and user prescription medication is actually surprisingly common. So what’s topical for you this month in sleep, Moira?

Dr. Moira Junge:Well, definitely the Sleep Awareness Week of course at the start of October and Australasian Sleep Association annual conference called “Sleep Down Under” which is becoming bigger and bigger and better every year, isn’t it? It’s looking forward to that.

Dr. David Cunnington:Yeah, absolutely. So we’re off to that in a couple of weeks and where there are over 600 registrants. So it’s looking like being a really successful meeting.

Dr. Moira Junge:Yes, truly international more and more. What about you?

Dr. David Cunnington:So as well as down to the conference and I will see you there. Before that, I’m just going via Lucknow in India to another conference and that’s really shaping up well as well and we’ve got over 500 delegates coming to that meeting from all around Asia and some international speakers.

We’ve set our dates for the conference in India next year. So put it in your calendar, October 11thto 13th, 2019 in Nagpur.

Dr. Moira Junge:Fantastic.

Dr. David Cunnington:Nagpur is famous for oranges. So famous for oranges and orange juice.

Dr. Moira Junge:Gets your vitamin C up.

Dr. David Cunnington:Exactly. And a couple of things we’re doing in the practice, we’re running some clinical trials, so clinical trial of some new medications in insomnia. So dual orexin receptor antagonist. So a similar family of drugs to Suvorexant that we’ve talked about before in the podcast and we’re also looking at trialling a once nightly form of sodium oxybate for narcolepsy, which is really exciting because that is quite a novel type of medication for narcolepsy. If we can get something like that proven that it’s working, registered in Australia, I think that will be a big move forward for patients.

Dr. Moira Junge:Incredible. Will it drop the price or not necessarily?

Dr. David Cunnington:We would hope so because once it’s registered, then we’ve got some leverage to be able to look at reimbursement. But we haven’t even been able to look at reimbursement because the government won’t reimburse a drug that’s not approved for you.

Dr. Moira Junge:That’s right. So it’s just baby steps I guess.

Dr. David Cunnington:Yeah. We’re getting there.

Dr. David Cunnington:The theme for this month’s podcast topic is sleeping pills. So why talk about this? Well, insomnia is common and that’s even if you define insomnia as difficulty getting to sleep, staying asleep, symptoms for three months or more and impacting on daytime functioning. Most epidemiological surveys suggest that’s around one in six adults in developed countries like Australia and the United States. Insomnia is a really common problem and people often are resorting to medications over the counter or prescription medications to help manage their insomnia.

We’re talking about them and we’ve got a really great interview with Wallace Mendelson coming up and one of the things I liked about that interview in the book that Wallace has recently written called “Sleeping Pills” was the historical context. He had really put a lot of work into and you will hear and talk about it is how throughout the ages people have used different substances to help with sleep and I think that helps us understand a bit how we use it in this day and age.

Dr. Moira Junge:And that’s not a new thing.

Dr. David Cunnington:Moira, you and I have both got a pretty strong bias to go with non-drug approaches upfront.

Dr. Moira Junge:Absolutely. Well, particularly as a psychologist. It’s not my area of expertise or licensing agreement. You know, I don’t have the right to prescribe but I have a philosophy anyway that non-drug strategies for insomnia are better. But over the years, obviously working alongside people like you and other medical colleagues, I’ve softened if you like. I do understand that there are plenty of occasions where people do need medication. But I still would have a strong philosophy that it’s short term and/or intermittent let’s say where I stand on it and that’s over-the-counter ones as well.

As well as the prescribed ones and the thing is from my clinical practice, it’s the over-the-counter ones that have been such a surprise to me over the last 20 years or so, just things that I won’t even name what they have because I don’t want – I just was shocked at the things that I wouldn’t have thought had a hypnotic quality that people would be using over-the-counter stuff and of course the things like cannabis and alcohol and other things that’s there in alarming sort of amounts.

And I think that that’s something we can cover off on a different one. But it’s sort of along the same lines of sleeping pills.

Dr. David Cunnington:It’s a good point and I think cannabis and sleep is a great topic. So we come to that I think in a future episode and yet people are using medications and whilst we’re very strong on the non-drug approach, I would absolutely agree with you. You know, even if I’m going to use a medication which is often because someone is very distressed or feeling quite unwell, always try and use a non-drug approach in parallel with that because if I can reduce the intensity of symptoms with the psychology-based approach, then the drugs got this work to do. I can use a lower dose or a less harmful drug that has got a better safety profile.

Dr. Moira Junge:I think what was life-changing for me like around about 10 years ago or so was the papers, the first of a few from Charles Morin’s group and looking at people who randomize – good quality, randomized control study looking at people with insomnia and now are assigned to either medication only, CBTI only or combination of the two. The people who had the combination of the two plus if they were off the medication by the time you ended their therapy at the 12-month follow-up. So people that did best with those ones.

It made me realize, hey, you know what, that’s OK – that’s enough evidence for me particularly when it was replicated years later. He has done this study a few times. So that was – I think I used to be a little bit too heavy-handed on my advice around – you know, at all costs, as quick as you can get off your medication and I hadn’t necessarily given the tools I needed to cope and to sort of more gradually come off the medication alongside learning the non-drug stuff.

I guess, yeah, it has been a bit of a – maybe that will come up later with the clinical tip I guess. That’s where I’ve come – I’ve sort of evolved if you like as a clinician.

Dr. David Cunnington:Thanks. So I had a chance to interview Wallace Mendelson and Wallace has been a professor of psychiatry and clinical pharmacology at the University of Chicago and has recently written a couple of books, The Science of Sleep. That was my pick a couple of months ago. I think even last month, it was my pick of the month and Sleeping Pills, which is – we talked through some of the content of his book Sleeping Pills in this interview.

Thanks Wallace very much for helping us out with the podcast.

Professor Wallace Mendelson:Well, it’s my pleasure. Thanks for allowing me to join you today.

Dr. David Cunnington:Congratulations on the two books that you’ve just recently released. I really enjoyed both of them and I think they’re great resources for people.

Professor Wallace Mendelson:Thank you very much. They’re both devoted to slightly different aspects of sleep. The Science of Sleep giving a general background of the whole topic and the sleeping pill book as its name indicated focusing in on treatment of insomnia. I hope that folks will find them helpful.

Dr. David Cunnington:In the book on understanding sleeping pills, I really enjoyed the section on the history of sleeping pills. Can you talk us through some of that history and sort of where we’ve come from?

Professor Wallace Mendelson:The history of using substances to help you sleep of course goes back to the very earliest times and of course the two agents that have been used going back centuries of course are opiates and alcohol. Both of them are actually kind of false friends of sleep.

In the case of alcohol, the problem is that although it can cause you to fall asleep a little sooner, you would have in effect a kind of mini withdrawal syndrome the same night that you take it. So that the second half of the night, you have extremely disturbed sleep and persons who are alcohol-addicted, some will take a drink to help them sleep. Of course, in the very short term of one night, it may help them sleep a little sooner.

But in the long term of course, it’s the worst possible thing you can do because it creates a kind of sleep disturbance which can go on even when you’re dry for months or even one or two years.

In the case of opiate, it actually produces more of a relaxed wakefulness kind of state rather than sleep and in fact when people who are not used to opiates take them, they often have disturbed sleep and a decrease of 50 percent or more of deep sleep, so-called slow wave sleep and persons who are addicted, the sleep is shorter with more awakenings with a less slow wave and REM.

A recent study showed that chronic users of opiate have chronically disturbed sleep, daytime sleepiness, fatigue and a high risk for depression. So, both of these historical substances are truly false friends of sleep.

Moving forward to the 19thcentury, the story of barbiturates appeared in late century as the handiwork of Adolf Von Baeyer who was a graduate student in the City of Ghent. He had been given the task of making a cyclic molecule from urea and an organic acid and he worked on this for months and months.

One night, he was successful and finally made this ring compound. He was so excited, that he went out to the local tavern. When he got to the tavern, it turned out that a celebration was already going on. Ghent was a military town and the soldiers were having a celebration for the feast of the patron saint of the artillery, Saint Barbara.

Somehow during the course of the evening, Saint Barbara and urea got combined into the term of this new discovery, the barbiturates. It wasn’t until the early 1900s that the first one that actually had the ability to induce sleep was developed by Fischer and von Mering. The two working in England to find a barbiturate derivative that would affect sleep.

When it finally happened, Fischer was on vacation in Italy and von Mering sent him a telegram and said, “We did it. We did it,” and Fischer said, “Well, that’s wonderful. Let’s name our compound after the city I’m vacationing in,” the most beautiful city in the world through his mind and that city was Verona and the first sedating barbiturate was Veronal. The barbiturates rapidly became the overwhelming hypnotic of the early 20thcentury.

Others of course were chloral hydrate, which had been discovered in the 1830s. There was new interest in it after James Young Simpson in Scotland found chloroform as an obstetrical anaesthetic. Chloroform is kind of an unpleasant substance to work with and in the 1860s, a chemist named Oscar Liebreich tried to find a substance that was more pleasant that would turn into chloroform in the body.

He found something which became known as chloral hydrate, which it turned out although he was wrong about his chemistry, it doesn’t make chloroform – it indeed helped people sleep and chloral hydrate along with barbiturates and several others were very effective, but on the other hand very toxic and addicting substances.

To come up a little more recently in the mid-1950s, a chemist named Leo Sternbach at Hoffmann-La Roche was trying to find a sleeping pill that would be safer than barbiturates. He didn’t have much success and he sort of stopped the project. In 1957, he was cleaning out his cupboard so to speak and throwing away all of these old bottles of substances that hadn’t worked.

He asked his assistant to do some basic animal testing on each of them before tossing them and after 39 bottles, the frustrated assistant came to him and said, “Surely enough is enough. None of these work,” and Sternbach’s reply was, “Well, let’s try number 40 before we quit.”

They’ve tried number 40 and it turned out that it was a powerful sedating drug. It caused sedation, muscle relaxation, ataxia and other symptoms. It was called chlordiazepoxide and shortly thereafter, became marketed as Librium, the first clinically used benzodiazepine. In the US, it was marketed in 1960. It wasn’t until 1970 that the first benzodiazepine specifically recommended for sleep became available and that was flurazepam.

Dr. David Cunnington:When you started your practice in psychiatry and sleep medicine in the late ‘70s. What were the tools that you could use for people with insomnia?

Professor Wallace Mendelson:Flurazepam didn’t come along until 1970 and it took several years before it became popular although then it became extremely popular. So, when I first started practice, barbiturate, chloral hydrate, other non-barbiturate agents like glutethimide were the main agents. They had many, many drawbacks of course. They’re very, very toxic in overdose. So that for typical barbiturates Phenobarbital, 10 therapeutic doses could often be lethal.

They’re highly addicting. The barbiturates also stimulate the enzymes in the liver to break down other drugs and of course they are respiratory suppressants.

Dr. David Cunnington:You know, I certainly still occasionally see people on barbiturates or chloral hydrate. It’s pretty rare and I must admit they’re often the sort of patients where nothing works and I do wonder what we’re treating and sometimes people are trying to chase an unrealistic absence of awareness.

Professor Wallace Mendelson:I have the same experience here and you still find discrepancies that’s being written, particularly in rural areas but by non-specialists.

Dr. David Cunnington:Let’s move forward to current times. How have the medications available changed? What are some of the things we’ve got available to us now?

Professor Wallace Mendelson:Well, I think there was a lot of impetus for changes to take place. There were issues of daytime sedation with barbiturates although now as I look back on it, I wonder how often it was true daytime sedation and how often it might have been exacerbation of sleep apnea, of unrecognized sleep apnea. But in any event, it was in the 1980s that we first began to see the so-called “Z Drug” starting with Zolpidem.

Their advantages over the barbiturates are very, very obvious. The advantages over the benzodiazepines continue to be argued to this day. From a purely basic science point of view, they have a number of advantages and that they’re binding to the GABA benzodiazepine receptor subtypes more specific to sleep so that they’re less likely to produce non-sleep effects.

Another way for the benzodiazepine, the therapeutic dose for sleep is very close to the dose that would produce other kinds of effects like ataxia, confusion and so on. For the newer Z drugs, there’s a wider margin, a so-called therapeutic window between the dose for sleep and the doses at which many of these other things appear.

Now as the years have gone on, the Z drugs have taught us that each new generation of drugs may have some benefits but are of course not magic pills.

Here in the US, I had noticed a study recently that the number of emergency room visits related to toxicity from Zolpidem actually doubled between 2005 and I think it was 2010 and it continues to go up.

Some of the things that we thought might not be problems continue to happen. Sleepwalking and complex behaviours began to be documented. It turned out those were not purely true from the – for only older drugs. Issues of sleep eating, sleep sex, sleep driving, sleep shopping even continue to appear.

Many of them do have respiratory depressant qualities albeit milder than benzodiazepine or older drugs. One of the other things that has happened in recent years has been the use of non-hypnotics for the purposes of sleep. I have some strong feelings about them. I would like to talk with you about it. But let me just finish with prescription drugs first, which are recommended specifically for sleep.

I guess the other development in recent years has been at least three kinds of drugs that work by an entirely different mechanism than the benzodiazepines or the Z drugs.

Certainly one of these is suvorexant, which works on the orexin system. An advantage to think of that particularly in people who haven’t done well on the older drugs. I would just utter a couple of notes of caution and one is that of course it also is a restricted drug. In studies of drug liking in people who have history of addictions, it came out as having similar drug liking to Zolpidem.

Another quality about it is that kinetics are such that drug exposure is greater in obese men and women. So when you combine those two, there’s a higher likelihood of side effects in obese women for whom the dose certainly should be lowered and of course because of its unique quality of working on this orexin system, occasional patients experience some of the symptoms which are usually associated with narcolepsy. This can include sleep paralysis and cataplexy, cataplexy being the sudden loss of muscle tone, usually an association with expression of emotion and sleep paralysis being at the transition of waking and sleep. So you’re finding yourself awake but unable to move, which can be a very scary proposition if you’re not familiar with it.

Other new drugs include melatonin receptor agonists in the US (ramelteon) or agomelatine as an antidepressant is my understanding. Just speaking of Ramelteon because I’m more familiar with it. It does have one significant advantage and that it is not a restricted drug with no evidence of drug liking or significant addiction. Disadvantages are that it takes longer to work, usually a week or two and it’s also very specific for helping sleep onset without helping total sleep or awakenings during the night.

The final drug is Doxepin, which is a new use for an old drug that’s a tricyclic antidepressant that has been around from the 1950s. But in recent years, it has been found that very low doses like three to six milligrams can help reducing the number of awakenings during sleep.

Again one advantage is that it’s not a restricted drug in terms of significant evidence of addictive properties, has some limitations, the most major one of which is that it doesn’t reduce the time it takes to fall asleep or increase total sleep significantly. But it can be slow for people to have awakenings during the night.

Dr. David Cunnington:Thanks. And then you mentioned before there are some non-indicated medications that have been used widely. You’ve got some strong opinions about. What are they?

Professor Wallace Mendelson:Doctors of course can prescribe a drug for any purpose they see fit. But when it is not the purpose that – in the US, the Food and Drug Administration or its equivalent in Australia have given a recommendation, which is known as an indication. When it’s used for a different purpose, it’s known as off-label prescribing. A couple of those have some concerns and the biggest concern I have is the more recent popularity and use of Quetiapine as a sleep agent. Quetiapine is a second generation anti-psychotic. It’s also used for mania and it’s a very, very potent kind of drug. It also has an indication in the US as a treatment for depression.

When somebody has been on at least two antidepressants and they’re not working. Sometimes used as an additional agent to make the antidepressant work harder so to speak. I have a lot of caution to the use of Quetiapine because I think a lot of non-specialist physicians don’t realize what a potent group of drugs that it comes from.

Certainly, the second generation drugs anti-psychotics have many benefits over the first generation drugs like Chlorpromazine or Stelazine but they certainly still have risks. The one that is particularly disturbing to me is the risk of a neurological disorder known as tardive dyskinesia.

Although this risk is decreased in the second generation drugs, it’s still present. The second-generation anti-psychotics can have powerful effects on your metabolism that can push you in the direction of weight gain and push you in the direction of diabetes.

Quetiapine is a little better in that than most of the others in that group but it’s still something possible. My own belief just in summary is that these are drugs that are better reserved for psychosis. I would mention the one use for Quetiapine for sleep that I do see is if you have somebody who has major depression and he hasn’t responded to at least two antidepressants.

If you use Quetiapine as adjunctive therapy in addition, you can be helping the depression and you can take advantage of any sedating qualities that Quetiapine might have. So that’s sort of the one exception.

Dr. David Cunnington:We have the same issue with Quetiapine in Australia. It has been used pretty commonly in primary care and I think seen as a more benign medication than what it really is. So, it’s not used with due respect and due caution.

To finish up, draw you out on some of your clinical experience to help some of the sort of clinicians that listen to the podcast. When you’re seeing somebody with insomnia, you’ve got at least tools that you could potentially use. How do you decide what you’re going to use in a given individual?

Professor Wallace Mendelson:Anxiety is a very major problem. So, it’s not just a sleep issue but an issue of anxiety in the person’s life in general or excessive anxiety focused on the sleep issue. I think there’s some room for using benzodiazepine. Aside from that group, I think that it’s probably wiser to use the newer drugs.

Incidentally I would just mention as a clinician for that same group of people where anxiety is a very major problem. That’s also a key to me that if I use non-medicine therapy and if doing CBTI.

I’m also very cautious in the progressive muscle relaxation portion because folks with a great deal of anxiety instead of becoming calmer, as you do muscle relaxation procedure, sometimes become even more anxious just as a little clinical observation. I guess the next thing I would mention is in making a decision to use which hypnotic, if there’s a history of substance abuse, I would avoid any of the scheduled drugs and of course substance abuse is terribly common. In the US, I think the current figure is about 20 percent of Americans stated they have used drugs for non-medical reasons at some time in their life and I’m sure the real number is substantially higher.

Now when you talk about what drugs can you use, the non-scheduled drugs would be Ramelteon and Doxepin and I think this might also be a case where one could consider using sedating antidepressants such as Trazodone and this very specialized use which is persons with a history of substance abuse.

I guess the next thing I do in choosing which drug to give is you want to match the kinetics of the drug to the specific patient’s problem. So for example, if the patient complains of waking up too early in the morning or having a lot of awakenings in the night or not sleeping long enough, I probably wouldn’t use the Z drug Zaleplon because it’s only helpful for going to sleep. It’s not helpful for these other things.

Conversely, if a person’s main problem is going to sleep, I wouldn’t use Doxepin because it primarily is helpful for awakenings in the night. So a very major factor would be matching a person’s drug to the specific complaints.

Dr. David Cunnington:Then when you’re using hypnotics or sleeping pills to help with insomnia, what are some red flags or things where a patient says something and you’re like, “Oh, I was going to be a bit wary here”? What are some things you’ve learned over the years?

Professor Wallace Mendelson:Well, the number one thing for me is to look for depression. You can do this at two points. The best point is before you ever start a medicine. The second point would be later if both you and the patient are feeling unhappy if things haven’t been more successful.

Now the reasons to go look at – for depression are twofold. First is the – if depression is present, not only will hypnotics not help. They may make the depression worse.

The key is if you think that depression is what’s going on. Then you need an antidepressant. If a person does have both depression and trouble sleeping, there’s pretty clearly a role for using a hypnotic as adjunctive treatment and depression that diagnosing and treating depression is definitely the first thing to think about. Of course, if the person with depression is having trouble sleeping, some of them are sedating and antidepressants can be of help.

I guess another thing is to reconsider the possibility of sleep apnea and this is for a couple of reasons. One of course is that if a person has sleep apnea, they could come in without realizing they have it and complain of poor-quality sleep, poor daytime sleepiness.

If a person that you put on a sleeping pill starts complaining of greater daytime sleepiness, it is possible of course that this is due to the extension of the therapeutic effect that it’s daytime sedation due to the medication.

But a second thing to always keep in mind is the increase in daytime sleepiness may be because the sleeping pill you gave exacerbated the sleep disorder breathing. So those are the two biggest to me and I have to close with one final one and that is whenever you’re giving a hypnotic, by far the most important thing to do is try to work with a patient who has realistic expectations.

Insomnia is a terrible kind of suffering. So, you can certainly understand a person’s motivation to want action and want action quickly. There’s suffering. They want release. But in spite of the strong need or desire for something that’s going to be fast and do a total job, that’s closer to magic. That’s not medicine.

Most of these medicines can help sleep. But you may have to try more than one. You may have to try different doses. You may need to go back to the beginning and rethink things. Like we just mentioned, like for instance, was there unrecognized depression?

So, it’s very important to start with the patient to explain this and to explain that the likelihood is that they are going to be helped and that they’re going to feel better. But it’s not realistic to think that this will happen overnight or to think that suddenly the whole world has changed and it’s kind of a magical answer.

On the other hand, you can say that folks that you work with will get better and they just have to be patient and persistent.

Dr. David Cunnington:Thanks very much. They’re really great tips and I agree with you. Setting expectation is the really important thing and teasing out what are people dissatisfied about sleep and trying to recalibrate them if they are unrealistic in what they hope to get out of treatment.

So thanks a lot for helping us out with that and yeah, thanks again for the books that you’ve written. I think they’re really great resources.

Professor Wallace Mendelson:Well, thank you. Again, The Science of Sleepand Understanding Sleeping Pillsare both available on Amazon and they cover the kind of material that we’ve talked about today.

Dr. Moira Junge:That was a great interview. Really enjoyed that. I think you’ve sort of covered it all.

Dr. David Cunnington:Yeah, it was really great and plus the topics that he covered really do follow the outline of his book Sleeping Pills. So I can highly recommend that. If you’re looking for a bit more depth and you want to sort of flesh that out and as you said, it is available via Amazon. I read it on a Kindle. But I’ve also now got a hard copy of the book.

So look for that if you’re looking for more information. On SleepHub, there’s also a link on medications for insomnia and then some links through to more information on different medications and actually use that post from SleepHub as the basis for writing a book chapter in the Australian textbook on sleep medicine. So it’s good information.

Moira, you and I together with Tony Fernando wrote an article for the Medical Journal of Australia now about five years ago.

Dr. Moira Junge:Yeah. 2013, wasn’t it?

Dr. David Cunnington:Yeah. That gives a nice summary too of non-drug strategies, medications for insomnia and how to link the two together and that’s publicly available.

Dr. David Cunnington:So Moira, what’s your clinical tip of the month?

Dr. Moira Junge:Well, I think what I alluded to earlier in our episode that I think that we need to be both non-prescribers and medical professionals, need to be aware of the benefits of both, of having non-drug strategies alongside the drug strategies. I would prefer to see medication not started wherever possible, but being aware that particularly very high distress and particularly the high distress that can be even leading to say suicidality et cetera, pretty extreme conditions where you just need to take the heat out of it a little bit, particularly if they’re waiting to get into someone to help them with non-drug strategies.

Sometimes it’s a number of weeks as we know. Yeah, I think that I would encourage people to see not either or, that often the combination can be good, but to be withdrawing or less dependency upon the hypnotics or the sleeping pills as the confidence or the skill base in non-drug strategies emerges and coming off it in a supervised way and involving the prescriber. It’s always a good idea.

Dr. David Cunnington:Thank you.

Dr. Moira Junge:What’s your pick of the month, Dave?

Dr. David Cunnington:So this month it’s Julie Flygare’s book Wide Awake and Dreaming. Julie wrote the book a number of years ago and it’s about her own personal experience of when she was around the time of being diagnosed with narcolepsy, with cataplexy.

Yeah, and the struggles that she had and then her progress as she became established on treatment and sort of got to better understand how to manage your symptoms. People I see with narcolepsy and their friends and family have consistently found that a really helpful resource just to better understand what it’s like and the symptoms people get.

So it’s going to be released as an audio book, which is fantastic, and Julie herself reads it and writes it. I always like audio books that the author actually narrates. It just has such – a lot more warmth and sort of personal touch to it. I can highly recommend Julie’s Book Wide Awake and Dreaming. It was in a sort of hard copy but now also as an audio book. What about for you, Moira?

Dr. Moira Junge:Well, I guess knowing that we’re doing this episode on sleeping pills, what caught my eye the last month – actually one of his other books is – a guy called Dr. Ray Moynihan, Australian researcher. His book from 2005 called Selling Sicknesswas a really big best seller, which I didn’t know about this at the time. Was it across your radar back then?

Dr. David Cunnington:Yes, because it was in that book that he claimed restless legs didn’t exist and it was a made-up sort of fiction of the pharmaceutical industry.

Dr. Moira Junge:Yeah. I mean I’m probably not as hard line as him with his anti-pharmaceuticals by any stretch. But I guess it catches my eye that we definitely have a worldwide problem with over-prescribing and over-pathologizing. We would have to agree.

Dr. David Cunnington:And even from his book in 2005, I absolutely agree with his message. It was just a little too strong.

Dr. Moira Junge:So I think that it’s a little bit controversial perhaps in line of – we’re talking about sleeping pills and all – well, this medicine is wonderful. It has worked and I don’t want to be disparaging against the idea of pharmaceuticals, whatsoever. But I think it’s probably just a nice little balance is to – to draw our attention to and the book that I had come across in the last month was Sex, Lies and Pharmaceuticals. That was in 2010 that he wrote it and it caused an absolute international storm because it was around this sort of – he says like it’s made-up but I think it’s really made-up, female sexual dysfunction disorder or females not wanting to have sex and suddenly let’s give them all these pills. I would say let’s just let them sleep.

These women are just – they’re tired. They’re not interested. They don’t have a dysfunction.

In my other life is talking around that like the history of psychology and different theories and like this week. So I was on the post-modern perspectives and this idea of social constructionism that – as a society, we can just make up stuff. So that’s where he came into my spotlight and the radar was there. Yes. So I just thought that’s going to be my pick of the month. Not that I’m endorsing his views or anything like that. But I think it might just have its worth, people having a look at that and thinking about, yeah, sort of the massive multibillion-dollar business of pharmaceuticals and at least put the spotlight on that.

Dr. David Cunnington:So look out over the next few episodes of some topics that we’re going to cover. So we’re going to look to do an episode on napping and also episodes on menopause and as we talked a little bit earlier, I think cannabis and use of cannabinoids in sleep would be a great topic for us to cover and we had a nice suggestion from a listener about revisiting use of devices to measure sleep. We did an episode with James Slater talking about some of the devices a couple of years ago. But that field moves so fast.

Dr. Moira Junge:Absolutely. Time for an update.

Dr. David Cunnington:Thanks for listening to this episode of the podcast.

Dr. Moira Junge:And we love hearing from you. So please send us any suggestions at podcast@sleephub.com.auand of course we always ask you to do this and some of you do. Thank you very much and keep them coming. We would like you to do a review if you can on iTunes and subscribe via any podcast catcher or via the SleepTalk app.

Dr. David Cunnington:Thanks a lot.

Dr. Moira Junge:Farewell.

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