Use OTC Sleep Aids With Caution

The sleeping pill of choice for many Americans with insomnia can be purchased over the counter at drug and grocery stores. But a new study shows that many older adults who use OTC sleep aids know little about them and may be using them in ways that do more harm than good.

Sleeping pill users should read the label of OTC sleep medicationsIt annoys me when people dismiss sleeping pills as categorically harmful. Yes, they can be used inappropriately and it’s important to be informed about their downsides. But the existence of downsides doesn’t necessarily mean the risks associated with using them outweigh the benefits.

The sleeping pill of choice for many Americans with insomnia can be purchased over the counter at drug and grocery stores. But a new study shows that many older adults who use OTC sleep aids know little about them and may be using them in ways that do more harm than good.

Older Americans Use Them and Like Them

Participants in the new study were adults in the United States aged 60 and older who were managing their sleep problems with nonprescription sleep aids. University of Pittsburgh investigators interviewed 116 by telephone and found that well over half were satisfied with their medication and felt it improved their sleep.

Asked about her satisfaction with one such drug, an interviewee replied that she was “pretty satisfied. It does help me fall asleep and stay asleep, and go back to sleep when I invariably get up once or twice a night.”

“There is a dramatic difference when I use it versus when I don’t,” another explained.

This jibes with the results of other, quantitative research. The prevalence of insomnia and other sleep problems among older adults is high and OTC sleep aids are widely available. About 17% of older adults in the United States turn for relief to antihistamine-containing sleep aids like Unisom and Simply Sleep.

How OTC Sleep Aids Work

Diphenhydramine and doxylamine are the active ingredients in antihistamine sleep aids. They block the action of histamine neurons, which are generally active when we’re awake and inactive when we’re asleep.

“Marked drowsiness may occur,” is the type of warning that usually appears on the label. This propensity to cause sedation is likely why, despite few controlled trials supporting their efficacy for insomnia, these drugs are seen as effective by many older adults. The trials that have been conducted suggest these antihistamine sleep aids may have more to offer sleep maintenance insomniacs than people who need help falling asleep at the beginning of the night.

Side Effects of OTC Sleep Aids

But like most prescription medications, OTC sleep aids are not intended for nightly or long-term use. Continuous use has been found to lead to the development of tolerance, tempting users to take more of the drug to get the same sedative effect. Yet in the Pittsburgh study, nearly half of the participants reported using OTC sleep meds daily or very often. Over half reported using them for more than a year.

Fewer than a quarter of the study participants had studied the label on their medication to find out about the recommended dosage or about warnings and possible side effects.

“I never really paid any attention to the directions,” an interviewee said. “I take a couple before I go to bed, about twenty minutes before I go to sleep, I go upstairs and go to bed. That’s it.”

Common side effects to be aware of are morning grogginess (our bodies process drugs more slowly as we age) and blurred vision, constipation, and trouble urinating (for more on this, see my post on OTC sleep aids and anticholinergic effects).

Drug-Drug Interactions

Possible drug-drug interactions is another factor to take into account, given that almost 40% of older Americans are taking five or more prescription medications. Studies have shown that diphenhydramine (the main ingredient in many OTC sleep aids, including Benadryl, Sominex, Nytol, ZzzQuil, and Simply Sleep) interferes with the body’s metabolizing of at least three commonly prescribed drugs:

  1. tamoxifen, an anti-estrogen drug used to treat breast cancer and lower breast cancer risk
  2. metoprolol (Lopressor), a beta blocker used to treat high blood pressure and heart problems
  3. venlafaxine (Effexor), a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) used to treat depression

Reducing the effectiveness of a drug taken to manage a serious health condition isn’t something most of us would want to do. But information about all possible drug-drug interactions isn’t necessarily listed on the label of OTC sleep aids.

Americans seem to have the attitude that OTC meds are harmless—but that isn’t necessarily true. If you’re going to use an OTC sleeping pill, read the label for information about the proper dosage and potential side effects. Take concerns about possible drug-drug interactions to your doctor or pharmacist.

Sleeping Pills: Too Risky, or a Red-State, Blue-State Affair?

How do people with insomnia feel about sleeping pills?

Attitudes toward sleep medications differ from one American to the next, and between Americans and Australians, it turns out. Here’s a brief comparison that I hope will start a conversation.

Sleeping pills are viewed differently in Australia and the USHow do people with insomnia feel about sleeping pills?

Among 51 insomnia sufferers interviewed by Australian researchers in Sydney, both users and non-users of sleeping pills (or sleeping tablets) held negative views of sleep medications.

When I asked this same question of the 90-odd American insomniacs I interviewed for my book, the response was more divided. Some people viewed prescription sleeping pills as harmful and said they’d never use them. Others felt their sleep medications were helpful and would not want to give them up. Here’s what I wrote:

Poll the sleepless about sleeping pills, and you come up with . . . a red-state, blue-state affair. In one camp are the pill abstainers . . . and in the other, insomniacs who’d sooner dump their iPhones than part with their pills.

Pro or con, attitudes about sleeping pills are often strongly held. Following is a brief comparison of Australian and American attitudes that I hope will start a conversation.

Safety vs. Effectiveness

Both the Australians and the Americans felt that pharmaceutical sleep aids were stronger and more effective at putting people to sleep than over-the-counter (OTC) sleep aids or “natural” sleep aids such as valerian or melatonin.

But most Australians said they didn’t like taking sleep medication. They expressed a definite preference for natural products based on the notion that natural products were gentler on the body and had fewer harmful effects. In the majority view, safety concerns outweighed concerns about sleeping tablets’ effectiveness.

“I’ll take something that isn’t as effective so it doesn’t have any negative consequences,” said a man quoted in the Australian study.

A woman, comparing how she felt about taking the sleeping pill temazepam (Restoril) with how she felt about about the prospect of taking melatonin, said this: “I felt it’s a more natural remedy than the temazepam. So I think I was less stressed about taking it.”

But the Australians were divided as to whether prescription or OTC medication was the safer option. Some thought OTC sleep aids (medications containing diphenhydramine, such as Benadryl and Tylenol PM in the United States) were safer because they were available without a prescription and therefore less potent and apt to have fewer side effects. Others felt the safer alternative was to go with a prescription medication recommended by a doctor who was familiar with one’s individual medical needs and could supervise the process.

Among Americans, a Split

About half of the insomniacs I interviewed felt they needed medication to get a good night’s sleep and were mainly concerned about medications’ effectiveness. Jane M. wrote the following comment on one of my earlier blogs. It epitomizes the feelings of insomniacs who were satisfied with the sleeping pills they were using, having decided the benefits outweighed concern about risks.

“I was first prescribed Ambien many years ago, and don’t think I could have continued my work life this long without it. I sleep soundly eight hours every night, wake up with lots of energy, and have always wanted to meet the discoverer of the formula to thank him or her.

“My gratitude is deeply felt. My mother, who died in 1983, sat up half the night for years. I think there are genetic issues, hormone issues, aging issues . . . I could walk 20 miles a day and I still wouldn’t be able to fall asleep. Some people have asked, ‘What if you become addicted?’ to which my answer has always been ‘So what?’ I am addicted to sleep, good health, and a strong work ethic. Ambien has made it all possible for me into my mid-70s.”

Some Americans Concerned About Risks

The other half of my respondents voiced reservations about sleeping pills, similar to the Australians. Their reasons were mixed. Some did not think of insomnia as a medical problem, preferring to address it through changes in lifestyle or psychotherapy rather than with drugs.

Other insomniacs shied away from using sleeping pills because of negative feelings about medication overall and about prescription hypnotics in particular. Still others felt they simply couldn’t tolerate such potent medication.

“I can’t take any hardcore pharmaceuticals,” an insomniac told me. “A mild antidepressant, that’s something I’d consider. But I’m afraid of sleeping pills.”

Unlike the Australians, few of the American insomniacs I spoke with had anything good to say about so-called natural sleep aids—herbal teas, melatonin, lavender. Based on my interviews, I would venture to suggest that here in the United States, the concept of the natural sleep aid does not have the strongly positive connotation it has in Australia.

But some Americans said they got relief from insomnia using OTC sleep aids like Benadryl and Unisom, which they felt were likely to be gentler and less harmful than prescription pharmaceuticals.

Accounting for Attitudinal Differences

The differences (and similarities) spelled out here may not be representative of Australians and Americans overall. The sample sizes are small, and the years when the interviews were conducted were different (2013–2014 for the Australian study; 2004–2008 for my book). Physician prescribing patterns and the public health information patients receive about insomnia and sleeping pills may be different as well.

But my point is not to make an evidence-based claim about attitudes in Australia and the United States. Rather, I’m interested in knowing how readers of this blog feel about sleeping pills, OTC sleep medications, and “natural” complementary sleep aids, and why.

Please take a minute to comment below, and like and share on social media. Thank you!

The Low-Down on OTC Sleep Aids

Over-the-counter sleeping pills are readily available at the pharmacy: drugs like ZzzQuil, Benadryl, Unisom and Tylenol PM. All promise sound, refreshing sleep. Just how well do live up to that promise, and are they as harmless as they’re said to be?

OTC-sleep-aidOver-the-counter sleeping pills are readily available at the pharmacy: drugs like ZzzQuil, Benadryl, Unisom and Tylenol PM. All promise sound, refreshing sleep. Just how well do live up to that promise, and are they as harmless as they’re said to be?

These sleep aids work by blocking the secretion of histamine, a neurotransmitter that keeps you awake. Nearly every insomnia sufferer I know has tried them at some time or another, and some are satisfied customers.

“Whatever’s in Unisom, I’ve found it works for me pretty well,” says Dale, a marketing expert I interviewed for my book, whose main problem is getting to sleep at the beginning of the night and who sometimes wakes up in the middle of the night. “It’s 80 to 90 percent reliable.”

Other people with insomnia dismiss over-the-counter sleep aids as worthless. Existing scientific research suggests their efficacy is indeed fairly limited.

The active ingredient in most OTC sleeping pills is diphenhydramine (some formulations of Unisom contain doxylamine, a similar drug). In one study, diphenhydramine moderately increased subjects’ sleep efficiency (i.e., they spent more of their time in bed sleeping rather than lying awake).* In another study, older insomniacs taking the drug woke up a little less frequently at night.** Pretty small gains. Yet what behaves like a sugar pill for one insomniac can apparently work magic for another.

Downsides of OTC Sleep Aids

You might think, because these drugs are sold over the counter, that you can use them however you see fit without risk. Some are advertised as “non-habit-forming.” But here it’s better to be cautious. Studies suggest that if you take them every night, you’ll wind up needing to increase the dose to get the same sedative effect.

“Over-the-counter antihistamines may have a role for short-term insomnia treatment in younger adults,” write the authors of a review paper published last year, “but tolerance develops rapidly.”*** So nightly use of OTC sleep aids is not a good idea.

Lingering Effects

The other problem with these antihistamines is that their sedative effects are relatively long lasting and can cause morning drowsiness. Compared to newer prescription sleep meds, they have long elimination half-lives. (Half-life is the time it takes for a dose of a drug in the blood plasma to decrease by half.)

Diphenhydramine has a half-life of 2.4 to 9.3 hours, and its half-life tends to increase with users’ age. It will leave some people—older adults, especially—feeling groggy in the morning. The half-life of doxylamine is about 10 hours, and typically longer in older adults. It, too, may cause morning drowsiness, which increases the risk of falls and driving incidents.

Dale has found a way to cut down on the grogginess. “I use half the recommended dosage,” he says. “That minimizes the hangover in the morning.”

If you’re using OTC sleep aids, keep these caveats in mind.

*    Valerian-hops and Diphenhydramine

**  Temazepam and Diphenhydramine

*** Histamine-1 receptor antagonism