"The big sleep: Canada's dangerous love affair with tranquillizers"

This article is from the Ottawa Citizen newspaper.

http://www.ottawacitizen.com/health/sleep+Canada+dangerous+love+affair+with+tranquillizers/6925474/story.html

The big sleep: Canada's dangerous love affair with tranquillizers

Sharon Kirkey, Postmedia News  07.12.2012

Public angst over the abuse of painkillers is overshadowing what Canadian researchers say is an even more pressing problem: the nation's growing love affair with sleeping pills.

The number of prescriptions dispensed for benzodiazepines and other sedatives jumped to more than 20 million in 2011, from 16.4 million in 2006, according to market research firm IMS Brogan.

Use of one drug alone — zopiclone, one of the so-called "Z" drugs — nearly doubled over the same period, from 2.9 million prescriptions, to five million in 2011.

Prescriptions are mounting as new and controversial research from Canada and the U.S. is tying sleeping pills to an elevated risk of an early death.

The drugs are intended for occasional, short-term use only, but observers say it's not uncommon for doctors to hand over prescriptions for a month's supply, with six or 12 repeats, increasing the risk of dependence and, in the case of benzodiazepines, potentially "horrendous" withdrawal.

"People who start these drugs need to know that you could end up in a long-term medical adventure," said Canadian drug policy researcher Alan Cassels.

Yet the use of benzodiazepines and other drugs prescribed for sleep is even more deeply ingrained in our culture than the use of opioids, said Deborah Cumming, national priority adviser at the Canadian Centre on Substance Abuse. The pills have become so ubiquitous, so normalized, that some say they are like the new Aspirin.

"When you look at the types of prescription drugs that are commonly abused or have abuse potential, it's sedatives and tranquillizers," said Cumming.

Women and the elderly — the people most vulnerable to the side effects — are the highest users. Women are also drinking more, making for a potentially lethal multi-drug mix.

"I think the sort of party chatter is, 'Well, if I can't sleep I'll just have a sleeping pill tonight' as they're downing their fourth glass of red wine," said Anne Rochon Ford, executive director of the Canadian Women's Health Network. "It doesn't seem to set of any alarm bells for a lot of people, and that's very disturbing.

"We've become fixated on, 'I must have X number of hours of sleep or I will not be functional tomorrow.' So there's this panic that sets in if they're not getting this sleep, and they think, 'Oh my god, I better take a pill.'

"We've become such a sped-up society, and medication has become an easy solution."

Canadians are not only being increasingly prescribed traditional sleep drugs, but powerful antipsychotics once reserved for schizophrenia and mania are now also being used for the treatment of insomnia. The drugs — so-called "atypical antipsychotics", a class that includes quetiapine (Seroquel) and olanzapine (Zyprexa) — can cause rapid and substantial weight gain, as well as abnormal fat and glucose regulation, increasing the risk of diabetes and cardiovascular disease.

The drugs are heavy-hitting tranquillizers that should never be used for insomnia unless the patient has an underlying major psychiatric disorder, sleep specialists say.

"To pull those out as a treatment for insomnia is some kind of desperation," said Dr. Rachel Morehouse, professor in the department of psychiatry at Dalhousie University in Halifax and medical director of the Atlantic Sleep Centre.

"It's like hitting a bird on a wire with a cannonball."

Sleeping pills, which depress brain function, should be used only in emergencies — no more than two weeks at a time, said Cassels, of the University of Victoria.

But in 2002, researchers in B.C. reported that benzodiazepines, as well as the newer Z drugs — zopiclone and zaleplon — were being prescribed to thousands of residents in amounts 10 times higher than recommended. About four per cent of the population of B.C. — about 170,000 people — received more than 100 pills in 2002.

Extrapolated across the country, "that would be about 1.3 million Canadians in 2002," Cassels said. "Now it has to be much, much more."

The IMS data shows that the number of zopiclone prescriptions is growing at twice the rate of prescriptions for lorazepam, a benzodiazepine drug.

When Z drugs reached the market in the late half of the 1980s, they were promoted as being less addictive than benzodiazepines. Though chemically different, zopiclone binds to the same receptors by boosting the effect of a brain chemical called gamma-amino butyric acid. The acid acts as the body's "natural tranquillizer" by telling neurons to slow down.

Dr. James MacFarlane, an assistant professor of pediatrics and psychiatry at the University of Toronto, said zopiclone is more specific in its effects, and therefore has fewer side effects, and that its addiction potential is "extremely small," if it exists at all.

But Cassels said doctors are switching to the Z drugs under the false impression that, "since it's not technically a benzo, it must be safer."

A 2007 article in the journal Canadian Family Physician concluded that doctors should have the same concerns with prescribing zopiclone as they would with putting a patient on a benzodiazepine, noting that the drug has become "well known" in addict circles (in the U.K. it goes by the street name "zim-zims") and that some patients might be at risk of dependence, especially after prolonged use.

More alarming, a study published this year in the British Medical Journal linked sleeping pills with a greater than threefold increased risk of death over an average 2.5 years of followup — even among patients prescribed as few as four to 18 pills a year. The "hazards of hypnotics" were seen in every age group, the researchers reported, adding that the "meagre benefits" of the drugs don't justify the "substantial risks."

Tranquillizers and sleeping pills can impair motor and cognitive skills required for actions such as driving, they said. The drugs have been linked with an increase in car crashes and falls due to "hangover" effects. The drugs also can increase breathing problems during sleep. Some studies suggest they increase the risk of depression and suicide.

But MacFarlane, director of education and a clinical consultant at MedSleep, a network of sleep clinics, called the findings disturbing and "very premature." MacFarlane said it's absurd to suggest that even those who took as few as 18 pills a year had increased mortality. "It's impossible. (If it were true), then it's poison. Are you telling me that someone who takes two zopiclone tablets has an increased risk of dying?"

The study cannot prove cause-and-effect, just an association, "and it could be anything," MacFarlane said. "It could be a common factor in that population that has nothing to do with the meds," suggesting it's an indication of something larger going on.

Still, MacFarlane says sleep specialists are urging GPs across Canada to prescribe the drugs more judiciously, and that non-drug approaches, including cognitive behaviour therapy — which includes changing the psychological problems that perpetuate insomnia, such as excessive worry — should be among the first-line treatments.

If a sleeping pill is tried, and the patient doesn't respond, "you really have to dig a bit deeper to try to find out what's really going on," adds Morehouse, of Dalhousie University and Memorial University of Newfoundland.

"Is the patient depressed? Is the patient addicted to something? Is there an unbelievable psychosocial nightmare happening in their life?"

We also need to question the urge to reach for a chemical fix in a society where many of us, she said, are sleep-deprived and running on fumes.

"There's this underlying anxiety with the economic crisis — we're all wearing four and five different hats — and there's this constant level of anxiety," added Cumming, of the Centre on Substance Abuse.

"We're a pill popping nation," she said. Instead of slowing things down and looking at ways to improve sleep, "we'll just take a little pill."