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Those Sleeping Pills May Be Killing You
dstates writes "A recent article in in BMJ Open reports a strong association between the use of prescription sleeping pills and mortality. The study used electronic health records for 2.5 million people covered by the Geisinger Health System to find 12 thousand who had been prescribed sleeping pills and a matched set of controls. Death rates were much higher in the patients taking sleeping pills and the risk increases with age. Kudos to the authors for publishing this in an open access journal."
The people taking the medications might be dying sooner because they have insomnia which is not fixed by sleeping pills easily. The study should not compare with the general populace since they are, by definition, better sleepers than the group that isn't able to get good sleep.
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I couldn't find anything in it to suggest they had actually done a double-blind trial, or even a half-assed blind trial, so their results are purely correlation, and not causation, despite the time they spent talking about causation. They do suggest that 'hangovers' from the drugs are a cause of traffic accidents and such, though, so they at least thought of that.
No mention about mental stability that I saw.
"If you make people think they're thinking, they'll love you; But if you really make them think, they'll hate you." - DM
Drug companies spend more on marketing than they spend on research. Is it any surprise that these stories keep coming up? SSRIs were going to cure everyone's depression. Now we find out that they're addictive, and only effective in the very worst cases of depression. Vioxx was going to usher in a new age of pain relief for arthritis, turns out it killed tens of thousands of people. Hormone replacement therapy was considered essential to prevent osteoporosis in women. Turns out it also causes bone remodeling that makes certain types of fractures even more common. Don't be surprised if we find out in the future that wonder drugs like statins carry risks we haven't been made aware of.
Pharmaceutical companies should not be allowed to market. Not to the general public, and not to doctors either.
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Not screaming in terror, like his passengers.
Have gnu, will travel.
Most people taking prescription sleeping pills have been fighting sleep disorders for a long time, probably their entire adult lives. Getting terrible sleep for 30 or 40 years will probably increase your mortality regardless of what pills you're taking. Do the same study again only this time instead of looking at what drugs they're on, give them a sleep disorder questionnaire, drowsiness survey, and a sleep study. Then you'll have enough data that I actually care to look at your results.
I quit smoking because I don't want to get cancer, and I don't want to smell bad all the time, and I don't want to be out of breath walking up the stairs. That said, I loved smoking. I still miss it every day, but the risks are greater than the rewards.
Stop taking my sleeping pills? Hah. Have you ever been so tired that you get a sore throat? Or that you argue with yourself at a stop light, "no, don't close your eyes, I know it would feel really really good but if you do that you'll miss the green and might not wake up until somebody knocks on your window"? Your legs shake, you feel sick to your stomach, your palms sweat constantly, your eyes try to close with all their might until you can hear the muscles straining in your ears.
Now try feeling like that for months on end. Stop taking my sleeping pills? Fuck that shit, I'd rather die early.
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Urgent bulletin. A new study has found that people having extended stays inside hospitals have a much higher mortality rate than people who don't. Avoid hospitals at all costs.
Melatonin is fine and I highly recommend its use, opposed to traditional sleep aids (I use it). Melatonin is a sleep aid, in that it aids you in falling asleep... but it is different from traditional (prescription) sleep aids such as Ambien, in that it is a hormone supplement.
Melatonin is a non-benzodiazepine, while traditional sleep aids are benzodiazepines. Melatonin (N-acetyl-5 methoxytryptamine) is a compound naturally created in the pineal gland of the brain which triggers sleep. This should not be confused with the feeling of being tired, depleted of energy, or "heavy eyes." Traditional sleep aids act more like an anesthetic, actually making you feel tired and/or knocking you out.
Melatonin is non-habit forming, nor does the body develop tolerances for it, as in drugs like Ambien. It's kind of like a "passive" sleep aid, while Ambien/Benadryl/Lunesta/etc would be "active" sleep aids. There's a reason why it is available over-the-counter.
Note- while you can get Melatonin over-the-counter, you'll likely find nothing higher than 1mg doses (sometimes up to 3mg). You CAN, however, get a prescription for it. Then you can get a higher dose (up to 5mg?), in larger quantities (bottle of 40 as opposed to over-the-counter pack of 14ish), and your insurance will likely cover it.
Warning- with higher doses, especially if your body is already producing it's own, it may take a while for your body to expel the excess in the morning. This could make you feel groggy, make it hard to wake up, and make it too easy for you to fall back asleep (i.e. while driving). Take it 20-60min before sleep, sleep for at least 8 hours, give yourself 20-60min to wake up before driving.
Hope this helps! :o]
The patients did not know they were being monitored (blind.) The doctors/nurses who entered the charts didn't know their patients' data would be used for this research (double-blind.) The people who analyzed the data, however, had everything upfront to poll and draw whatever conclusions they were looking for. "Using a query into the EHR..." "A further query of this subset..." "For each hypnotic user, we attempted to identify two controls with no record of a hypnotic prescription..." Sounds like they need a triple-blind experimental design.
Since they were looking at people who died, I think the ability to get them to answer questions would be much more interesting than what the answers would be.
"The population is mostly of low socio-economic status, having less than high school education and less than one-third are insured under the Geisinger Health Plan."
"We were unable to control for depression, anxiety and other emotional factors because of Pennsylvania laws protecting the confidentiality of these diagnoses."
The results of this study ought to be interpreted in light both of the socio-economics, demographics, and regional characteristics of the population studied, and of the potentially crucial categories of comorbidity that were excluded.
My own use of zolpidem (Ambien) was during a time of an extraordinary convergence of situational stress factors. Once the stress conditions resolved, I was able to discontinue the drug.
I showed your post to an MD, who said that while everything you asserted is more or less true, what you failed to assert far outweighs the value of the information you did provide. Melatonin has documented negative interactions with Coumadin, Warfarin, and Aspirin, which are widely prescribed anti-coagulants. Melatonin will also nullify the effects of any corticosteriods you happen to be on. So -- do us all a favor, eh, and don't leave off the bad parts just because you are a fanboi of the good parts.
No. When you do an experiment, i.e. purposely manipulate one variable, you establish a causal connection. Identifying and explaining the mechanism is nice, and establishes the character and directness of your causal relationship. Trials are experiments.
Correlation comes from observational studies where you do not manipulate any variables yourself, you just look for natural or preexisting variation.
A simplified example - if I look at a bunch of people who take sleeping pills and a bunch who don't, and measure how likely they are to die, I get a correlation (maybe) - dying and taking sleeping pills are correlated, but I don't know if dying causes people to take sleeping pills, whether sleeping pills tend to cause you to die, or whether some other factor (being crazy maybe) causes you to both take sleeping pills and die.
If I take a bunch of random people and give some sleeping pills and others no sleeping pills, if the ones I give the pills die significantly more often then I can conclude that sleeping pills cause death (by some mechanism I don't yet know).
Most of the people I know who take sleeping pills are not necessarily the most stable people in the world to begin with. Sorry to all you Ambien fans.
Theoretically, yes. In practice I don't think so.
This 'confounding by indication' is one of the biggest problems in pharmacoepidemiology. We know that people take meds because there is something wrong with them. We also suspect that taking certain meds over a long period of time is bad for you, particularly if you are already at high risk. So how can you separate those effects? A lot of statisticians spend a lot of time thinking about this, and 'adjusting for everything you can think of', propensity scoring and very tight matching of cases and controls seem to be the most often used solutions. None of these is satisfactory as they obviously don't adjust for things you can't measure. Use of instrumental variables is another possibility but there is rarely a good instrument to use.
Ideally you would run a randomised trial of a med to check whether death rates or adverse drug reactions are higher in the group taking them, but this is impractical because often the required trial would be enormous (massively expensive and time consuming), would have to recruit many of the 'high risk' people that are the groups most at risk of excess mortality but are usually not recruited into trials, and could only really examine one compound at a time. Also trials exclude people taking many other medications, or with comorbid medical conditions, because these may be unsafe and would again dilute the true effects - however it is likely that unknown drug-drug interactions are the cause of a lot of the problems we think we are seeing.
It's easy to snipe at this kind of research since its 'correlation not causation' but this really is the best that is possible at the moment when trying to answer these extremely important questions regarding drug safety. If anybody has any better ideas we'd be glad to hear them.
You could have answered that with a simple act of RTFA. In short: no. They had no access to their subjects' mental health records.
I put up my screed on the weakness of the study (after seeing it covered by the Grauniad) at http://tmblr.co/ZaUL7yHBNSh0 before I saw it here, and the short version of my unassailable opinion is that it is a deeply flawed study whose data is just good enough to make a strong case for further study, undermined by the authors drawing unsupportable conclusions and pointlessly denigrating prior work and practical experience.
And yes, hypnotics are often taken by people for whom insomnia is a secondary condition grounded in deeper problems. That doesn't mean the hypnotics are not very useful in enabling them to address the deeper problems. Speaking from personal experience, a dozen doses of Ambien taken over the space of about 2 months during the breakup of my first marriage were critical to saving my job, my ability to eventually pull out of a deep depression, and possibly as many as 4 lives. When life is slicing deep enough that you cannot sleep for days on end, the lack of sleep itself gnaws on the stripped bones of sanity.
The main recommended use of hypnotics is for short periods in cases where insomnia itself is causing additional problems and more comprehensive treatments for underlying primary causes are too slow and/or are impeded by the effects of insomnia. Real primary insomnia that can be managed with hypnotics is pretty rare. A valid conclusion from the study is that people in that one HMO in rural PA who are being prescribed hypnotics are not getting adequate overall care, and that the inadequacy correlates with the amount of hypnotics that they are being prescribed. The authors claim (and I tend to believe them) that there is a growing consensus that CBT is a better treatment for chronic insomnia, but CBT is not something a doctor can write a scrip for and have the patient sleeping soundly that night for a few bucks. It can also uncover and address underlying issues like depression, OCD, and other cases where insomnia is really just a symptom of a more complex primary mental disorder. Of course, if you are a researcher specializing in retrospective studies of this sort who has been given access to a very large data set of patient records by an HMO, you don't have a strong incentive to write a conclusion that this HMO is controlling costs by encouraging doctors to prescribe cheap drugs instead of referring patients to expensive months-long rounds of a talk therapy, even when the best type seems to be the relatively efficient CBT.
None of these is satisfactory as they obviously don't adjust for things you can't measure
Or things you won't measure for whatever convoluted reason.
For example, back pain patients given powerful painkillers recover slower or not at all compared to no painkillers.
Example of false reasoning: I overstrained my back doing some overambitious carpentry alone. Intense pain when sitting or standing, laying on back not so bad. Went to doc, did not accept script for painkillers because I slept on my back just fine and everything I do sitting or standing is not allowed while on pain killers anyway (can't even drive to work if I'm high on painkillers). Also doc is all nervous that I'm dr shopping for abuse meds and really chilled out and got more helpful once he realized it was perfectly clear that I was only genuinely trying to fix my back. blah blah blah. The point is the diagnosis of "back pain" is the same for me and someone who's in agony even when lying down so they need painkillers just to sleep. No great stretch of imagination that the guy in more agony than myself is more F'd up and takes longer to recover (took me only about half a week, but I've heard if you really F up your back it can be semi-permanent, months maybe). Multiply this by 15K and you get a whopper like "taking painkillers means it takes months to recover from back pain diagnosis instead of days"
"Science flies us to the moon. Religion flies us into buildings." - Victor Stenger