Ending the Vicious Cycle of Insomnia Without Prescription Sleeping Pills

Ending the Vicious Cycle of Insomnia Without Prescription Sleeping Pills
Instead of laying in bed awake, you may as well get up and meditate or do some CBT-I, both of which have been proven to help you get to sleep. (Shutterstock)
Jeff Perkin

“O sleep! O gentle sleep! Nature’s soft nurse, how have I frighted thee? That thou no more wilt weigh mine eyelids down and sleep my senses in forgetfulness?”—William Shakespeare, Henry IV, Part 2, Act 3, Scene 1

The state of worldly affairs is enough to keep anyone awake, but when our sleep is regularly disrupted, it sets off a vicious cycle of fatigue and anxiety. Luckily, there are ways out of this loop besides sleeping pills—and you likely don’t even need the mythic eight hours of sleep per night.

There are some rarely discussed factors surrounding sleep that we can use to get the rest we need without having to alter our brain chemistry with drugs.

Television commercials may suggest that a sleeping pill can help you get a night of restful sleep and return to your more energetic self, but the fact that the side effect warnings for these drugs can take up most of the ad’s air time is telling. However, if you're desperate for sleep, it’s all too easy to ignore the potential side effects and pretend that the small print doesn’t apply to you.

However, this is a deadly serious area of concern, according to sleep researcher Dr. Daniel F. Kripke, a licensed physician certified by the American Board of Psychiatry and Neurology and an emeritus professor of psychiatry at the University of California–San Diego.

Kripke has been studying sleep for years, including doing research in his earlier years for pharmaceutical companies. That changed, however, as he recounted in a comprehensive guide to the dangers of sleeping pills that he released online.

“Sleeping pills are hazardous to your health and could cause death from cancer, infections, overdoses, respiratory failure, other illnesses, or accidents.,” he wrote in “The Dark Side of Sleeping Pills.”

Kripke wrote in his final acknowledgments at the end of the book how he stopped accepting any fees from pharmaceutical manufacturers years ago so that he could freely report what he was discovering in his research.

“I also stopped accepting fees from tort lawyers or class-action attorneys. It is important that readers understand for whom an author works. Being supported largely by public funds, I have felt responsible for explaining the research results in the public interest,” he wrote.

Fortunately, there are many options insomniacs can explore before resorting to pills. Cognitive behavioral therapy for insomnia (CBT-I), bright light therapy, and meditation are a few of the proven ways to relax the mind.

Common Sleep Deterrents

It’s important to remember that lying in bed worrying won’t help. If you don’t feel sleepy, why not sit in meditation or use CBT-I to reframe the anxious thoughts you may be experiencing?

Removing caffeine and alcohol before bed is also important. Caffeine’s effects can last for up to five hours. Alcohol may help you get to sleep, but also has the tendency to wake people up mid-sleep when their blood alcohol level falls.

People who drink early may also experience difficulty initially falling asleep. Limiting alcohol intake and not drinking every night is key to making sure you're getting restful sleep regularly. Combining alcohol with sleeping pills can be very dangerous because both drugs can alter breathing, brain function, and heart rate via suppression of the central nervous system.

Other common sleep deterrents are eating sugary or processed foods before bed and staying up late staring at screens. The blue light from our screens can trick the brain into thinking it's morning. Use a filter on your screens or wear glasses that filter blue light. Before taking medications, consider supplementing with l-Tryptophan, valerian, magnesium, vitamin B12, chamomile tea, or other relaxing herbal teas or fragrances, such as lavender oil.

Cognitive Behavioral Therapy for Insomnia

Few things can keep us up at night as easily as errant thinking. Negative thoughts can have wide-ranging effects on our health and well-being. To the extent that we believe and identify with our thoughts, they can be surprisingly destructive. CBT-I helps a person to question harmful thoughts and replace them with something constructive.
In a study, “Management of Insomnia Disorder,” published by the Agency for Healthcare Research and Quality, researchers wrote, “Cognitive behavioral therapy for insomnia (CBT-I) improved global outcomes and nearly all sleep parameters in the general adult population, older adults, and adults with pain.”

The researchers didn’t find evidence of any adverse effects.

While they were hesitant to compare CBT-I to sleeping medications, they did write that “observational studies suggest that hypnotics (sleeping medications) may be associated with dementia, fractures, and major injury.”

The American College of Physicians even recommends CBT-I as a “first-line treatment” for insomnia over prescription medications.

Bright Light Therapy

Whether you think of yourself as a morning person or a night owl, you may have a “circadian rhythm timing disorder” in which your body clock is moving either too fast or too slow.

“Advanced sleep phase” is the term given to people whose body clock is running too fast. Common in the elderly, advanced sleep phase involves getting up and going to bed earlier than is socially normal. It may be caused by the deterioration of vision and less light intake because of cataracts, smaller pupils, glaucoma, and other causes of macular degeneration.

Advanced sleep phase can be problematic if the person finds that they fall asleep unintentionally or can’t get enough sleep because of waking too early. Bright light therapy, using an LED light box or other bright lamp, can stimulate people in the evening and help to keep them in a more normal circadian rhythm.

People whose body clock is moving too slow have a “delayed sleep phase” in which they're receiving wake/sleep signals too late. Insomnia related to a delayed sleep phase involves a person not being able to get to sleep until very late at night. This may involve spending hours in bed trying to get to sleep and then struggling to wake up at the desired time.

Delayed sleep phase is commonly associated with oversleeping and depression. Abnormal drowsiness and fatigue in the morning can result in a person being overly dependent on stimulants or being more susceptible to accidents when they're rushed to get somewhere. Associated with rebellious behavior, delayed sleep phase is more commonly experienced by young adults, although it does also affect older adults and some elderly people.

People experiencing this timing disorder can use bright light therapy to get more light early in the morning. According to Kripke, delayed sleep phase can be a stubborn condition and can require the person to expose themselves to a very bright light for one to two hours each morning.

“Arranging to receive that light may be hard to fit in with daily habits,” Kripke said.

“I usually find that people with delayed sleep phase need one of the bright fluorescent light boxes. One convenient way to get a strong dose of morning light is to use a light box (maybe a box arranged for 10,000 lux) for 30 min at breakfast time. For people who work at a desk, placing the light box on the desk and turning it on all morning might be effective, even if one cannot sit at the desk all of the time.”

Kripke said sitting near a window or just opening the curtains rarely offers enough light to treat the condition.

To learn more about bright light therapy and its uses, consult Kripke’s free online book, “Brighten Your Life.”

Mindfulness Meditation

When we're really stressed or worried about something, it can be very difficult to sleep. Getting out of bed to sit in meditation can help resolve troubled thoughts and feelings.

What's causing the feeling? Fear? Uncertainty? Feel the feeling and allow the thoughts to pass without engaging in them. After sitting for a while, you'll either dissipate the feeling or be ready to sleep.

Only when you feel you're ready to sleep should you return to bed. Don’t worry about the number of hours you're going to get. You’ll get what you can. Relaxing is the priority. Light some incense or play some soothing music if you want.

Meditation has the power to put one in touch with a deeper aspect of oneself. In that place of peace, our worldly concerns can lighten and a sense of calm can soothe the nervous system. Meditation in and of itself can be deeply restful.

According to a study published in the Sleep Research Society’s journal, Sleep, doctors wrote, “Given that insomnia disorders are defined by nocturnal sleep disturbance and waking dysfunction, the present findings demonstrate the efficacy of mindfulness meditation to improve both nocturnal symptoms and waking distress in those patients with elevated sleep-related arousal.
“Interventions featuring mindfulness meditation have positive patient-reported benefits and could be a viable treatment option for chronic insomnia.”

Do We Really Need 8 Hours?

It may be surprising to learn that people who sleep less on average, about 6 1/2 hours per night, may actually live longer and be less depressed than people who sleep eight or more hours.
“The folk belief that we should sleep 8 hours seems to be incorrect. Numerous studies have shown that self-reported sleep longer than 7.5 hours or shorter than 6.5 hours predicts increased mortality risk,” Kripke and other researchers reported in a study.

“People who sleep five or six hours may be reassured.”

Short sleepers may actually live longer in many cases than people who sleep eight or more hours per night. Surprisingly, people who say they have insomnia are also less likely to be depressed because depression is generally correlated with oversleeping.

Spend Less Time in Bed?

Excessive worry about the fallacies surrounding sleep can cause people to force themselves to bed even when they aren’t sleepy. Whatever your bedtime is, Kripke said that “you should not go to bed if you do not feel sleepy.”

It seems like common sense when you think about it.

“Moreover, if you awaken at night and no longer feel sleepy, get out of bed, and do not go back until you are sleepy again and expect to fall asleep," he said. "Even after being up during the night, you should get out of bed by your regular awakening time, because sleeping late tends to make the problem worse.”

Sleeping Pill Dangers

In “The Dark Side of Sleeping Pills,” Kripke wrote that “American Cancer Society data from over one million people showed that use of sleeping pills was associated with more deaths within six years, but insomnia by itself was not associated with any death risk.”
Writing about a study that he conducted with other researchers from Scripps Clinic Viterbi Family Sleep Center, he said, “From electronic medical records, we studied over 10,000 patients who took sleeping pills and over 20,000 matched patients who did not take sleeping pills. The patients who took sleeping pills died 4.6 times as often during follow-ups averaging 2.5 years. Patients who took higher doses (averaging over 132 pills per year) died 5.3 times as often. Even those patients who took fewer than 18 pills per year had 3.6 times the deaths of patients who took no hypnotics.”

While this correlation doesn't prove causation, Kripke goes on to suggest that “if sleeping pills cause even a small portion of the excess deaths and cancers associated with their use, they are too dangerous to use.” He said doing large, randomized, controlled trials posed ethical challenges and would also run counter to the interests of pharmaceutical companies.

“If sleeping pill companies believed that such trials would prove that their products were safe, they would have done such controlled trials many years ago,” Kripke said.

According to his work, the following sleeping pills are “associated with significant mortality risk”:
  • Zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, and Zolpimist)
  • Temazepam (Restoril)
  • Eszopiclone (Lunesta)
  • Zaleplon (Sonata)
  • Triazolam (Halcion)
  • Flurazepam (Dalmane, Dalmadorm)
  • Estazolam (Prosom)
  • Quazepam (Doral)
  • Barbiturates (especially phenobarbital)
  • Antihistamines, mainly diphenhydramine


Shockingly, Kripke found that “those who averaged two to three sleeping pills per week or more were 35 percent more likely to develop a new cancer within an average of 2.5 years.”

“As of July 2018, there were at least 42 published studies of the mortality risks of sleeping pills," he said. "Of the 42 studies which reported either greater or lesser mortality associated with sleeping pills, 40 studies showed that people taking sleeping pills died sooner.”

A population-based cohort study in Taiwan compared users and nonusers of zolpidem (Ambien), which is “the most popular hypnotic in Taiwan and the U.S.,” according to Kripke.
After an eight-year follow-up period, reseachers found a significantly larger cancer hazard associated with those who took high-dosage zolpidem (300 or more milligrams per year). High-dosage of 300 or milligrams would equate to roughly 60 doses per year for women and as little as 30 doses per year for men, according to Mayo Clinic dosage recommendations for regular tablets (extended release is a higher concentration and therefore would require fewer tablets still).
The highest cancer risk was for oral cancer, which had a “related hazard ratio of 2.36.” That means that people taking zolpidem were, on average, 2.36 times as likely to develop oral cancer as opposed to people not taking the medication over an eight-year period. Kidney, esophageal, breast, liver, lung, and bladder cancers had a “related hazard ratio of 1.6” with men being at higher risk than women. The Taiwanese researchers concluded that “the use of zolpidem may be associated with an increased risk of subsequent cancer. Further large-scale and in-depth investigations in this area are warranted.”

Other Serious Risks

Depression, worsened sleep apnea, and a strong association with suicide are other risk factors to consider when considering sleeping medication.
“Modern hypnotics were associated with an increased incidence of depression in data released by the FDA,” Kripke said.

Suicide is also “strongly associated.”

The Food and Drug Administration (FDA) stated that sleeping pills shouldn't be taken by people with sleep apnea because of the risk of making it worse. Kripke has studied the prevalence of sleep-disordered breathing among people aged 40 to 64 years old and among community-dwelling elderly. His findings raise concerns about the widespread likelihood of people with sleep apnea also taking sleeping pills.

In “The Dark Side of Sleeping Pills,” he wrote, “The problem is that almost everybody above age 40 has some sleep apnea, and the majority of people over 65 would meet commonly-used criteria for a diagnosis of sleep apnea. Therefore, a large proportion of people taking sleeping pills are making their apnea worse. Over a period of many years, anything which makes sleep apnea worse would be expected to cause high blood pressure, and therefore, to increase the risk of heart attacks, heart failure, and strokes.”

Complex Sleep Behaviors

The bizarre risks of some sleeping medications are often most publicized because they're rare and seem highly improbable to the average person. These “complex sleep behaviors” include “sleepwalking, sleep driving and engaging in other activities while not fully awake, such as unsafely using a stove.” This gives serious meaning to the drugs’ classification as “hypnotics.”
It’s important to be aware of the warnings so that you can monitor any potential side effects. If you have any of these strange reactions in any form, the FDA has said in a statement that you shouldn't be taking sleeping pills, including “eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, and Zolpimist).”
As of April 2019, the FDA announced the use of their “most prominent warning” on the drugs listed above.

Then-Acting FDA Commissioner Ned Sharpless said, “These incidents can occur after the first dose of these sleep medicines or after a longer period of treatment and can occur in patients without any history of these behaviors and even at the lowest recommended doses.”

The risk of complex sleep behaviors is very rare but increases when sleeping medications are combined with even small amounts of alcohol.

Getting Off Sleeping Pills

On top of the significant risks of these medications, it appears that they provide very little benefit.
“The recommended doses objectively increase sleep little if at all, daytime performance is often made worse (not better), and the lack of general health benefits is commonly misrepresented in advertising,” peer-reviewed research by Kripke reads.

Nevertheless, it's important that you consult your prescribing doctor before discontinuing a prescribed sleeping medication, especially when considering withdrawing from larger doses.

“Many experts feel that patients who have been taking higher doses or a modest regular dosage for a long time may need to slowly taper off the medication, reducing their dosage by a small portion every week or two," Kripke said. "Even with slow tapering, withdrawal from sleeping pills can cause at least a few nights of insomnia, anxiety (both day and night), tremulousness, and other symptoms. People will have much less difficulty withdrawing from sleeping pills if they first begin CBT-I treatment.”