Sleeping Pills: Risks and Realities

Q & A with Dr. Donald R. Jasinski, a toxicologist and renowned expert in the field of chemical dependency
By Rich Maloof for MSN Health & Fitness

The sad news this week of actor Heath Ledger’s passing was followed immediately by a landslide of conjecture about his life and death. Police reports of sleeping pills and other medications on the premises gave way to the speculation that nowadays seems inevitable after a celebrity dies. As this article was being posted, an official toxicology report was still days away.

MSN Health & Fitness consulted Dr. Donald R. Jasinski, a toxicologist and renowned expert in the field of chemical dependency, to get the straight facts about the realities and risks associated with sleeping pills. Jasinski is professor of medicine at Johns Hopkins University School of Medicine and chief of the Center for Chemical Dependence at Johns Hopkins Bayview Medical Center.

Q: Can you first identify the different classes of sleeping pills, and explain which ones carry the risk of a lethal overdose?

A: An overdose is possible with all of them. The issue, though, is the amount of drug for the particular overdose. There are different toxicities for each type.

Antihistamines
First are the over-the-counter sleeping pills. Most of those are the antihistamine known as diaphenhydramine, or Benadryl, which is used very commonly as a sleeping pill. The recommended dosage for adults is usually 25 milligrams to 50 milligrams, while the lethal dose is usually somewhere over a gram. So, Benadryl is fairly safe—but if you take enough of it, yes, you can get toxicity. Death is pretty rare but you can get a toxicity from it.

Major tranquilizers
Then there are the major tranquilizers. These are probably the most widely prescribed.
Psychiatrists will often prescribe trazodone—one common trade name is Desyrel—as an anti-depressant, but doctors widely prescribe it as a sleeping pill, which is an off-label use. Trazodone is pretty safe and not known to be particularly addicting.

Barbiturates
The third class is barbiturates, but I haven’t seen anyone take barbiturates in years. A few are still on the market but hardly anyone uses them anymore.
Benzodiazepines and related sedatives

The other class is those related to the benzodiazepines, including minor tranquilizers. They include drugs [sold under the names] Valium, Xanax, Sonata, and Lunesta. The prototype drug in this class is zolpidem, or Ambien. In therapeutic use, it can produce dizzyness, light-headedness, lethargy and maybe some gastrointestinal upset, but that’s relatively minor.

Q: What are the toxicity risks of benzodiazepines?

A: Taken alone, you can get drowsiness, you can change your heart rate, your speech will get slurred, you’ll vomit, you’ll get confused, you can hallucinate. You can get agitated and your heart rate goes up. Occasionally, with a very big dose, you can go into a coma.If you go into poisoning, you can get respiratory depression and CNS [central nervous system] depression. But usually people don’t die.

The big problem comes when you mix these with other drugs. If you look at the Drug Abuse Warning Network, DAWN, for drug-related deaths and emergency room visits, most incidents of toxicity related to benzodiazepines occur when they’re mixed with alcohol or with opiates. Drugs such as morphine, codeine, oxycodone and hydrocodone are opiates.

Q: Is toxicity expected when they’re mixed with antidepressants or anti-anxiety meds?

A: It depends. Some medications for mood disorders are also benzodiazepines, and these types of drugs are not particularly addictive. It’s usually the other two classes of drugs—the alcohol or the opiates.

Sometimes, with the mixing of [sleeping pills] and anti-depressants, you might have a toxic action on the heart. If you mix drugs you sometimes get a lethal combination.

Q: How do they damage the heart?

A: Some of these drugs may make the heart susceptible to stimulation and cause an arrhythmia. That’s why you worry about cocaine on top of some of these drugs. What happens is, cocaine stimulates the heart, and the stimulation can all of a sudden throw the heart into an arrhythmia.
The other issue here is that you have a high incidence of sudden death syndrome.

Q: Sudden death associated with what?

A: For unexplained reasons, people just die. You see young people dying an unexplained death, and sometimes it’s thought to be that they had a propensity toward a cardiac arrhythmia. There is this susceptibility in certain people, and sometimes it’s thought that the drugs make it worse.

Q: So a person can be susceptible with no indication of an existing condition.

A: Some people simply seem to have susceptibilities to sudden death syndrome. Is susceptibility innate? Susceptibility can be congenital, meaning you’re born with it, or it can be induced—say by drugs or something else.

Q: Are some people more likely than others to have a toxic reaction to sleeping pills?

A: Generally the toxicity with these drugs is relatively low. But you always find a rare person who will take a low, therapeutic dose of a drug and have a bad reaction to it. Drug response is often measured in a “distribution curve,” a simple bell-shaped curve. Most people fall right in the middle. At the front end of the curve you have a few people who don’t respond at all to the drug, and at tail end you get a few people who are hypersensitive.

Q: How loose are the standards for prescribing sleeping pills? Are there specific diagnostic criteria?

A: Well, there’s a very high incidence of insomnia, especially with the aging population. A lot of people have trouble sleeping for various sorts of reasons. So it’s been pretty standard to prescribe certain sleeping pills. I have no idea exactly how many are out there, but my guess is that millions of people take them without any problems. The problems come with people tending to increase the dose on their own, or mixing them with alcohol or other drugs.

Q: Are they commonly abused for psychoactive effects?

A: No. If you’re going to abuse one to get high, it’s usually diazepam, which is Valium; alprazolam, which is Xanax; or lorazepam, which is Ativan. Some [sleeping pills] can produce psychoactive effects, but they’re not particularly useful for this. They’re not a drug of abuse where they’re being sold on the street for people to get high. People may abuse them, but when you push the dose you generally fall asleep.

Q: You mentioned the possibility of arrhythmia. Aren’t most of these overdose fatalities caused by respiratory failure?

A: Most of the deaths involving sleeping pills and alcohol or opioid drugs are due to respiratory depression. It’s depressing the brain center that controls respiration. You have two mechanisms for breathing, simply speaking. You can voluntarily take a breath, or, if you hold your breath, the carbon dioxide in your bloodstream builds up and stimulates a center in your brain that makes you take a breath. That’s why you can’t kill yourself just by holding your breath.

What happens is, if you give somebody these drugs, it lowers the sensitivity of the respiratory center to the carbon dioxide. Eventually it blocks the response to carbon dioxide. So you first take something that makes you fall asleep, and eventually you lose that automatic protective mechanism.

You probably can’t produce complete respiratory depression with most of the diazepenes, but when you mix them with alcohol or opiates, you can shut that mechanism down.

Q: Are there any other misconceptions about sleeping pill use and abuse we should address?

A: I think the issue is underestimating the danger of mixing them with other drugs. They are fairly safe drugs—the problem is big doses and drinking. Toxicity is generally not a concern unless you’re taking particularly big doses, you’re sensitive to the drug, or if you’re combining them with alcohol or other drugs.

Interview conducted and compiled by Rich Maloof.

Source: MSN