♪ Bob and Brad ♪
♪ the two most famous physical therapists ♪
♪ on the Internet. ♪
- Welcome my friends to the Bob and Brad podcast.
Produced by Bob and Brad,
the two most famous physical therapists on the internet.
I'm Bob.
I'm exactly one half of the Bob and Brad team.
I'm joined by Chris, the pharmacist, smartest guy I know.
Or at least in the top five,
- Oh.
- I'll give you that.
So today we're gonna talk about the truth
about sleeping pills, Ambien, Lunesta, Sonata.
We might even talk about another one.
Are they dangerous?
You know, so we're going to get into this.
- Yeah absolutely.
- And now these are called Z drugs.
- Z drugs, just primarily only because they have the names,
The Zs. That's why.
- The Z is the other name they have.
- Yeah, just a quick...
- Like zolpidem and...
- Yep, zolpidem, eszopiclone, and zaleplon.
- So they all have the Zs in it.
- Yep. That's why.
- Well, I unfortunately have some experience with this.
I was always a great sleeper, like the best sleeper ever.
And I ran to some problem with sleeping
and I didn't have any coping mechanisms
and I already was doing all the things
which we recommend you should try first,
all the natural way
- Sure
- to try to get to sleep.
- Yep.
- I know one of the suggestions,
the most important suggestion is
that you go to sleep at the same time every night.
- Yeah. They talk about sleep hygiene.
That's, you know, I mean 70, 80% of sleep, you know,
I mean it certainly affects, I mean, well,
let's talk about these numbers.
I mean, you're talking about 50 to 70 million Americans
at some point or regularly have difficulty sleeping.
- Sure.
- So those are, I mean that's a large amount
of people in our population.
And so.
- It affects your health greatly.
- Yeah.
Top to bottom, there are so many things
that sleep is restorative.
So when a lot of people, you know,
when you first see their approach a pharmacy,
or if you talked to your doctor,
you know, 70 to 80% of those problems
can be corrected with good sleep hygiene and proper.
- Sure.
- So it's the,
- Keeping the room cool,
- Yeah. Cool room,
- just keep it dark,
- Same time or approximately every night
easing into the evening, relaxing activities.
- Right. Turning your lights down as you,
- Exactly.
Darkness, it starts to bring those melatonin levels up.
So, I mean, that's really important for that,
but you know we're a busy society as a whole.
And so as Americans, we are running a garden pretty much
from the moment we wake up, you know
you got the kids, you're running around at schools,
working on a project, working on a business project.
I mean, we are just a busy society.
And so unfortunately insomnia can encroach on that
in a lot of times, sleep hygiene goes out the window.
I mean, that's the first place to attack it.
So if you can ease into your night, minimize caffeine,
minimize alcohol, you know, leading to your evening.
- Caffeine, it can stay in your system for quite a while.
- Long time.
- So probably no caffeine after lunch.
- Yeah. I mean, well lunch,
or not much later than three or four in the afternoon.
And there's some people with variance, you know,
some people have incredible tolerance to caffeine
so it kind of depends.
We have to tailor it to the patient
because it just kind of depends
on their patterns and what they do.
But yeah, if you're having a cup of coffee
at eight o'clock probably not going to help
the sleep scenario.
And the same thing with alcohol is kind of interesting.
Cause there's, you know if you just had a beer
and you're like,
"I'll take a beer before bed and I'll fall right to sleep."
Well, there's a paradoxical excitation
that it can occur with just even simply a beer,
glass of wine.
Or which you think is relaxing,
but it's actually stimulating.
And then it actually affects your REM sleep.
And then all of a sudden,
which is rapid eye movement
and that's that portion of the sleep
that's so important for us to reset our brains.
- Restore. Yeah.
- And we miss out on a lot of that.
So that sleep hygiene is critical,
and watching out for certain drugs that can impact sleep.
So those are some of the non-drug things we can do before.
And you do want to see your doctor too,
because if let's say the criteria is 30 days in a row
and you're not sleeping well,
that's kind of the medical criteria.
I tend to be,
I'm somewhat impatient.
It's like, if you, if you haven't slept in two weeks,
- Yeah, that's a long time.
- You're probably affecting your immune system.
You're definitely probably going to be affecting
your work life, your social skills.
I mean, cause you can be short tempered.
- Absolutely.
- I mean, there's a lot of things
that absolutely affect you.
And so we want to be super duper careful that,
and so what if it's a thyroid issue that's not controlled?
What if there's something going on with your adrenal glands?
What if there's something else
that's triggering these types of things,
you know, as a pharmacist, there's no way on Earth
I could possibly know.
And that's what we have to go to the go-to
which is your physician or your practitioner
where they can ask the certain questions
and run the certain tests
to make sure that there's maybe something else
that's out there creating the problem
that you just didn't even know.
And you're kind of falling asleep, getting frustrated,
beating your head against the wall because, "I can't sleep."
And it is such a frustrating scenario
for patients across the board.
It's awful
- Yeah because you can't will it.
- No!
- And the more you think about it, the worst it gets.
- The worst it gets, absolutely.
- And you know one of the problems that I have,
you know, is when I, which a lot of people have,
is if you go on vacation or if you go to,
I was going to a conference,
and one time I had trouble sleeping
because there was road noise and I didn't sleep all night,
and then I had to,
- Perform.
- Perform a conference.
- Yeah.
- And so I, I mean,
I want to make sure it's well known here
that we are not advocate of the drugs if we can.
And we try to go off prescriptions,
we try to the natural ways,
that's the Bob and Brad way,
- Yeah.
- But there's times where you may need to use them
for a short period of time.
- Yep.
- Or maybe use them just like you said
when we go on vacation or go on conference
- Yeah I mean you know,
the whole invention of the Z drugs in general,
you know, it was based off of benzodiazepines.
The benzos came into effect in the fifties
and we thought they were great drugs.
And then over time we realized
that there was tolerance and addiction.
So in came the nineties.
And so the first Z drug on the market
was Ambien or Zolpidem.
And so when I,
early in my career 25 years ago,
I mean, you could, I mean,
you may as well put it in the water,
as far as the prescribing habits at that time.
- Yes it was that proper.
- It was so prevalent because it worked great
and really the distinct advantage of the Z drugs
that they have over benzodiazepines
and the false impression that they get,
they are safer but there's a caveat to that.
I mean, long-term,
none of these.
Whether it's a benzo or if it's a Z drug,
they're not designed for long-term use.
But yet I've got patients that have been it forever.
And when you bring up, you know, to the patient,
there are newer studies that are suggesting
it could be affecting your memory.
- Dementia, right?
- So dementia, I mean,
and some of those studies are conflicting too.
- Sure.
- So it's kind of tough and you put it,
I actually,
there's an interesting doctor that had talked
about a discussion that he had with a patient
to try and get her off of a one for sleeping medications
it was met with a lot of animosity
and it's tough because when we don't get our sleep,
I mean,
it's kind of like you're taking away your best friend.
- Yup. Yup.
- It's like, gosh, you can't take that away from me
because how am I gonna get rest?
- If I don't sleep well,
the day's not gonna go, well.
- Sure.
- It's just isn't.
- Yeah.
And it can ruin vacations.
- Yeah, it can ruin performance.
Let's say you have to be focused at work,
or just, I mean, even with your family, your friends,
- Yeah.
- social interactions.
I mean, you know, having proper sleep
fixes a lot of other instance
- Yes it does.
- I mean it's restorative,
It's helpful to your immune system.
I mean, there's so many things out there that, you know,
so it's critical to get that sleep.
But it's such a hard challenge, you know,
and that's why your doctor is so incredibly important
and trying to find the right mix for you to keep you safe.
- And then, well, you know
the end goal of trying to get off of them.
- Yup. Yeah.
- I mean it's a temporary fix.
- Right now,
and if you look at like you take Kaiser Permanente,
which is a West coast health system,
which is about 12 million members strong,
their optimum goal is to have anybody,
whether it's a benzodiazepine or specifically the Z drugs,
only two weeks of consistent use
before we want them to either taper or discontinue
going forward and then using intermittently for, you know
that occasional night where like,
"Oh, I had a crazy day and I just can't unwind."
You know, then it's very appropriate to use.
And within the three drugs,
whether it's Ambien, Lunesta, or Sonata,
which again would be
the zolpidem, the eszopiclone, or also the zaleplon,
in that order for the generic names, you know,
we want to make sure,
you know, the doctor's going to be very critical
in selecting, which one's the right one
for your particular situation.
Because, you know, with the Ambien
has an extended release formulation,
and Lunesta has a longer action.
So we have to be careful.
- Ambien has both forms, right?
- It has the regular strength,
but then it has a,
it's an interesting drug.
Yeah. It's pretty cool.
Yeah. It works for four hours
and then you get a burst four hours later
that keeps you to sleep.
So it's for people that actually can wake up.
And I mean, that's the problem is when people use drugs
we'll pick on Ambien right now,
Zolpidem when it's used on a regular basis,
over and over again,
actually loses effectiveness.
- Yeah. And that's what I found
because I was on Ambien and it worked fantastic for,
I mean, one half pill
- Yes.
- That's what I take, it took the hour.
- No, but I mean,
- But then it was to the point
where it will only work for three hours.
- Yep. Yeah. You develop a tolerance
to all these medications relatively quickly
and the Sonata or the zaleplon
is actually one of the more interesting
because it really only works for about an hour.
It's designed for people that just can't fall asleep.
- Can't get to sleep.
- And then actually,
within the dosing guidelines for the FDA,
and actually the manufacturer says,
if you wake up within four hours
and you have at least four hours more you have to sleep,
you can repeat that dose.
- Oh you can.
- It's so short acting, but it's interesting
that all these Z drugs can get this weird amnesia effects.
So when you take this drug
you want to go to bed right away.
That is absolutely critical.
- You don't want to feel it working.
I mean, you know,
I could not sleep and it put me to sleep.
- Absolutely. And you know,
the thing is is that it can put you into a hypnotic state.
And so basically where you can sleep-eat,
you can sleep-walk and going,
"Man, I want to go to the McDonald's
and get a shake" kind of thing.
And also in your sleep-driving
and you drove through somebody
- You call that ambient zombie or Z drug zombies.
- Z drug zombies, I mean,
there's a lot of different ways.
So it's a powerful, powerful drug.
And so when you take it, you need to go to bed, right away.
- Yeah. People were found binge-eating,
cleaning their house, driving a car, having sex.
- No, I mean, yeah, lots of strange things,
but also getting really weird things that show up
from Amazon the next day.
And you're like, Oh my gosh, like $10,000 blender.
I mean it's, and we can laugh about it.
And it is kind of funny, but it's not.
Because it's, you know, you can not fight these drugs.
They are very powerful.
- Roseanne Barr made that racist remarks.
She blamed on Ambien and the Ambien manufacturer.
- Oh they back tracked it.
- They said no, they said racism is not
a known side effect of Ambien.
- No, and today's society that's, you know,
- Yeah not an excuse.
- And that's why she was fired.
- Sure.
- And rightfully so.
- Yeah.
- Yeah. You know, I mean,
that's social exceptions,
I mean, that's, that's not there
but the drugs do have these very powerful effects.
We have to respect them.
We have to use them effectively.
So it's very, very critical for that.
- The thing I found out Chris,
is that, you know
as I started weaning off of it,
the fact that it was just there helping,
you know what I mean
I'm going to go to sleep and if I can't get to sleep,
it's I can just take this and that calmed me down
and it stopped my mind from spinning.
- Yup. Just knowing that it's there.
I think there's an aspect.
I mean, there's a psychological aspect to it
and there's a physical aspect to it.
And so all of these medications, again,
like I said the tolerance does develop,
you know, and I think a lot of times
when people fall on that like, and when you,
I mean I had a conversation with my patients yesterday.
I said, you know, you have
and she said, well, I've tried everything.
I've done the counseling.
And then, you know, so there's still millions and millions
upon Americans that these are a very requisite
and very appropriate and a portion of their lives.
And yes, we want people to use it as minimally as possible.
But sometimes there's just times where, you know
for whatever reason, brain chemistry,
psychological chemistry, history, I mean,
there's a lot of other things that are going on
underneath the surface that the doctor needs to get to.
And they work exclusive with the patient to ensure
that we're getting the best possible care
and try and keep them safe as possible.
But yeah, just have that psychological factor
that just knowing you can go to that.
- Yes.
- And sometimes people are like,
"Oh I can go three days and kind of wing it.
But yeah on that fourth day,
I'm going to have to take that medication."
And sometimes that's enough, you know
that's when we get you back in
we kind of get your reset and you're good to go.
Exercise, minimizing caffeine, sleep hygiene.
We put it all together in a complete package.
And then, hey, we got a better quality of life.
- This is a little bit on the side.
But with the ambient ER
obviously you can't cut that in half.
- No you cannot split that because what will happen,
you'll get a bolus dose,
your stomach acid is going to degrade that.
And it's going to basically launch
all that ambien into your system.
- How would that be if you only took half of it?
- You're just going to churn through it.
I mean, you're going to, you can take half the drug
but you're going to get all the drug
that's in that half tablet.
- Oh yeah sure.
- It's going to elute out into your system.
So you're not going to get that
because if it's a compression matrix tablet,
which is kind of interesting.
The manufacturer's quite genius when they did this.
And then basically they just found a way
to get it around your stomach acid, get it into your gut.
And then, so it's got two parts.
You have your immediate release
and then four hours later, boom,
it's absorbing again.
But it's absorbing in the intestines rather than, you know,
so, well they're actually all absorbed in the intestines
but the first round passes the stomach acid
that helps to get it going, gets in the intestines,
absorbs into your system and then makes you tired.
And it works within 20 minutes.
- So I tried the Lunesta too,
and that seemed to keep me asleep longer.
- Yup, and it does, it does.
- I mean that was eight hours.
- Yeah. And you have to give yourself,
especially that constantly point for pharmacist is, you know
you want eight hours and even realistically,
probably about 10 hours out of your system,
because if you're driving and all sudden
you get in a car accident and, you know
"I took my Lunesta last night."
Well, you know, that's an operating while intoxicated
- Yeah, you're at risk.
- So that's what he risk.
And so it's something that, you know
we have to be careful with that.
And as we age, that's another big risk
because unfortunately as we age,
our metabolism slow down,
drug stays in the system higher and longer.
So it's really,
- So as you age sleep becomes more difficult
for a lot of people.
- It does for a lot of different reasons.
And we talk about our sleep cycles.
You know, it's very important as we age.
I mean like a newborn in particular,
I mean they sleep 16 hours a day.
Maybe not, you know, five minutes,
If you are a new parent five minutes at a time,
but you know, and then,
- As a teenager, I could sleep 12 hours.
- Well, yeah, but you had a lot of growth changes going on.
- Yeah. Yeah. Yeah.
I mean, I think we all could.
And you know, but it's interesting.
Sleep cycles themselves by the time
a child is five years old,
it mimics an adult's,
it's just a longer period of time
in the four phases of sleep.
So it's kind of interesting when you look at it
from that response, but you know,
more importantly with respect to these medications
and you use the example of Ambien ER
and also your Lunesta.
You want to make sure that you've got
that eight hour gap minimum,
before you consider thinking about things
that require like work or business,
- Sure.
- Or driving, or you know, if you're going to do a workout,
I mean you could,
it could actually affect your coordination
- We were gonna mention this too Chris.
We were going to talk about
I actually had a fall and what had happened.
One, I didn't have lights on in the room so that down
but I got up and I'm in the middle of the night
and I was on Ambien and I was trying to get to the bathroom
and I'm like,
- Yup.
- I was tired.
- Oh yeah.
Well, no, it, it absolutely messes with you.
I mean, and from a coordination standpoint
and again, as we age that's why the importance
of these things is we have to be exceedingly careful
with the prescribing of them.
And it can,
you're a very coordinated person
- Yeah.
- And it took you for a loop.
I mean, as we age, or maybe some of our muscles
aren't firing the way we want it to
let's say we're 75 years old.
You take that fall, you hit your head on a counter.
You, I mean, you can break a hip.
- You could kill yourself I mean.
- I mean, it's that serious.
- There's downward slide after that.
- And so that's why we have to be cautious with that.
I mean, you know, and as we age again
we kind of touched on it.
We don't need as much sleep as we age,
but that's not to say that you still need sleep.
- Right.
- So it's very, very critical.
I mean, it's funny when you look at different species
I mean like a giraffe only sleeps 30 minutes a day,
which I thought was really kind of interesting.
- Well, it's funny
- But five minutes at a time.
- Humans are the only ones
that are not falling the sleep cycle of sunlight, you know,
I mean, because we can artificially create light
and so we can work at longer hours and
- Yup, exactly.
- A bad thing for humans actually
- Yeah. You know our shift work makes it very challenging
people that travel for a living.
Like you said, you had trouble in hotels.
So I mean, there's a lot of appropriate uses
for these Z drugs, but you know,
again you want to use it with a level of caution.
- Yeah. Well, sure.
Now what would you recommend as far as length of time?
- Well, the guidelines that are kind of being placed in
now, currently, they really say two weeks
of consecutive use and then to taper
and, or try and find another mechanism, you know.
And you want to, even when you're using the Z drugs,
still asleep hygiene it's gotta be a mainstay
- Yes. Yes.
- Of everything that we do.
I mean, it's getting actually adequate sunlight
during the day if we can, which, you know
if we work at a nine to five position, you know
we're in the Northern hemisphere for us here
sun's gone by the time we get out of work.
So it doesn't always work to our advantage.
So it may be, but if we can, you know
we'd like to get some outdoor activity
if it's all possible, even though it's cold.
Because daylight is important.
So hopefully there's a window
or something that we can at least get some of that.
But the reality of it is, is that you still
want to fall into that sleep hygiene pattern.
And so try and use it.
- I want to warn against,
and you,
I'm sure you'll back me up on this a hundred percent.
Taking a melatonin and if you keep taking it,
your body stops manufacturing it, am I correct?
- Yep. Yeah. Some of the studies suggest
that if we repeatedly take
the over the counter supplement melatonin
that it can actually shut down our natural system.
- Yeah.
- So basically when it gets dark out,
melatonin goes up, makes us tired.
When it's light out drops, we wake up.
I mean, that's our circadian rhythm.
So it's critical for our functioning.
And, you know we have so many people now
that work third shifts.
I mean, there's physicians, there's nurses,
there's manufacturers, there's just people
that are night owls.
But you know, it's still so critical for us to make sure
we get that adequate amount of sleep.
And so when you use these drugs longer than that,
I mean the studies actually show that if beyond two weeks,
you actually revert back
to the same sleep patterns you had pre drug.
So you really want to use it for a short period of time,
get your body caught up
so that you're functioning cognitively
and feeling well because sleep also affects
our immune systems, the way we feel, our behavior,
I mean, it's everything.
- Yes.
- So once we can get reset,
we want to try and rely on our own natural methods
to try and sleep.
And then for the occasional use or difficulty sleeping,
it's there for you.
- Yeah.
- But then again, there's some people,
I mean you've got PTSD, you've got,
I mean there's a lot of other things out there
and there's multiple other medications
that doctors will certainly try and or encourage,
but sometimes it just doesn't work that way.
- Yeah. And I mean, you might be someone
that's having difficulty with pain
- Yup.
- and having trouble sleeping because of that.
I mean, there's this
- There are multitude of reasons why doctors
have people on these things long-term
- Sure.
- So the guidelines are one thing.
But you know, each situation is individual.
So I mean, we've got what 340 million Americans.
So there's, you know, we'll call 70 million Americans
that have each individual different sleep issues
on a given day.
And so we have to treat them each as individuals
and what's best, you know,
what works well for Bob might not work well for Chris,
may not work well for Liz, may not work well for Mike.
So, I mean, it just kind of depends on the person
and what we can do to try and keep ourselves going forward
in the most healthy way possible.
- Well, I'm really happy that I'm completely off it now.
And, you only get by on what far is asleep.
- I've got problems but
(Chris laughing)
- All right.
Thanks everybody for listening and watching
and check us out on all our channels.
- Thanks everyone.
- Yep.