Z drugs keep sleep-aid market awake

By Leslie Tamura
Washington Post Staff Writer
Tuesday, February 15, 2011; 12:17 AM

With almost a third of Americans reporting sleep problems, it's not surprising that sales of Ambien, Sonata and similar sleep aids are high: It's a $1.8 billion market.

Pharmacists filled close to 48 million prescriptions for such non-benzodiazepines - or "Z drugs," so nicknamed because most of their chemical names start with the letter Z - in 2009, according to health-care research company IMS Health. That's more than twice as many as were filled in 2002.

"Everyone is looking for something to help them sleep," said Lawrence Epstein, an instructor at Harvard Medical School and medical director of Sleep HealthCenters, a network of medical centers and clinics for people with sleep disorders.

Z drugs - Ambien was the first to reach the U.S. market, in 1992 - are less likely to cause dependency and side effects than the older generation of benzodiazepines such as Ativan and Dalmane. Both classes of drugs activate the neurotransmitter that induces sleep, the gamma-aminobutyric acid (GABA) receptor complex.

But the benzodiazepines also relax muscles and reduce anxiety - effects that can be beneficial but have the potential to cause respiratory failure and other muscle-related problems. And they often left users feeling drowsy for hours after awakening.

Z drugs are more targeted; designed to activate a specific part of the GABA complex, they get you to sleep with fewer concerns about dependency and side effects.

Analysts expect patients to use more prescription sleep aids as generic versions of Z drugs continue to emerge.

A generic, less expensive form of Ambien (zolpidem tartrate) went on the market in 2005 and instantly "became a 'best-buy' drug from a safety, effectiveness and affordability point of view," said Jon Schommer, a professor at the University of Minnesota's College of Pharmacy in Minneapolis. In October 2010, a generic version of Ambien CR was introduced. Generic Lunesta is expected to hit the market next year.

Most Z drugs get you to sleep in less than an hour, according to the 2008 Consumer Reports Best Buy Drugs analysis, and their effects last at least four hours. Market leaders Ambien, Ambien CR and Lunesta can sustain sleep as long as six to eight hours. Epstein said both new and old classes of sleep aids add only 20 to 30 minutes to a night's sleep, on average, but even that amount makes most people feel more rested.

If you take one of these aids, doctors recommend you go to bed immediately and allow enough time to rest. After actor John Stamos appeared to be drunk on an Australian talk show in June 2007, he said he had taken a morning dose of Ambien to help with his jet lag.

"Now I know that Ambien is an eight-hour sleeping pill, so if you take it, you better get eight hours' sleep," Stamos told TV Guide.

The Food and Drug Administration has approved Ambien and Sonata for short-term treatment of insomnia, up to five weeks. Lunesta and Ambien CR are approved for long-term use, up to six months.

None of the Z drugs have been studied or FDA-approved for use longer than six months.

Sleep medications "are best used for a short-term intervention [for patients] where you can break their cycle, reset their sleep pattern and get them back on a more appropriate schedule," Epstein said.

With short-term use under the direction of a clinician, sleep aids should not cause big problems, Epstein said, but dependency and withdrawal effects remain concerns.

When patients stop taking sleeping pills, doctors say, they should do so gradually because they could experience "rebound insomnia," where their sleep problems get worse than they were before.

And patients should be aware that the most effective tactic is to attack whatever physical or emotional problems are causing sleeplessness.

"Sleeping pills are not going to cure you," said Charles Cutler, an internist in Norristown, Pa. "It's not like a shot of penicillin and you move on with your life."

"The overwhelming percent of patients with sleep disturbances have emotional concerns that are bothering them and keeping them awake," Cutler said. "There may be other things going on in your life that we have to fix."

Cutler says he feels comfortable prescribing sleep aids only when he has talked with patients about a variety of possible causes for their insomnia: an old mattress, watching television before sleep, sleep apnea, weight gain, financial strain, relationship problems, etc.

"We live in a society where people want sort of quick answers and quick solutions to sometimes complicated problems," Cutler said. "Sleeping pills are a short-term Band-Aid."

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