So, on a particularly fallow night, with nothing better to do, I am alone with the word “insomnia,” which flirts shamelessly. It wants me to take it out for a Google, and I relent, finally, at 3am. On this night, I ran across a scare article about the dangers of (OMG!)
Ambien addiction. Ambien is the original brand name of a fairly commonly prescribed sleeping pill called zolpidem tartrate, usually referred to as just “zolpidem,” but sometimes called by the brand name “Ambien” as well, even to refer to the generic drug.
Zolpidem was designed to be a less addictive version of barbiturates (eg, phenobarbital) and sedative-hypnotics (eg, benzodiazepines such as Valium/diazepam, and Restoril/temazepam), with fewer side effects. With zolpidem, it was hoped, people needing insomnia medications would not experience morning hangover, and the problem of addiction to sleeping pills would go away.
I’ve never taken barbiturates, and I’ve never been addicted to anything, but I’ve taken several things in the diazepam and temazepam families, and can attest to the nature and number of side effects those drugs bring. They are burdensome, and difficult to manage.
Ambien first entered the market in 1992. That last bit is important. It was nearly 30 years ago. There are people able to prescribe this drug today, who were not even born when the drug entered the market. Bear this in mind. That is only five years after Prozac was rolled out, and four years before Detrol gave the world “Overactive bladder syndrome.” Keytruda, considered a fairly standard first-line cancer drug now, has been around only since 2014.
In 1992, practically everything else a doctor could prescribe for insomnia was either a daily pill for some other condition which had somnolence as a side effect (seizure drugs, or antipsychotic drugs mainly), and other side effects as well, such as weight gain; or a HIGHLY addictive drug from the classes of barbiturates, or benzodiazepines (sedatives/hypnotics), none of which was intended to be used long term.
The latter drugs are sometimes described as “dangerously” addictive, because it is possible to become addicted to them even when taking them exactly as directed. This is something else that should be borne in mind when considering the relative “evils” of zolpidem.
Now, practically any drug will lead to bad outcomes if abused. Even taking high doses of vitamin C can lead to a sort of addiction, which is to say, that going “cold turkey” off high doses of vitamin C, even while still getting the USRDA, can lead to something called “reverse scurvy.” Basically, you can get scurvy symptoms in spite of getting adequate vitamin C, because your body has become accustomed to eliminating most of your intake. If you want to kick a vitamin C habit, better to taper off. There are risks to high doses of vitamin C, including iron poisoning, and kidney stones, so good reasons to kick it, too.
You can actually overdose on several vitamins, and a number of OTC cold remedies, as well as acetaminophen (Tylenol). But you can take them as directed indefinitely without any problem, provided your general health is good.
Anyway, Ambien, zolpidem. It works by binding to GABAA receptors, which are the same receptors used by benzodiazepines. Therefore, zolpidem works in a similar manner to Valium; however, the big difference is that, because zolpidem has been “tweaked” in the lab, its half-life is only about 3 hours. The half-life of Xanax (alprazolam) is 11-12 hours; Valium (diazepam) is about 40 hours, and Klonopin (clonazepam) is over 30 hours. This is why Xanax is good for panic attacks, and Valium and Klonopin are excellent for suppressing seizures, but prescribed as sleeping pills, they are addictive even when taken as directed. Someone taking one tablet of Valium every night takes tonight’s dose before last night’s has cleared their system. This also explains why zolpidem is much less likely to result in a morning fog.
It may seem counter-intuitive, but zolpidem is also more effective as a PRN than drugs with a long half-life. Trying to go to sleep the second night after taking a dose of Valium often does not work, and the reasons are complicated. The medication has not reached its first half-life mark, but that is actually what makes it problematic—the insomniac taking Valium learns to function the day after a dose, when the medication is still active in their system, instead of having passed through two or three half-lives, as zolpidem will have by the time they start their day.
Having learned to function all day with Valium in their system, the insomniac finds it becomes less effective as a sleep medication.
In addition, there is the psychological effect of taking a pill, and then feeling sleepy. This is part of the same phenomenon that gives us the placebo response, and the reason that in placebo-controlled drug trials, the placebo must look, and be administered, EXACTLY as the active drug.
Zolpidem, meanwhile, has gone through three half-lives in nine hours. Someone who takes it at 10pm has less than an effective dose by 7am the next morning, and a clear system by 10pm the next night.
To help prevent withdrawal, your doctor may lower your dose slowly. Withdrawal is more likely if you have used zolpidem for a long time or in high doses. Tell your doctor or pharmacist right away if you have withdrawal.
The article glosses over the fact that “high doses” means “not as prescribed.” It then continues to chronicle the woes of the zolpidem mire:
Abuse, Addiction, and Withdrawal
[R]esearch has shown that Ambien can produce tolerance, dependency, and withdrawal…. One of the most serious side effects [is] needing Ambien in order to feel comfortable and function normally [when awake].
Averting our eyes from the misuse of the term “side effects” for the moment, we can note that at least it is acknowledged that “If Ambien is taken according to a doctor’s orders and used on a short-term basis, chemical dependency and addiction are unlikely to develop.”
And that it is
Recreational users [who] often take Ambien in unsafe ways, such as crushing the drug into a powder and mixing it with alcoholic beverages or snorting it. Taking Ambien this way significantly increases the risk of over-sedation, overdose, and addiction.
We are introduced to a case study of a zolpidem abuser who took “excessively high doses,” and “discontinued [it] too quickly.” She experienced vaguely described “severe withdrawal symptoms,” which, after mentioning, the article goes on to say that
“Additional withdrawal symptoms may include:
- “Muscle cramps”
Without averring that “the woman” previously mentioned had experienced any of them, and yet the final effect is to link the list of symptoms with a real-life case.
We get to read a bit about burgeoning treatment centers for people addicted to prescription drugs, then the article allows that “[zolpidem] helps many people”; nonetheless, “this medication may sometimes cause addiction,” and suggests that one, “take this medication exactly as prescribed to lower the risk of addiction. Ask your doctor or pharmacist for more details.”
We are treated to another bullet list of side effects:
- Depression and/or suicidal thoughts
- Emotional blunting
- Impaired vision
- Disorientation Loss of appetite
- Inability to concentrate
- Memory loss
- Allergic reaction
- Muscle Cramps
- Rapid heartbeat
- Slow breathing rates
And told that “Finding a medication that provides satisfying sleep without serious side effects can be challenging.” Gee, really? That’s how I ended up with zolpidem in the first place.
Still, we are informed, “Some users have had a life-threatening allergic reaction to zolpidem.” Yeah. Some users have that reaction to penicillin. Some people have it to their high blood pressure medication—lisinopril is notorious for doing this to people even after they have taken it safely for more than a year. Heck, some people react this way to eggs or peanuts. I once met a guy allergic to cucumbers, which are 95% water. This isn’t really a strike against zolpidem, as far as I’m concerned, as much as an acknowledgement that no matter what it is, somewhere, someone is allergic to it.
What follows is a plug for a treatment center.
Then, “Cognitive Impairment.”
I’ll give them this. I’m cognitively impaired any time I’m asleep.
Sleepwalking and Other Activities
After taking Ambien before going to sleep, some individuals have experienced episodes of sleep walking and other unconscious behaviors. These activities include eating, driving, having sex, and holding conversations with other people. In these reported cases, the individuals were unaware of these activities while they were occurring.
For some users, sleep behaviors can be corrected by reducing the dose of Ambien, but in extreme cases, the drug may have to be discontinued in order to prevent the behavior.
I’m not skeptical of these things. I’m sure they have happened, just as I’m sure people have misused the medication, and developed dependency on it—I don’t know whether it’s the same kind of dependency that people can develop on alcohol or heroin, where sudden withdrawal can be deadly (and incidentally, during which, Valium is often used to prevent seizures), but I’m sure that withdrawal can be unpleasant for some people.
However, the insert that comes with every zolpidem prescription, whether you ask for it or not, warns you that the medication should not be taken by people with any of the following conditions: obstructive sleep apnea, myasthenia gravis, severe liver disease, respiratory depression, psychotic illnesses; nor by children. It should also not be taken by people who have a history of addiction to anything. The insert further says not to take the medication with alcohol.
I do not believe that never has anyone read the warnings and dismissed them. I don’t think that people who had problems with zolpidem were somehow failed by the cautionary system. I was made hyper-aware of them; in order for my doctor to agree to write me a prescription for the medication to begin with, I had to sign a piece of paper stating that I would not drink alcohol, nor use any illegal drug as long as I was taking zolpidem.
I’m sure a lot of problems blamed on the nature of zolpidem actually come from ignoring these warnings. It’s a little like blaming drunk driving on the nature of the automobile.
WebMD has an article on using zolpidem that is taken pretty much verbatim from the paper you get from the pharmacy: How to use Ambien. Especially relevant are the following passages: “Since zolpidem works quickly, take it right before you get into bed,” and “Do not take a dose of this drug unless you have time for a full night’s sleep of at least 7 to 8 hours.”
From How to use Ambien:
Do not take a dose of this drug unless you have time for a full night’s sleep of at least 7 to 8 hours. If you have to wake up before that, you may have some memory loss, https://www.webmd.com/brain/memory-loss and may have trouble safely doing any activity that requires alertness, such as driving or operating machinery.
That part about going right to bed is important. Zolpidem works fast. It works so fast, that I take it in bed. I don’t even want to walk from the kitchen into the bedroom, and climb up into the loft after taking it.
For the record, I have had prescriptions for zolpidem for more than 15 years. I take it as a PRN, which means I don’t take it every night. I take it only if I don’t fall asleep after 30 minutes, and then, I take 5mg, not the maximum dose of 10mg. I took it for several years, then didn’t take it for three years because I was pregnant, and breastfeeding. I didn’t experience any of the symptoms of withdrawal (didn’t get a lot of sleep, though, except in my third trimester, when I was exhausted all the time). I may take it several days in a row, then not take it for more than a week.
I take it as directed. I never take more than 10mg, and usually less. I don’t drink. I don’t take drugs that are not prescribed for me, with the exception of OTC pain medications (Tylenol, mostly).
I have had a few people accuse me of being addicted to it simply due to my long term use, but I don’t think they have a good handle on the meaning of addiction. Given any block of days, I am likely to have taken it for fewer than 50% of them. If that is addiction, then I’m also addicted to Tylenol, multivitamins, sumatriptan, and the several prescription medications I have been taking daily for years. Also, during allergy season, I’m addicted to Claritin.
There is an expression in the army: “One guy shits his pants; everyone wears a diaper.”
I am sure some people misuse zolpidem. I am also sure that some people misuse laxatives, coffee, Benadryl, and Snickers bars. I don’t see scare articles about those implying that there is no good use at all for those things. I also don’t see clinics dedicated to recovery from misuse of any of those things.
I don’t think that a recovery clinic for prescription drugs is inherently bad any more than zolpidem is inherently bad; however, a recovery clinic sponsoring scare articles to drum up business makes me grumpy. If the article were less mendacious, I might be able to let it go, but this one vilifies a medication that makes my life very much easier. For profit.
 CAVEAT: This is a general statement to make a point. I am not a doctor, and if I were, I would not give strangers advice over the internet. If you have been needing pain medication, or cold symptom relievers for longer than the label indicates is ideal, follow the printed advice, which is usually to see an actual doctor after a particular (short) period of using the product, typically about two weeks.
Which is to say, not insomniacs. [note added]