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Posted on 6-2-08 Pillows, Pills And... Profit
By Laura Barton and Charlie Brooker, The Guardian, February 5 2008
"Last week, I probably slept an average of two hours a night," he said. "I
couldn't stop thinking. My body was exhausted and my mind was still
going." One night, he took an Ambien sleeping pill, which didn't work. He
took a second one and fell into a stupor, only to wake up an hour later,
his mind still racing.
>From Heath Ledger's final interview, the New York Times
The days following Heath Ledger's death have swirled with speculation,
with tales of hard drugs and prescription pills, of anti-depressants and
sleeping tablets. Amid all the mutterings about heroin abuse and cocaine
addiction, it is the sleeping pills that seem most startling. Ledger,
plagued by the chronic insomnia that often accompanies depression, had
apparently come to rely on medication to get him to sleep. "I warned him
to stop," said Jack Nicholson. "I tell people about Ambien. Somebody said,
'Take this, it's mild.' I almost drove off a cliff 50 yards from my
house."
Ambien is now America's leading sleeping tablet. In 2005 alone 26.5m
Ambien prescriptions were written in the US. Available only on
prescription, it is none the less advertised on television and in
magazines. Introduced in 1993 by the medical corporation Sanofi-Aventis,
the tablet's active ingredient is Zolpidem, which decreases the time taken
to fall asleep and increases the length of time spent sleeping. It is not
without controversy: an increasing number of traffic arrests have revealed
Ambien to be a factor in impaired driving, prompting a number of lawsuits.
In the UK, where it is known as Stilnoct, it is suspected in six fatal
adverse drug reactions since 2002, according to the Medicines and
Healthcare Products Regulatory Agency (MHRA). However, these cases have
had little effect on sales. Yet Ambien and Stilnoct are just the tip of
the iceberg - upon our sleeplessness an entire industry rests.
In 2006, Forbes magazine ran an article about what it termed "the sleep
racket", the $20bn industry that has bloomed around our pursuit of the
perfect night's sleep: money spent on herbal balms, mattresses, sleep
clinics and, oh yes, sleeping tablets. Consider this: between 2000 and
2005, the US experienced a 60% increase in sleeping pill use (in the year
to September 2005 alone, sales of prescription sleeping pills grew by
27%), a fact largely attributable to the aggressive marketing campaigns
for drugs such as Lunesta, a prescription sleep aid manufactured by
Sepracor Inc. Sepracor's spending on advertising Lunesta over the drug's
first 11 months was $270m, exceeding the previous one-year record for
advertising of any drug. In 2006, the sleep-aid industry as a whole spent
$600m on advertising - a huge outlay, but not when one considers that
sales of Lunesta and Ambien topped $3bn.
The American sleep boom has yet to fully flourish on these shores, though
many view it as inevitable. Already the signs are there: in the last year,
Boots' sales of over-the-counter sleep aids have increased by 18%, 4,000
people called the insomnia helpline, and an increasing number of people
are visiting their GPs to complain of sleeping difficulties. According to
the Sleep Council, which represents the bed-and-mattress industry,
two-thirds of people say they get less sleep now than they did a few years
ago - around 90 minutes less, according to one leading American sleep
expert. "You probably have a generation that is quite sleep disturbed,"
says Kathleen McGrath, medical director of the Medical Advisory Service.
"I think we are looking at a time bomb."
Though medical science still knows very little about what happens when we
sleep, this lack of understanding has not prevented us from trying to
control it. For centuries we associated sleep, the night, and the dreams
it brought with gremlins and monsters, and even today it seems we still
regard sleep as a beast we wish to subdue. We buy earplugs, valerian
tincture, and how-to-sleep books. We put our faith in things named Pillow
Pearls, and tablets made of passiflora and wild lettuce. In 2006, the
hotel chain Travelodge appointed a director of sleep, who unveiled a
programme of blackout curtains, feng shui and goldfish.
Meanwhile, the science of mattresses grows ever more advanced. The
Silentnight Group, which is the leading bed manufacturer in the UK, sells
a bed approximately every 90 seconds, an increasing number of which are
made of memory foam, a dense, polyurethane material that adjusts to your
body shape and temperature. But we also have pocket spring, open spring,
latex, foam and gel, micro-quilted top layers "which cover the tufting for
a soft, bump-free finish", mattress toppers, pads and protectors. We sleep
under duck feathers, goose down and microfibre, and have shiatsu massaging
pillows, siliconised cluster fibre quilted pillows and spiral hollow fibre
jacquard pillows. Yet we are still driven to seek out advice from our GPs
about snoring, sleep apnoea, restless leg syndrome and, most commonly,
insomnia.
The record for staying awake is 264 hours (11 days), and was set in 1965
by Randy Gardner, a 17-year-old American high-school pupil. After four
days he began hallucinating, and believed he was a famous footballer.
Staying awake was at one time seen as an impressive test of human
endurance. Even in the 1980s, forgoing sleep was seen as a badge of honour
- Margaret Thatcher, of course, famously only slept for five hours a
night. These days, we place more value on sleep. "Twenty years ago,
research claimed that we could cut down the eight hours' sleep to five
hours, as three of those hours are spent in 'light' sleep," says Mark
Balgrove, senior lecturer in psychology at Swansea University. "But now we
realise that even cutting down by half an hour habitually can cause
problems."
Insomnia affects 5% of the population at any time, and 10% will experience
it at some point in their lives. Short-term, or transient, insomnia
generally occurs as a result of a change in circumstances - jetlag, say,
or a period of stress during examinations or bereavement, and lasts
anywhere from a few days to a few weeks. Long-term insomnia is an
inability to obtain adequate sleep that lasts for more than a month, and
can continue for years. Symptoms may include having trouble falling
asleep, staying asleep or waking up too early in the morning feeling
unrefreshed. It leaves sufferers feeling exhausted, irritable and unable
to concentrate on simple tasks. Nobody knows what causes it. "Some people
are just predisposed to insomnia, much as we talk about people with high
or low pain thresholds," says Kevin Morgan, an insomnia expert at
Loughborough University. "By and large, older people are more prone to
insomnia than younger people, as are women and people with high levels of
anxiety. But it's important to note that insomnia really means poor
daytime performance as a result of no sleep when there is opportunity to
sleep."
Some blame modern sleeplessness on the invention of the electric lightbulb
- the fact that our days are no longer dictated by the rising and setting
of the sun, that our stretches of darkness are now lit by the glare of the
streetlight and the neon sign. Others blame our increasingly sedentary
lifestyles: "People now are not physically tired but mentally tired," says
McGrath. Or the fact that, unlike in decades past, television and radio
stations now run all night. "Some people's bedrooms look like the Starship
Enterprise," she says. "Your bedroom is for two things: for sleep and for
sex, not necessarily in that order."
Morgan is more sceptical: "I don't subscribe to the idea that we live in
an increasingly sleep-hostile environment," he says. "All you've got to do
is read Engels' account of children sleeping in factories, or hear of
agricultural workers in years gone by to see that. The electric light
thing is interesting, but we tend not to build a world that's fully at
odds with our biological heritage. Whether you look at the steps of a
council flat or of a Roman temple, their height tends not to be beyond the
extension of our stride."
Our peculiar relationship with sleep is, Morgan suggests, "an extension of
our rather strange attitudes to our bodies. We've lost touch with our
bodies. Living the right kind of life has become the target of the 21st
century, and there are three principal pillars for health: diet, exercise
and sleep. Most people know about nutrition and calories and they have
cardio-vascular plans, but most people know nothing about sleep."
Surprisingly, lack of sleep knowledge can also extend to the medical
profession. "What many people don't realise is that GPs aren't
specifically trained to deal with sleep disorders," says McGrath. "They
probably spend less than five hours of training on managing sleep
disorders." The current medical solution to sleep problems is arguably
over-reliant on medication. "Sleep problems happen over time, so assessing
them takes time," says Morgan. "History-taking is probably the weakest
part of diagnosis: it means engaging with a patient - you have to 'unpack'
the patients."
Few GPs, Morgan suggests, are able to devote the time to history-taking
and finding out what lies behind the insomnia. "Clinical medicine operates
from a position of ownership," he says with exasperation. "Obstetrics own
childbirth, dermatologists own your skin ... But nobody owns insomnia. So
there is no clear conceptualisation. So drugs have become ascendent, and
the focus of everyone's attention."
Most sleeping tablets are, like Ambien, prescribed, and the volume
prescribed in the UK has remained about the same for 30 years. They work
by blocking the formation of memories. "They give you amnesia for the
period just before you fall asleep," explains Balgrove. This works because
insomniacs often overestimate how long it has taken them to get to sleep,
as well as underestimating how long they have slept. So while a study
conducted last year by the American National Institutes of Health found
that prescribed sleeping pills only grant an extra 12.8 minutes of sleep,
patients felt they had actually had an extra 32 minutes of sleep; the
amnesiac effect of the pills meant that they had forgotten the period in
which they struggled to fall asleep.
"Sleeping tablets started in two phases," Morgan says. "The first were
barbiturates, introduced in the 1940s and 50s. They worked extremely well
and became immense hits in the western world, but their addiction
potential was phenomenal and the dividing line between a toxic dose and
therapeutic dose was very fine." He cites the deaths of Tony Hancock and
Judy Garland as examples. "But they stimulated a need in the population to
ask for sleeping tablets. Around 1962 there was the invention of
benzodiazepines. They were remarkable drugs. They still are. They put
people to sleep, but they don't damage people. You could take a full
bottle, and you'd wake up two days later." However, overdose is possible
when taken in large quantities with other drugs, especially alcohol or
other central nervous system depressants.
Mogadon, one of the best known of the benzodiazepines, was introduced in
the mid-60s, created by Leo Sternbach, the inventor of Valium. By 1970
there were 30m benzodiazepine prescriptions a year. "Then society realised
it had a problem on its hands," notes Morgan. "Everybody got animated
about what they called tranquillisers and so benzodiazepine prescriptions
have been falling for 20 years, to something like five and a half million
today. But it tells you a lot about insomnia: those prescriptions for
benzodiazepines as tranquillisers fell, but benzodiazepine prescribed as
sleeping tablets only fell a little. The underlying demand did not go
away."
The continued attraction is, of course, that they are a very successful
treatment for insomnia - in the short term. "They work by shutting off the
systems that keep you awake," Morgan explains. "They make you feel groggy
and stupid, they interfere with memory. But tolerance diminishes quickly.
After a month they aren't giving the same hit of sleep, and after three to
four months probably not giving any benefit. After a year, it's probably
doing more harm than good.
"The toxicity is very, very low. They won't poison you. But this isn't to
say they won't harm you. They are very addictive, they are drugs of
dependence, and if you take them for long enough you will be dependent -
there is evidence in abundance. The paradox is that after taking them for
a long time they will not help you sleep, they will cause withdrawal
symptoms, and one of the main withdrawal symptoms is insomnia."
For Morgan, the dominant role of sleeping pills is cause for concern. He
would rather see greater access to cognitive behavioural therapy (CBT) for
insomnia sufferers. "It doesn't cost more," he says. "The direct costs of
sleeping tablets are generic, so against five sessions of CBT, the
indirect costs are higher. Five hours of CBT can deliver benefits in more
than 70% of cases. It gives a better quality of sleep up to a year later
and they have been empowered to look after their own sleep. CBT is about
telling people how to think and behave in a way that promotes better
sleep."
He talks of the sleeping tablets poised to arrive from abroad: melatonin
and over-the-counter treatments such as Tylenol PM. "The solution is not
another sleeping tablet," Morgan says. "People with insomnia don't have
benzodiazapine or melatonin discrepancies. The biggest problem with
contemporary sleeping tablets is that they provide excellent, safe
treatment for short-term insomnia. But most insomnia isn't short-term."
What we need, he suggests, is to reclaim our sleep. "Sleeping positions
are important, mattresses are important, bedroom environments are
important. Once you are sold on the idea that elements of your sleep are
within your control you can address them. Thirty years of sleeping tablets
have created passivity, the idea that it is out of your control. The
notion of involving people in their own sleep management is important and
effective."
But involving people in their own sleep management first requires a myth
to be dispelled - the long-standing idea that we all need eight hours
sleep. "Eight just comes from the national average," says Balgrove. Though
there are some studies that suggest eight hours' sleeep is optimal for
health, the crucial factor is that sleep is a personal matter.
Sleep demand is hard-wired so that most of us know how much we need," says
Morgan. "This personal calibration is far more valuable than the cultural
assumption that people need eight hours' sleep. Eight hours is a piece of
mythical nonsense. The average sleep is seven hours, but it's not
meaningful. A new-born baby has on average 17 hours' sleep. A 10-year-old
takes 10 to 12 hours. As we get older, our sleep duration gets shorter.
It's normal, it's healthy; we have shorter, lighter, more fragmented
sleep." Or, in McGrath's words: "You should take that eight hours and
shove it into a cocked hat. It's irrelevant."
In fact the notion of a solid, eight-hour block of sleep is a relatively
modern western invention. "In the past, we slept in two stages, that were
divided by about an hour of lucid wakefulness," says Morgan. "The dividing
phase of the two-shift sleep was usually around 1am. Pepys's diary is full
of interesting stuff about this. That started to disintegrate around the
19th century and it got historically lost."
An experiment by the National Institute of Health in the US found that a
group of men following a schedule that echoed that of wintertime - 10
hours of light and 14 hours of darkness - would also naturally begin to
sleep in two approximately four-hour stretches, waking in between for one
to three hours and simply lying there calmly before sleeping again. The
ability to remain calm during these periods of wakefulness, to accept that
it is a natural part of sleep, may be important. In other cultures, waking
in the night is seen as considerably less disastrous - among the !Kung in
Botswana and the Efe in Zaire, for example, people begin to hum, play the
thumb piano or even dance at these times.
But it is in many people's interest for us not to know about the
eight-hour myth. It is in many people's interest for us not to know about
CBT as a treatment for insomnia. Because upon our anxieties, our
insecurities and our feelings of inadequacy, a multi-billion pound
industry is built. If there is one calming thought as we lie awake, as
sleep eludes us, as we contemplate therapies and tinctures and tablets, it
is this: perhaps we are trying to attain the unattainable. Perhaps sleep
is just the latest part of our lives to have fallen prey to big business.
The sleep we are shown is airbrushed sleep, and we will never feel
satisfied with what we have because we are striving for an ideal slumber
that simply does not exist. Just as we spend millions on plastic surgery
and fork out for luxury face creams in an attempt to obtain the perfect
skin of the photoshopped model, so now we pay for duvets, draughts and
drugs, chasing a quality of sleep we can never have.
A waking nightmare: Charlie Brooker on living with insomnia
I'm an adult. I have abilities. I can read (quite quickly), write
(passably), draw (cartoons) and take someone's head off with a sniper
rifle from over a kilometre away (in video games). I can ride bikes, solve
Sudokus, and whistle. In short,
I am Superman. Or I would be, if there wasn't one niggling skill that
eludes me. I can't get to sleep.
In theory, falling asleep is easy. You lie down, close your eyes and enter
shutdown mode. Simple. Simpler than using a pencil. Unless, like me, you
have a brain that finds it hard to shut up. During the day, you can
distract it with books and websites and conversations and so on. But at
night, in a dark, quiet room, there is no escape. While your body tries to
drift away, your brain fidgets restlessly in your skull, huffing like a
backseat child , kicking its shoes into your back every four seconds and
asking stupid questions. It fiddles with dark thoughts, breaking off now
and then to hum a theme tune. And it incessantly moans about the length of
the journey.
And after an hour of this, your body starts joining in. Suddenly, nothing
feels right. It's too hot. Or too cold. There's a cramp in your neck. So
you shift about, trying to find an optimum position of comfort. But there
is none. Lie on your side and your arm is in the way. Lie on your back and
your head wants to roll left or right.
As for lying on your stomach - only a psychopath would try that. You can't
breathe, for God's sake.
Before long, two hours have gone by, so you start worrying about how late
it is. Congratulations. Now you're doomed. Straining to lose
consciousness, aching to sleep, doomed. You worry about tomorrow. The more
important tomorrow is, the worse it gets. All those things to do, and
you're going to feel as if you've been beaten up.
Someone once told me that if you want to know how you're going to feel in
a decade's time, you should stay awake all night and go into work. It
simulates 10 years of ageing apparently. I've done it many times, and it's
always grim. There's a bad taste in your mouth and a despairing ache
behind your eyes. You feel clammy and anxious. Your clothes stick to you.
You look and feel like Pete Doherty wheezing over the finish line of an
888-mile fun run. Sometimes, a weird hysteria takes hold of you, and the
strangest things become amusing. I once laughed out loud at an LED sign on
the London Underground that said "NEXT TRAIN APPROACHING". For some reason
my sleep-deprived mind found it hilarious. It's temporary insanity.
Clearly, this is a situation to be avoided at all costs. So you lie in
bed, straining to sleep, alternating between despair and fury, until you
reach your cut-off point. Mine is 7am. By 6am, I've generally given up,
and I'm on the sofa staring mournfully at GMTV, resigned to staying awake,
but then 7am rolls round and I can't fight exhaustion any longer. And then
I'm a frozen corpse. I stay dead to the world through alarms and phone
calls, and on one occasion, a fire drill. Some time around 11am, I wake in
a frothing panic, late for everything, condemned to play catch-up for the
rest of the day.
All of which gives me more to worry about later. At night. When I'm trying
to sleep. The cycle continues. The bastard thing.
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