World Benzodiazepine Awareness Day: Sleep apnea and anxiety drugs do not mix

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July 11 is the second annual observation of World Benzodiazepine Awareness Day (W-BAD), and for good reason. Use of this category of medications has increased dramatically over the last few years. With use, problems of addiction and unpleasant side effects have increased as well.

(Learn more about benzodiazepine use by watching this video, produced by W-BAD, here.)

The founders of W-BAD seek to “raise global awareness about the severe problem of medical-induced benzodiazepine drug dependency that continues to affect millions of unsuspecting, innocent people worldwide—either directly or indirectly.” Their mission? To focus on the problem of ordinary, everyday people being harmed by these drugs as a result of taking them ‘as prescribed’ (exactly as directed by their prescriber)—usually for stress, anxiety, sleep, etc.”

What’s wrong with this picture? The W-BAD asserts that “despite recommendations and warnings, doctors and other health care providers often prescribe these drugs repeatedly for prolonged periods without giving proper informed consent regarding the risks or appropriate advice on withdrawal protocols.”

What are benzodiazepines?

These comprise a class of drugs that may be designated as anxiolytics, hypnotics or anticonvulsants, though the way they affect the human body are virtually the same, regardless of the intent of the application. Here are the types of benzos you might be taking (or have taken in the past):

  • Ativan (lorazepam)
  • Klonopin (clonazepam)
  • Valium (diazepam)
  • Xanax (alprazolam)

Benzos do the following:

  • Reduce anxiety. Anxiolytics target panic and anxiety disorders, phobias, and panic attacks
  • Promote sleep. Hypnotics target insomnia
  • Relax the muscles. Myorelaxants target muscle spasticity and related disorders
  • Prevent seizures. Anticonvulsants target epilepsy and fits caused by drug use
  • Impair memory. Amnestics are useful in pre-operative preparations and better known as “twilight sleep”

Benzo are psychotropic medications typically prescribed to help people manage their anxiety. These drugs calm the body and the mind. When used in the short term, benzos can be extremely helpful and effective.

It’s when they’re taken continuously over long periods of time that they become problematic for users. A similar problem exists for a related classification of medications known as Z class drugs.

What are Z class drugs?

These aren’t benzos, per se. Officially they are classified as nonbenzodiazepine hypnotics. They include the common sleep aids known as Ambien (zolpidem), Lunesta (eszoplicone), and Sonata (zaleplon); note the “Z” present in their generic names?

Z class drugs work as benzodiazepine receptor agonists. This means they work on the brain chemistry in much the same way as their benzo counterparts.

To be fair, Z class drugs are considered a better option for addressing insomnia. Their side effects are less severe and they’re not thought to be as habit forming. But this doesn’t mean they can be taken every night for long periods of time.

How do benzodiazepines influence sleep?

These types of drugs mimic the chemical behavior of a neurotransmitter in the brain called gamma-aminobutyric acid (GABA). GABA is a naturally occurring substance in the brain which helps to induce sleepiness.

The difference between these two classes of hypnotic drugs has more to do with where they act on the brain. Benzos act on gamma-aminobutyric acid (GABA-A) receptors which induce sleepiness and have a relaxing affect. Z class hypnotics more specifically bind with other agents in a way that improves sleepiness, but which is not as useful for treating anxiety.

Are you taking benzodiazepine medications?

If so, you need to be aware that they aren’t meant to be taken over the long term. Even when a physician tells you to take them “as prescribed,” this does not mean they are safe to take for weeks, months, or years in a row. You should also be aware that if you have a sleep-breathing disorder, use of these drugs amplifies the risks of dangerous side effects.

A frequently cited study by Dr. Christian Guilleminault in 1990 (Journal of American Medicine) points out that these sedative hypnotic drugs adversely affect your brain’s ability to control and regulate breathing as you sleep. If you already have sleep apnea, this practically guarantees the severity of your disorder will worsen. Using benzos or Z class drugs to achieve sleep can be especially harmful to people with comorbid conditions like chronic obstructive pulmonary disease (COPD) or heart disease.

Benzos are associated with poor tone in the muscles of the upper airway, even in people without sleep breathing disorders. This can lead to troubling problems in which the brain doesn’t respond quickly enough to imbalances of oxygen and carbon dioxide in the bloodstream. (This is called the arousal threshold. For people using benzos or Z class drugs to fall asleep, it can be significantly delayed.) For those with sleep apnea, this means they are going to experience more and longer respiratory events.

What’s more, if you are mostly a heavy snorer, you’re far more likely to develop a full-blown case of obstructive sleep apnea (OSA) by using these medications to help you fall asleep.

Twenty years after the Guilleminault study was published, researchers took a closer look at the links between insomnia and sleep apnea, and some of their studies focused on benzodiazepine use.

What about Z class drugs?

They noted the problematic side effects of using benzos, such as habituation, dependency, rebound effects, and withdrawal, as well as their tendency to prolong apneas. However, the Z class drugs were shown to have little or no effect on breathing. They also have fewer side effects and drug interactions than benzos.

This might make a good argument for moving from a benzo to a Z class drug if insomnia and sleep apnea are dual conditions in a patient.

However, research just a few years later has shown that a compelling number of patients with treatment-resistant insomnia (around 90 percent!) actually suffered from untreated obstructive sleep apnea.

In addition, other studies have also shown that using sleep aids, even in those people who do not have obstructive sleep apnea, yields a higher likelihood of experiencing DIA, or drug-induced apnea, a condition of central sleep apnea caused by the depression of the respiratory system during sleep. This, too, was a development of long-term benzodiazepine use, and not as likely to happen if one is using a Z class drug.

Regardless, Z class drugs have problematic side effects even if they are safer to use to treat insomnia. People who use Ambien on a nightly basis will struggle with anxiety, confusion, depression, dizziness, excessive daytime drowsiness, hallucinations, nightmares, even suicidal thoughts.

Alternatives to sleeping pills

For those with OSA who struggle to get quality sleep: The latest research shows cognitive behavioral therapy (CBT) and CBT-i (an insomnia-specific application) to be better long-term treatments for addressing sleep problems like insomnia. For people with OSA, this might be a better option than taking both a pill and using PAP therapy.

If you are concerned about sleeping pill use, you can ask your doctor for local options for receiving therapy. Note that sudden discontinued use of any of these drugs can lead to significant withdrawal effects; if you want to quit using a benzo or Z class drug, please do so under the advisement of a healthcare professional. Be prepared for the transition to take a few weeks.