Chapter 5
Recommendations of Experts

In 1979, a distinguished committee of our national Institute of Medicine considered the risks and benefits of hypnotics. Noting concern with the side effects and risks of sleeping pills balanced by the lack of evidence for long-term benefit, this distinguished committee recommended that hypnotics generally be limited to short-term use.[51]  In 1983, a Consensus Conference held by the National Institutes of Health on the treatment of insomnia. This group recommended that sleeping pills be used mainly for up to three weeks, not longer.[52]  Another consensus conference was held in 1990 to discuss problems of sleep in aging. Complaints of insomnia are much more common among people above age 60 years, and 40-50% of all sleeping pills are taken in the U.S. by people over 60. This consensus group also recommended only short-term use of sleeping pills.[53]  A new committee of the Institute of Medicine concluded in 1997 that the data only supported use of Halcion for two weeks.[54]  In the summer of 2005, the National Institutes of Health had a consensus conference[55]  about insomnia, which emphasized how little we understand about chronic insomnia. This group of experts concluded that the evidence for behavioral therapy for chronic insomnia was better than evidence for long-term use of sleeping pills, though this group of experts failed to frankly condemn long-term sleeping pill use. In summary, there is expert consensus that the medical evidence does not support chronic use of sleeping pills.

A meta-analysis (combined analysis) of a large number of sleeping pill trials was published in the British Medical Journal, one of the most authoritative medical journals.[56]  This analysis, focusing on studies of people with insomnia over 60 years of age, concluded that long-term use of sleeping pills more often does harm than good. This conclusion was reached without considering risks of mortality and cancer, which further tip the likelihood towards harm. More recently, the American Geriatrics Society recommended that older patients avoid benzodiazepines or benzodiazepine-like sleeping pills in all situations.[57] To follow this recommendation would immediately eliminate about half of the sleeping pill prescriptions in America.

As mentioned, The American College of Physicians guidelines suggested that CBT-I always be tried before sleeping pills. The Guidelines expressed doubt that sleeping pills should ever be used, even short-term.[58]  Similarly, the European guideline for treatment of insomnia recommended that CBT-I be tried before hypnotics, and emphasized both the weakness of evidence for hypnotics benefits and the strong evidence for serious harm to physical and mental health.[59]

In conclusion, most experts without financial ties to the sleeping pill industry have reached the same conclusions as mine even before seeing our 2012 data about mortality and cancer. Since 2012, much more evidence about the risks of sleeping pills has accumulated. Drug companies have marketed an impression that sleeping pills are accepted by spending hundreds of millions of dollars promoting their drugs on TV and with direct marketing to doctors. Drug companies supply doctors with free lunches, trips to conferences in luxury hotels and large “speaking fees” once they have arrived to persuade doctors to listen to their propaganda. Despite all this, the opinion of the majority of experts without financial conflicts agrees with what you will read in this ebook.

Endnotes for Chapter 5

51. Institute of Medicine. Sleeping Pills, Insomnia, and Medical Practice. National Academy of Sciences, Washington, D.C., 1979. Full text available at the National Academies Press websiteLink to a website outside this eBook.[return]

52. Consensus Conference. Drugs and insomnia. The use of medications to promote sleep. JAMA. 1984;251(18):2410-2414. [return]

53. Monjan, A. A. Sleep disorders of older people: report of a consensus conference. Hospital and Community Psychiatry 41(7), 743-744. 1990. [return]

54. Committee on Halcion, Institute of Medicine. Halcion: An Independent Assessment of Safety and Efficacy Data.  National Academy of Sciences, Washington, D.C., 1997. PDF available for download from the National Academies Press websiteLink to a website outside this eBook[return]

55. NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults, NIH Consensus and State-of-the-Science Statements Volume 22, Number 2, June 13-15, 2005. NIH Office of the Director. Available as a PDF document at the National Institutes of Health’s website, to a website outside this eBook. [return]

56. Glass, J, Lanctot, KL, Herrmann, N, Sproule, BA, Busto, EU. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 2005;331:1169Link to a website outside this eBook. [return]

57. Fick, D. M. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society 63(11), 2227-2246. 2015. Link to a website outside this eBook. [return]

58. Wilt, T. J., MacDonald, R., Brasure, M. , Olson, C. M., Carlyle, M., Fuchs, E., Khawaja, I. S., Diem, S., Koffel, E., Ouellette, J., Butler, M., and Kane, R. L., Pharmacologic Treatment of Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern.Med 165(2), 103-112. 5-3-2016.Link to a website outside this eBook [return]

59. Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Dolenc, Groselj L., Ellis, J. G., Espie, C. A., Garcia-Borreguero, D., Gjerstad, M., Goncalves, M., Hertenstein, E., Jansson-Frojmark, M., Jennum, P. J., Leger, D., Nissen, C., Parrino, L., Paunio, T., Pevernagie, D., Verbraecken, J., Weess, H. G., Wichniak, A., Zavalko, I., Arnardottir, E. S., Deleanu, O. C., Strazisar, B., Zoetmulder, M., and Spiegelhalder, K. European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research 26(6), 675-700. 2017. Link to a website outside this eBook. [return]