Insomnia, Ambien and Personal Harm-Reduction

Gayle Greene’s Sunday Review piece defending sleeping pills shines some valuable nuance on the medicate/don’t medicate debate. Greene, who has long struggled with severe insomnia, writes that a new study claiming to find a link between sleeping pills and premature mortality doesn’t really pass methodological muster.

That said, she isn’t blind to the dangers of sleeping pills. But she is a realist:

These medications alter sleep cycles, so that the sleep they provide may not have the deep restorative benefits of natural sleep. They adversely affect memory and coordination, which can be bad news for the elderly, the group that takes them most. And you can develop a tolerance to them, causing you to take larger and larger doses to get the same effect. But the sleep they provide may make the difference between having a life or not.

Greene’s piece hits pretty close to home for me, because I’m currently on Ambien and have encountered firsthand all the thorny issues that come with it.

For as long as I can remember, I’ve been a terrible, terrible sleeper. I just can’t fall asleep; it takes me hours, usually. My brain is unable to turn off, and there are many occasions when I will be dead-tired at the end of the day, unable to think of anything but sleep, only to feel my brain starting to whir up from idle like an airliner’s engines the second I lay down. (That said, I should acknowledge that it sounds like Greene had a tougher time adapting to a constant lack of sleep than I did—I certainly had my fair share of zombiefied days, but never the difficulties she writes about.)

I resisted medication for a long time. But at some point last year, I realized that my chronic lack of sleep could be seriously screwing up my health in profound ways, so I reluctantly got a prescription for Ambien.

The stuff works for me. That’s not to say I wake up feeling as refreshed as I want to, or that I don’t still have nights when I’m tossing and turning, but on the average night I take an Ambien before I go to bed, I fall asleep quickly—something I just wasn’t capable of before I got my prescription.

Ambien has some serious, weird potential side effects, and dependency/tolerance are major issues as well. So it’s understandable, to a certain extent, that neither of the doctors who have prescribed me Ambien (one in Cambridge, where I used to live, and one at Princeton) have done so in a carte blanche manner—both encouraged me to make other, non-pharmacological attempts to improve my sleep, and my current prescription is contingent on regular appointments with a behavioral sleep specialist.

So I get that it’s not ideal to be be on Ambien. But at the same time, I haven’t experienced any side effects. It’s doing what it’s supposed to be doing. And yet every time I get a refill for a medication that really does improve my quality of life, I have to go through a process that makes me feel like a drug trafficker, I have to get lectured about how I shouldn’t be so reliant on this medication that I never really wanted to be on in the first place. At some point the medical professionals in my life may cut me off, whether or not I’ve made enough progress to cast the pills aside.

It’s frustrating. But what it comes down to is that we are rarely presented with ideal options. In the public-health world, “harm reduction” is a popular concept; it basically means, as the name implies, figuring out what will reduce harm in the real world, rather than evaluating policy through the prism of unattainable ideals. In a perfect world we could simply get everyone off heroin; in the real world, there are hardened, treatment-resistant heroin addicts, and from a harm-reduction standpoint it might actually make sense to simply give them heroin in a clinical setting.

I had to make a more personal, micro-level harm-reduction decision about Ambien. My choice wasn’t between insomnia and a drug that would fix everything at no cost; it was between insomnia and a drug that would greatly improve things, but one that I could become dependent on and which might lead me to one day sleep-drive to the store or wake up with a tattoo of Rick Santorum on my thigh. At the time, it was an easy choice—I was sick of not getting sleep.

I’m still happy with the choice and will continue to make it, assuming they let me. But there does seem to be a tacit assumption that Ambien is worse than non-Ambien, even for people who suffer no ill effects from it, and that’s why I constantly feel like I’m on the defensive about this, like I need to couch what has so far been a pharmacological success story in an endless series of explanations and justifications.

Jesse Singal

Jesse Singal is a former opinion writer for The Boston Globe and former web editor of the Washington Monthly. He is currently a master's student at Princeton's Woodrow Wilson School of Public and International Policy. Follow him on Twitter at @jessesingal.