#394 ‒ Sleep pharmacology: the role of medications in healthy sleep, the promise of emerging therapies, and the evidence for common sleep supplements

The biological foundations of sleep, the major drivers of sleep dysfunction, and the role sleep medications can play when appropriately matched to specific sleep problems [1:00]

• In this episode, Peter focuses on sleep pharmacology
• We’ve had plenty of previous episodes about sleep
  • We’ve talked about sleep biology, sleep hygiene, even cognitive behavioral therapy for insomnia (CBT-I), and even different sleep supplements
• But we’ve never done anything more than a skim of the surface on sleep medications
• The intention of this episode is to fill that obviously very important void

Sleep is a biological imperative 

• A pioneer of modern sleep research first put the problem this way, “If sleep does not serve an absolutely vital function, then it is the biggest mistake the evolutionary process has ever made.”
• When you’re asleep, you can’t protect yourself from predators, you can’t hunt, you can’t find a mate
  • You are, as the phrase goes, “Dead to the world.” 

Natural selection insisted that we do it anyway–every single night for our entire lives: that should tell you something 

Peter’s framework to think about sleep problems 

• Because most people (including most clinicians) don’t diagnose them correctly

Almost every sleep issue can be traced back to one or more of 4 things 

1 – Sleep pressure

• That build up of the drive to sleep the longer you’re awake

2 – Circadian timing

• Whether your internal clock is aligned with the light, dark cycle

3 – Hyperarousal

• A state where your brain is effectively holding the gas pedal down when you’re trying to sleep

4 – Sleep architecture

• The quality and structure of the sleep you’re actually getting

Every tool we’re going to talk about–behavioral, psychological, or pharmacological–works by acting on one or more of these 

• Most failures happen when you apply a perfectly good tool to the wrong problem
• Few organisms in their natural environment have trouble sleeping
• How did we get to a place where 36% of US adults fail to get the 7 hours of sleep that most people need each day for optimal health and functioning?
  • Where more than half of adults report difficulty sleeping and over 22% actually meet diagnostic criteria for insomnia 

The answer is that we’ve engineered an environment that disrupts all 4 of those systems at the same time 

Our sleep is regulated by 2 processes that were sculpted by over half a billion years of evolutionary experience 

1 – Process S: the accumulation of pressure to sleep

• This is a homeostatic process where sleep pressure builds as a result of brain activity
  • Though the mechanism for this sleep pressure has not been identified
• The longer you’re awake, the more it builds, until eventually it overwhelms you and your sleep
• Think of it like a battery that discharges while you’re awake and recharges during sleep 

2 – Process C: the circadian process

• This is your internal clock anchored to the light dark cycle, coordinated by melatonin at night and cortisol in the morning
• It’s not just one clock–it’s a central clock in the brain with hierarchical peripheral clocks governing individual cells and organs

The problem with modern life 

• We now spend almost all of our time indoors under light that’s too dim during the day and too bright at night
• We go to bed when our to-do list is finally exhausted, not when our body is biologically ready
• We use caffeine to push through the afternoon, alcohol to wind down at night, and then wonder why we sleep like garbage 
• Jet lag, daylight savings time, and many prescription drugs further disrupt the natural regulators of sleep

It’s our systematic engineering away of these environmental cues that makes sleep a struggle for so many of us 

Here’s something that might surprise you: our hunter-gatherer ancestors didn’t sleep dramatically more than we do 

• The data suggests their total sleep time is roughly comparable to ours, and some have even more fragmented sleep 
• But they have extraordinarily strong circadian rhythms and report almost no difficulty sleeping
• Some of their languages don’t even have a word for insomnia! 

One tool in our toolkit for getting our sleep back in order is sleep medications 

Peter emphasizes, “Medications are NOT the foundation of good sleep.”

• The foundation of good sleep is behavioral
  • It’s aligning our lifestyles, environments, and mental attitudes with the cues our biology needs for good sleep
• But sleep medications can be useful tools when used skillfully, matched to this specific problem–ideally, as a short-term bridge rather than a long-term crutch
• For people dealing with acute crisis situations, chronic pain, or deeply rooted anxiety, they can often fill a gap that we can’t meet through our own efforts

“The keyword is matched, because these drugs vary enormously in how they work, what they do to your sleep architecture, how long they last, and what their risks are.”‒ Peter Attia

Reasons to be cautious with sleep medications 

• Reaching for a drug without understanding the problem you’re treating is a recipe for tolerance, dependence, worsened sleep architecture, or the all too common scenario of needing more to get less

In this episode, we’ll cover  

• The bare bones basics of sleep biology and how to support it,
• All the major classes of sleep medications
  • How they work
  • What they do to and for your sleep
  • Which ones work best for your problems
  • Their side effects
  • The risk of dependence
• Peter will spend extra time discussing the potential the newest class of sleep medications (DORAs) might have for Alzheimer’s prevention in high-risk patients 
• We’ll discuss some off-label medications and dietary supplements used for sleep, although that’s not our focus
• We have lots of content on such tools

Our focus here today will be on prescription medications, which we’ll be discussing in detail for the first time 

Sleep hygiene, circadian alignment, and the medical causes of insomnia: building the foundation for effective sleep treatment [7:15]

• Good sleep is built through sleep hygiene, much of which involves adapting your behaviors to align with the homeostatic and circadian sleep processes 
• Align the circadian process [Process C] through things like:
  • Regular wake-up, meals, and bedtimes
  • Getting sunlight as soon as you can after waking up
  • Reducing light exposure and stressors in the hours before bed
  • Making the bedroom cool and dark
• Enhancing the homeostatic process [Process S] is done by cultivating and conserving your sleep pressure by
  • Getting higher intensity exercise performed earlier in the day 
  • Or light exercise in the evening 
  • Avoiding sleeping in, napping, or drinking coffee in the afternoon 

{end of show notes preview}