There are many forms of torture but two have appetites all of their own. One is not to be able to stay awake. People with narcolepsy and even those with sleep apnoea know how hungry sleep can be; it can eat you whole.
The other form of torture is not to be able to stay asleep. Insomnia is a fussy eater. It will calmly let a person stew; it can sit on the end of someone’s bed and watch them cook. Insomnia doesn’t believe in comforting pillow talk. It can whisper horrible things at half past three. Experts say insomnia is a symptom rather than a disease but it can be hard to know what it is a symptom of. Sometimes it is a symptom of itself: it is often the case that the worse people sleep, the worse they sleep.
History is a catalogue of the strange things people have done to get a decent night’s sleep. Benjamin Franklin (1706–1790) was a one-man renaissance and an individual of spare common sense; he embodied what became the governing myth of American independence, that a single person could be an entire culture all on their own. Like Thomas Edison, he was fascinated by electricity. Unlike Edison, he had time for sleep. What he didn’t have time for was sleeplessness. His remedy for insomnia was simple: get two beds. If you couldn’t sleep in one, then surely you’d be able to sleep in the other. His reasoning was typically transparent: people slept badly because they were too hot. The reason they got too hot was either because they had too many bedclothes or they had eaten too much or both:
Nothing is more common in the newspapers than instances of people who, after eating a hearty supper, are found dead abed in the morning.
Franklin recommends having a cool bed handy to hop into. If you can’t afford two beds, then you should get up, walk around without your clothes until ‘your skin has had time to discharge its load’ and you can’t take the cold any more:
. . . you will soon fall asleep and your sleep will be sweet and pleasant. All the scenes presented to your fancy will be, too, of the pleasing kind. I am often as agreeably entertained by them as by the scenery of an opera.
Franklin says that he learned these lessons from the story of Methuselah, the grandfather of Noah, who holds the distinction of having lived longer than anyone else in the Bible, a work full of folk who were in no hurry to meet their maker. According to Franklin, Methuselah’s secret was that he spent most of his nine hundred and something years sleeping out of doors in the fresh air and, indeed, only agreed to his second five hundred years on condition he could continue sleeping under the stars; it would be interesting to know Franklin’s source for this information because the Book of Genesis deals with Methuselah’s millennium in a couple of lines as it rushes headlong towards the flood. Franklin condemns aerophobia, a word he used to describe fear of sleeping with the window open. These days the same word can mean fear of flying as well as fear of airborne germs. Not only do we have more phobia words but the ones we have are working harder.
If only it was as easy as Franklin thought. Those who suffer from insomnia know that the condition can be callous, often defying explanation and thumbing its nose at attempts to deal with it in a reasonable way. One result has been that, for centuries, insomniacs have been an exploited group and their difficulties have been a goldmine for everybody from hypnotists to pillow makers. Insomnia is worth lots and lots of money; its hostages can be prepared to pay a king’s ransom to escape. As long as people continue to be lured by images of perfect sleep, as opposed to adequate sleep, this will remain the case. For centuries, the insomnia industry has been good at selling a product which it can’t deliver and which people often don’t need anyway. In this, it shares something with the cosmetic surgery trade: there’s no such thing as a perfect body and, even if there was, nobody needs one. But it’s harder to make big bucks out of reality. Fantasies are cheap to build and easy to rent.
Drug companies are among those who have done very nicely out of insomnia. The trouble is that not everyone has done nicely out of them.
On the evening of 13 September 2007, the night she died, Mairéad Costigan was staying with her parents, Michael and Margaret, in the Sydney harbourside suburb of Lavender Bay. Mairéad, aged thirty, retreated here occasionally from her place in Paddington. She had had a busy day: she had applied for more teaching work at the university, she’d bought a top to wear, paid for new glasses which she would collect later and arranged some meetings for the following week. It had been a full day in a full life. She was planning to meet her sister for brunch on the weekend, a friend for coffee on the following week and was talking about a trip to London in the near future; she wasn’t saying goodbye to anyone. Mairéad had recently completed work on a doctorate in philosophy, having written a thesis on aspects of justice and politics in Plato’s Republic. She was a gifted thinker and her work in philosophy had turned heads. A semester’s teaching at the university had proved demanding, partly because Mairéad’s main interest was research, but there was only a couple of weeks of that to go; the pressure was lifting. In many respects, it was a life to envy. There was no conceivable reason to let it go.
That night, she watched TV with her mother in her parents’ room then, at 9.25 pm, said she was going to mark some essays. She changed into her pyjamas in readiness for bed and wrote an email arranging a work meeting for lunchtime the following Monday, a message that she never sent.
Mairéad had lived with insomnia for a long time. According to her sister, Siobhán Costigan, she didn’t have trouble falling asleep, but staying asleep could be a real bother. Nocturnal noise was especially difficult; she had a ritual for closing windows tight before going to bed to ensure quiet. She even made sure there were weights on papers in the house so they didn’t rustle and disturb her.
Mairéad had tried different remedies over the years and, for about nine months, had been taking a drug called zolpidem, prescribed for her at a bulk-billing group medical practice where she had seen three or four different doctors all with access to the same records. The practice had kept Mairéad on zolpidem far longer than recommended.
Since its launch onto the market in the early nineties, zolpidem has been a bonanza for drug companies. In 2005 alone, some 26.5 million prescriptions were issued in the USA where, although it is only available on prescription, it touts for business in the open marketplace so that patients know what to tell the doctor to write on those little pads at the end of their nine minutes. In Australia, the drug has only been available since 2000 but by 2007 was the second most commonly prescribed sleeping tablet, behind temazepam. Zolpidem represents a very big slice of a very big pie.
Siobhán Costigan was concerned when she heard that Mairéad was on zolpidem. There had been a well-publicised incident the year before when Jon Mark, aged thirty-seven, had climbed over the balcony of his twelfth floor apartment while sleepwalking and had fallen to his death. Jon, who had been taking zolpidem, had only been married for a couple of months; his wife had been at pre-school with Mairéad and her sisters, Siobhán and Sascha, so they were troubled by the story. In the time Mairéad was taking zolpidem, Siobhán and some friends had noticed changes in her personality and behaviour: she had been easily confused, jumpy, prone to lose things such as her wallet, keys or phone, and her short-term memory seemed poor. Her insomnia was getting worse, not better.
Six days before she died, Mairéad switched medication. She moved to a drug called zopiclone, which she took scrupulously according to instructions. When she died, there were precisely six missing from the pack, suggesting to the police that she had done what she was told and taken one a day. Zolpidem, zopiclone and the more recent zaleplon are known, because of their names, as ‘Z class’ drugs. Z-class drugs have been seen as successors to benzodiazepines, which appeared in the sixties and dominated the market from the seventies. These, in turn, took over from the barbiturates which were developed in Germany before World War I and became common in the forties and fifties; Adolf von Baeyer invented barbituric acid in the 1860s when, for reasons best known to himself, he wondered what you got when you mixed animals’ urine with apple juice. It was over forty years before someone else noticed that this brew made dogs fall asleep. Both Benzos and Barbies, simple sedatives by the standards of contemporary pharmacology, had notorious side effects, not least their addictive properties. My mother, a pharmacist for fifty years, used to think that half the country was on them. She described them mildly as ‘habit forming’. What she meant was that they didn’t just help lives, they took them over.
Before Benzos and Barbies, there was opium, which dealt wonderfully with insomnia but, as well as being addictive, had the shortcoming of replacing insomnia with chronic sleeplessness. For some people this wasn’t so bad because the little sleep which was produced by opium, often taken as laudanum, was visited by such appalling dreams that users were just as happy to be awake after all. Samuel Taylor Coleridge, the famously garrulous poet, was crippled by opium, although his fellow addict, Thomas de Quincey, author of The Confessions of an English Opium Eater (1856), loathed Coleridge’s ‘eternal stream of talk which never once intermitted’ and lamented that Coleridge never shut up, either awake or asleep, so it was hard to tell what state he was in at any time. Shakespeare knew both about opium (‘the poppy’) and mandrake (‘mandragora’) as well as other ‘drowsy syrups of the world’, none of which could help poor Desdemona. Before Shakespeare there was valerian, used by the Romans and Greeks. Before that there was bound to have been something else. In short, it’s been a long quest, one that is by no means over yet.
At the other end of the spectrum, the US military has reportedly been trying to develop medication to enable soldiers to survive for longer periods without sleep, making them immune to the effects of sleep deprivation: they have been trying to find drugs that will enable the human brain to mimic what happens in the brains of birds which stay awake for long periods during intercontinental migration. They have also been experimenting with modafinil, a drug used in treating narcolepsy, hoping that it might offer a key to enabling soldiers to wage war 24/7. Bear in mind that the Three Mile Island nuclear disaster of 1979, the Challenger space shuttle disaster of 1986, the Chernobyl nuclear disaster of 1986 and the Exxon Valdez oil tanker disaster of 1989 have all been attributed to various levels of sleep deprivation in key personnel. It’s obvious from this that what the world really needs is sleepless soldiers sitting in front of panels of flashing buttons.
The Z-class drugs of the last fifteen years sound like a new line of Mercedes Benz. But they are not without problems of their own.
Z-class drugs act fast, one of their attractions. Soon after getting into her pyjamas on 13 September 2007, possibly while she was still sitting at her computer, Mairéad Costigan got up suddenly and left her parents’ apartment. On her way out, she walked past her father who was asleep in front of the TV, something her sister says she would never have done if she’d been conscious because she’d been concerned about her dad’s health and had accompanied him to heart-exercise classes. It was a cool evening in Sydney, the temperature falling to eleven degrees celsius overnight, but Mairéad was barefoot and only wearing her pyjamas. She was normally particular about her appearance but her hair was unkempt. The reason was that she was already fast asleep. She never woke again.
Mairéad walked in her sleep up onto the cycleway of the Sydney Harbour Bridge. Cyclists are possessive of this little piece of turf; pedestrians have a dedicated walkway on the other side of the bridge and cyclists will always bark at stray walkers to get off their side and back where they belong. The CCTV footage of that night shows Mairéad zig-zagging along the cycleway; a couple of bikes slipped past her but she was oblivious to them and any curt advice they may have sent her way. Soon afterwards, Mairéad climbed the chest-high parapet of the bridge and it was from here that she slipped.
Her landing twenty metres below was heard by a homeless man in a bus shelter; a passing nurse tried to revive her but her injuries were horrific, with the exception of her hands and arms, which had escaped the force of the impact. Had Mairéad been awake, she would have instinctively put her hands out to cushion her landing. But she didn’t.
It was not yet ten o’clock. When the police called on Mairéad’s parents several hours later, her mother, Margaret, responded to the news by naming the medication Mairéad was on.
The toxicology showed no alcohol in Mairéad’s system nor any other drug apart from zopiclone. She had no history of depressive or mental illness.
Even if this were an isolated case, it would be impossible to believe it was suicide. But it is not an isolated case. Z-class drugs have been associated with a range of strange sleep behaviours.
Before long, Siobhán Costigan and her sister, Sascha, had flown to Brisbane to speak with Dr Geraldine Moses, a clinical pharmacist who was the founder of the Adverse Medicine Events Line, a phone-in service based at Brisbane’s Mater Hospital and funded by the National Prescribing Service. The line began as a port of call for people who were experiencing difficulties with medication. It gives advice but also listens to stories; it has become a significant conduit for the grass-roots experience of consumers to reach the authorities such as the Therapeutic Goods Administration (TGA), who regulate the availability of medicines. A third of the calls made to the Adverse Medicine Events Line report unexpected side effects, many of which have not been described in any official literature.
Geraldine grew up with a first-hand understanding of the mystique that can surround medicines, especially so-called wonder drugs. Her father ran a pharmacy in the centre of Brisbane where he became renowned for his hangover cures. After a big night, headsore people, mainly blokes, would make their way into the city from the suburbs in search of Mr Moses’ ministrations. There was something about the father confessor in Moses’ approach; he kept a special section of the pharmacy where he could sit people down and talk to them.
‘Dad’s magic hangover cure was really just codeine,’ explains Moses. ‘But the tablets were red. The customers had confidence in them because of that. Dad said that people believed that all good medicines were red.’
In her own career, Geraldine found she had a gift for explaining how medication worked in a clear and accessible manner, cutting through the aura that can hover around those blister packs. In the mid-nineties, she had a popular segment on national talkback radio doing just that. It is still a widespread need; Australians take a lot of tablets.
When Geraldine Moses started hearing stories about the Z-class drugs such as zolpidem, she initially dismissed them. The reports were too outlandish. Besides, there were plenty of people who loved these drugs and were grateful to them. But the stories just kept coming, each one as improbable as the one before it. Most of them concerned what are known as parasomnias, the name given to things people do when they are asleep which they should only do when awake. Sleepwalking, sleeptalking, sleepdriving, sleepironing, sleepcleaning, sleepsex, sleepcooking and sleepeating are all parasomnias. So is sleepcarwashing. So, unfortunately, are various forms of sleepviolence, including violence to oneself.
Here’s a sample. A man got in his car and drove 500 kilometres from Innisfail to Cooktown where he had a cup of tea with friends in the middle of the night. When the friends rang the next day to check he got home safely, he had no recollection whatsoever of having made the trip. Another man, who slept in the nude, found himself in his car at a service station about to fill up with petrol. He then realised he had forgotten his wallet. He had forgotten his wallet because he had forgotten his clothes.
These stories aren’t really funny. A woman needed half her leg amputated after she slipped and broke the leg as she was cleaning her bath while she was still asleep. Not even the pain of a broken bone woke her and the angle at which she fell cut off circulation to the leg, killing the limb. When she finally awoke, she was close to a multi-organ collapse. Another woman mysteriously gained forty-three kilograms; her partner confronted her with evidence of her nocturnal cooking extravaganzas and she was dumbfounded. Yet another woman broke into the house of a former boyfriend and is still dealing with the legal fallout. Still another let an ugly ex into the house and had sex with him, feeling sick when she awoke to the fact. In April 2008, a judge in Sydney accepted that one Robert Kingston, who was involved in a traffic accident when he was driving on the wrong side of the road in his sleep attire with a blood alcohol level of 0.105 per cent, may have been acting strangely because of the zolpidem in his system. By that stage, the Australian Therapeutic Goods Administration (TGA) had received over a thousand reports of bizarre reactions to zolpidem, ten per cent of them related to driving.
Worst of all is an increasing list of people who have managed to kill themselves while asleep. Geraldine Moses says that her modest helpline has already received fifteen such reports. Once the story of Mairéad Costigan received publicity, another family from Western Australia made contact to talk about a similar tragedy which had befallen a young woman there. These stories do not include the near misses: the man who texted a goodbye message to his family from a beach in the middle of the night and awoke in hospital; the woman who pointed a gun to her head and was just lucky the gun jammed. The one and only constant in all these scenarios is the presence of a Z-class drug.
Geraldine Moses attributes the problems to the sophisticated manner in which the drugs work. The older generation of sleeping tablets are simply sedatives and help at bedtime by creating calm. But zolpidem actually changes the architecture of sleep. In Moses’ words, it disturbs the great symphony of sleep.
Zolpidem works by stimulating the pathways used in the brain by a hormone called dopamine, produced in the hypothalamus. Dopamine has a job description as long as your arm but helping to organise sleep is part of it. In improving traffic flow for dopamine, zolpidem extends the time a sleeper spends in stage three and stage four sleep and delays the onset of REM sleep. It thus alters the natural progression of the sleep cycle and blurs the boundaries between REM and non-REM sleep. For some people, this means an increased likelihood of parasomnias such as sleepwalking, taking place during a stage of sleep when the body is not paralysed in the way nature usually arranges to prevent us acting out our dreams. For a significant number of those people, the results have been tragic.
As well as negatives, zolpidem has had some unexpected positives. These include a case reported in South Africa of a young man, Louis Engelbrecht, who spent three years in a coma after the bicycle he was riding was hit by a car near home; he seemed unable to respond to any communication from outside himself. His mother, Seinie, noticed that he had become increasingly restless, tearing at his own bedding, and so his doctor, Wally Nel, prescribed zolpidem for him; a coma is not sleep (a key difference is that sleep is easily reversible), so the idea of giving sleep medication to someone in a coma is not as bizarre as it sounds. Within half an hour, Louis had spoken to his mother for the first time in years. The drug is now being used on a range of people suffering brain injury, with a reasonable level of success. Zolpidem has also been found helpful to patients with Bell’s palsy, Parkinson’s disease and even restless legs syndrome, all of which is good news. But you do have to scratch your head. All drugs have side effects and are inevitably released onto the market, and in this case become part of millions of lives, without the manufacturer knowing everything they do. Indeed, says Geraldine Moses, all kinds of tests are done on new drugs before they are released, but their impact on sleep is seldom investigated.
Six months after her sister’s death, Siobhán Costigan had given up most of her work as a graphic designer to spend time getting to the bottom of what happened to her sister and to publicise Mairéad’s experience with Z-class drugs. The Costigans were among those who campaigned for the TGA to have the drug rescheduled in February 2008, meaning that it would be categorised alongside drugs which are much harder to access. The TGA fell short of rescheduling but imposed a ‘black box’ warning on the product which advised of ‘potentially dangerous complex sleep-related behaviours’, ensuring that both patients and prescribers were more aware of its track record. For Siobhán, this was at least a step in the right direction. She points out that the TGA is a government agency partly funded by the pharmaceutical industry; companies pay fees to have drugs registered.
The manufacturers of zolpidem have responded to adverse publicity with a poker face. A communications representative of one company said that they had been inundated with calls from people who had benefited from the drug but that the media wasn’t interested in them. In a statement released in April 2007, one of the pharmaceutical companies said that problems with the drug had usually resulted from its improper use, especially taking it with alcohol. This was assuredly not the case with Mairéad Costigan. Consumer information for the drug published in June 2007 included a list of ‘side effects’, at the beginning and end of which, in bold type, was the advice: ‘do not be alarmed by this list of possible side effects. You may not experience any of them.’ The last dot point on a secondary list of ‘less common adverse effects’ is ‘sleep walking or other behaviours whilst asleep’. Blink and you’d miss it.