So-called “Z drugs” such as zopiclone, were first approved as prescription sleeping tablets in the U.S. in 1993, and these are now more often used for insomnia than benzodiazepines such as Valium® (diazepam) or Mogadon® (nitrazepam)(5). However, whether these newer generation drugs which seem to act on different sites of the same GABA-A receptors as benzodiazepines, are in fact safer than their older cousins, is debatable. While their shorter duration of action and different receptor affinities may be associated with a slightly lower risk of dependency, they seem to be just as likely to lead to motor vehicle accidents & falls leading to fractures, particularly in older adults. These are major adverse events associated with the use of these drugs, and together with the risk of dependency, remain real concerns especially with ongoing use. Their prolonged use in young adults, can also compromise cognition, and have other negative adverse events in this age group. Finally, a range of other rare but serious adverse events from Z- drugs have been implicated in recent years, including dementia, infections, respiratory disease exacerbation and pancreatitis(6).

While the once widespread use of strong sedative antihistamine drugs to help knock out infants and children at night seems to have dissipated in recent years, other pharmaceutical drugs apart from benzodiazepines and Z drugs, are still widely used for stress management and associated sleeping difficulties. These include some powerful prescription-only drugs such as antipsychotics, antihistamines and opiates, which in many countries now, are being taken for sleep disorders and related ‘off label’ indications, and not just for their approved uses.

A cross-sectional study in 2015 also revealed that 42% of patients in the community taking a benzodiazepine or zopiclone for insomnia had experienced at least one adverse event, 52% had tried to stop, and that 23% of those taking Z drugs, wanted to stop taking the drug.

Given all of this, it is hardly surprising that many look for a herbal alternative to assist them to nod off and sleep soundly at night. However, while there seems to be a huge array of products out there said to help, including a large array of herbal teas with sleep-invoking names and packaging, when it comes to clinical trials showing that these actually work, there doesn’t seem to be a whole lot of compelling evidence.

A review of clinical trials of herbal products for insomnia, published in the December 2015 journal Sleep Medicine Reviews, evaluated 14 randomised clinical trials involving a total of 1602 participants with insomnia(7). The authors concluded that very few of these trials showed improved sleep quality and duration following herbal interventions. Of relevance perhaps, was that virtually all trials involved the use of herb combinations rather than individual agents. However, as is the case with such trials, the quality of the products involved, and doses used, varied enormously.

One of the best known herbs used traditionally for insomnia, is Valerian (Valeriana officinalis) root. While there has been a mixed appreciation of its value in recent years, and its taste and odour aren’t exactly pleasant, comments from the esteemed German medical practitioner and phytotherapist Rudolf Weiss, who widely prescribed Valerian and other herbs while in Russian captivity with limited drug supplies during World War 2, are salient:

“Valerian is beyond doubt a good and genuine sedative. There is however one aspect that has often been neglected: to be properly effective, valerian has to be prescribed in a sufficiently high dosage. It is almost pointless to give ten or twenty drops of valerian tincture; any effect here would be largely psychotherapy. The dose has to be very much larger, at least a whole teaspoonful of the tincture in water or on sugar…..the single dose of one teaspoonful may, if necessary, be repeated two or three times at short intervals. The greater effectiveness of some proprietary valerian preparations is due to the fact that this has been taken into account, with the dosage made sufficiently high”(8).

Medical conditions or other physical ailments, can also be partly or largely contributory to a poor night’s sleep, and identifying and trying to manage these with appropriate herbal medicines, can also be worthwhile. These include menopause, depression, aches and pains due to arthritis or injury, migraines, alcohol or drug withdrawal, or adverse effects to drugs such as prednisone or methamphetamine.

Clinical trials have shown Valerian and a combination of Valerian with Lemon Balm to improve the quality of sleep in postmenopausal women(9,10). Valerian with acupressure also improved the quantity and quality of sleep in patients with acute coronary syndrome(11). Another trial found Valerian to improve sleep in HIV patients taking the antiviral drug efavirenz(12), and a combination of Valerian, Hops and Zizyphus, to improve both total sleep time and night awakenings frequency(13).

There is in fact much more in the way of good quality published research supporting the benefits of herbal interventions in cases of anxiety or associated conditions, than straight insomnia. Evidence from clinical trials and other studies of anxiolytic as opposed to sedative effects for various medicinal herbs, is already substantive, and growing. As discussed in my February 2017 blog, there are many herbs which have been successfully traditionally used for anxiety. They include Chamomile, Lavender, Skullcap, Passionflower, Valerian, Kava, Lemon balm, Zizyphus, Hops and Withania.

Extracts of the Polynesian plant Kava (Piper methysticum) became popular towards the end of last century, for the management of anxiety disorders and related insomnia. While product type and phytochemistry, and doses used in clinical trials have been highly variable, a clear benefit has been shown in most cases.

Taking adequate doses of these anxiolytic herbs can certainly help promote a better quality sleep, and provide some relief to debilitating insomnia. Most anxiolytic drugs and sedative drugs work on the same GABA receptors, and it is not surprising that the same mode of action probably applies also to herbal medicines. By acting to help ease tension, anxiety and stress, they can effectively address some of the underlying and contributory factors to lack of sleep.

It is clear that more clinical studies to better determine efficacious herbal medicines and optimal doses, are sorely needed for the management of sleep disorders. However, their ability to help prevent insomnia, or avoid the need to take pharmaceutical drugs with a relatively high risk of adverse events, is well established. It is this ability of herbal medicines when properly selected and prescribed to address more than the outcome of a long-standing or acute underlying imbalance in health, but rather to help rebalance overall health and overcome weaknesses in several contributory areas, that makes them such excellent prophylactics. And after all, a prophylactic is preferable to a sticking plaster, especially one that is prone to fall off or leak when left on too long.

Refs:

1. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006. The National Academies Collection: Reports funded by National Institutes of Health.
2. Brzecka A et al, Front Neurosci. 2018 May 31;12:330.
3. Zitting KM Sci Rep. 2018 Jul 23;8(1):11052
4. Bordoloi M, Ramtekkar U. Med Sci (Basel) 2018 Sep 14;6(3).
5. Pollmann AS et al. BMC Pharmacology and Toxicology 2015; 16:19.
6. Brandt J et al, Drugs RD 2017 Dec;17(4):493-507.
7. Leach MJ, Page AT, Sleep Med Rev 2015;24:1-12.
8. Weiss Rudolf Fritz Lehrbuch der Phytotherapie (Herbal Medicine): Published by Hippokrates Verlag, Stuttgart, Germany, 1960. English edition first published 1988.
9. Taavoni S et al, Menopause. 2011 Sep;18(9):951-5
10. Taavoni S et al, Complement Ther Clin Pract. 2013 Nov;19(4):193-6.
11. Bagheri-Nesami M. J Tradit Complement Med. 2015 Jan 31;5(4):241-7
12. Ahmada M et al, Ann Pharmacother. 2017 Jun;51(6):457-464
13. Palmiera G, Nat Sci Sleep. 2017 May 26;9:163-169