Health and Shopping Blog

There are many stories on the internet (and elsewhere) about people who take ambien expecting a good night’s sleep, and then wake up to discover that they have been eating peanut-butter sandwiches during the night - personally, the only way I’d ever eat a peanut-butter sandwich is if I was asleep and then had no memory of it afterwards. Taste is personal. But back to the urban myths. It seems that people have been sleepwaking their way through routine tasks and putting themselves in danger by trying to cook or, worse, driving a car. The FDA, never a body to be panicked into anything, last year required all drugs that are classed as “sedative hypnotics” to carry a warning. It’s a strange kind of warning. It goes, “If you take this drug, don’t walk around when you’re alseep.” But you get the idea.

Anyway, because sleep-aid medications are a part of this broad class of sedative hypnotics, I thought I’d better say a few words about it. By the way, did you know that the number of prescriptions for sleep-aids grew by 10% in 2007? That millions more prescrptions than in 2006 and does not include all the internet sales that avoid the need for a prescrption. So a vast number of people, not just in the US, but around the world, are knocking back sleep-aids like ambien (the brand leader).

So, what is the real scale of this sleepwalking phenom? Well, the World Health Organization (WHO?) has just woken up to the potential problem and has been gathering evidence. The use of sedative hypnotics for insomnia has been around for decades. In the good old days of the last century, people were happily swallowing benzodiazepines and then experiencing minor disorientations. Some found their memory was affected or they were more likely to get confused. With the more modern varieties of drugs (which are nonbenzodiazepines - that makes you feel better does it not?), we now have reports of some behavioral disturbances (fancy words including confusion, agitation and, of course, sleepwalking).

To find out exactly what level of crisis the world is facing, the WHO instructed its Collaborating Centre for International Drug Monitoring to spread its net wide. It draws its data from twenty-four countries which gives us a good snapshot of what is going on around the world. The latest news is just in. You’d better prepare yourselves for a shock. In 2006/7, there were 867 reports of adverse reactions following the use of nonbenzodiazepines. That is 36 reports per country over a 365 day period. Now go back to the fact that millions of people around the world are taking sedative hypnotics and you have a true measure of the scale of the problem.

Oh, and I forgot to mention that experts around the world are not entirely sure why people sleepwalk. The cause could be anything (including an adverse reaction to a drug). So before internet gurus and newspaper journalists get all excited about the latest story about a driver running a defense in a criminal trial for dangerous driving, let’s remember that defendants will seize on any possibility to avoid a conviction. Personally, I’d blame the lawyers before I’d blame ambien for sleepwalking.

For once, I’m going to put on my physician’s hat and give you the view from the other side.

So my patient has walked through the door and, in the same breath as blurting out that he’s suffering erectile dysfunction (ED), he’s also into the knee-jerk questions about where to buy Viagra, should he risk buying Viagra online, and so on. I know Pfizer Inc. did a wonderful thing when they invented Viagra, but that medication so dominates the public consciousness that many men seem have never even heard about Cialis or Levitra, let alone all the other treatments that are available and may be necessary. Still even though my patients are predictable, they are at least coming through the door to get treatment. Ten years ago that did not happen. The world is a better place thanks to Pfizer Inc.

So what was I thinking during the question-and-answer session and the physical examination?

Well, my first step was to review the medical records to see if there were any immediate clues. If there are existing diseases or one of the medications currently on prescription has an ED side effect, we have solved the case before we start. I should let you in on a small medical secret. About a quarter of all the cases that we see are drug-related. Usually, we simply change the medication and the ED goes away. Alternatively, we have to counsel lifestyle changes because the excessive alcohol consumption or recreational drug of choice is not doing the patient any favors.

The next most obvious possibility is Type 2 Diabetes. This is growing more common but this patient isn’t complaining about any increase in thirst or appetite, his weight looks much as it was the last time we met. During the physical, I’ll look for acanthosis nigricans which are darker patches of skin in the arm pit or round the neck. I may also do a blood sugar test just to be thorough. Blood pressure tests out in the normal range, so that’s another good sign.

The questions are designed to establish whether we’re dealing with problems of desire (which could be psychological or physical), whether it’s purely ED or there are also problems with ejaculation and orgasm, and to check up on those lifestyle choices which could be the real problem.

The physical examination tries to cover as many possibilities as possible in as short a time as possible. Most men find an examination deeply embarrassing so keeping it short is a “good thing”. I’m looking for anything that might suggest a systemic problem. So, I’m obviously going to start with the penis. Some of my questions have probed whether the penis has changed shape in any way or perhaps the erection is painful. A physical examination could find evidence of lumps or the answers to the questions may reveal that the penis now bends or curves when erect, all of which could suggest Peyronie’s disease. Similarly, if the penis is not sensitive when I touch it, this may indicate possible problems in the peripheral nervous system.

If the testicles feel slightly smaller than I would expect, this can suggest a low testosterone level. Following the same idea and taking a quick overview of the body also allows me to look for any changes to the usual distribution of body hair or any enlargement to the pectorals (a polite way of suggesting that my patient may be developing small breasts). Any such abnormality can indicate problems with the hormone balance or the endocrine system. I’m also testing the pulses in both the wrists and ankles. If there are any circulatory problems, I’m likely to find a decrease pulse at the extremities.

So these are all the quick and easy explanations. In most cases, there is little to suggest the need to go on to further tests and I can then get into a discussion of the medication options. This is when the patient finally begins to look more comfortable again. We have finally come back to his original questions, except that I’m also telling him about Cialis and Levitra. Viagra may have the name, but Cialis in particular does have some interesting characteristics.