Bitter Pills
Melatonin, Ozempic, Naltrexone, Oh My!
We lifelong insomniacs are a special bunch. We can function on four hours of sleep. We are impervious to jet lag. We have the power to defy the advice of experts as we stubbornly lie awake through the night.
This is because, as any true insomniac will agree, the advice of experts is bunkum. Avoid food, alcohol, and blue light at least two hours before bed? Avoided! Keep the bedroom cool and dark? Kept! Try meditation? Tried! And so on. And yet still we toss and turn.
Experts’ suggestions may work fine for people who occasionally lie awake ruminating over temporary stresses, but they are useless for insomniacs. For example, experts recommend that we try “cognitive shuffling”—distracting ourselves from our worries by thinking about something else. This strategy actually hypes me up. When I count backwards from a hundred by sevens, I start factoring every number. I have lain awake for hours mentally mapping the layouts of every home I have ever visited or retracing every path I have ever hiked. I once woke up at 2am and couldn’t get back to sleep because I was trying to think of as many dog breeds as I could for each letter of the alphabet (keeshond, kelpie, komondor, kuvasz . . . ). You get the idea.
And the stakes are high. Research shows that “lack of sleep in middle age may increase dementia risk.” Sigh. Why not just title these articles “Sorry, Guys: People Who Suffer from One Incurable Scourge Are Also at Risk for Another Incurable Scourge” and be done with it?
It all sounds pretty hopeless, doesn’t it? But my story has a happy ending. Turns out that insomnia is in fact curable, and the treatment is both safe and cheap.
Miracle Drug
A year’s supply of generic melatonin costs about $10 at Target, and the pills actually work. Unlike Ambien, whose side-effects include midnight binges, or Xanax, which is addictive, melatonin in my experience has only one side-effect—vivid dreams. I can live with that! Most nights I take a 5mg pill, fall asleep within half an hour, and either sleep through the night or quickly return to sleep after waking in the wee hours. Every morning I awaken bright and early, alert and refreshed, with no need for an alarm. For the first time in my life,1 I sleep like a normal person.
If melatonin is such a miracle, why did it take me so long to give it a try? I was influenced by our culture’s suspicion of medication. Articles about melatonin always emphasize that there “might be” risks (without citing proof of specific risks from double-blind controlled studies). They fret that melatonin might be habit-forming, or make us groggy, or cause a truly terrifying number of truly terrible problems, including, mysteriously, both diarrhea and constipation. Even the psychiatrist and rationalist Scott Alexander evinces an irrational suspicion of melatonin when he recommends that if we absolutely must use melatonin, we do so as infrequently as possible and limit ourselves to the laughably low dose of 0.3mg. In thrall to the naturalistic fallacy, these experts encourage us to prefer ineffective lifestyle changes to an effective pill.
You’d think we were talking about plutonium.
Anyway, I had to learn to ignore the catastrophizing and to appreciate the actual, rather than the feared, effect of melatonin: a good night’s sleep. The same phenomenon—a cultural suspicion of safe and effective medications and a preference for the natural approach—applies to other conditions too. It’s all well and good to maintain a positive attitude, improve our diets, exercise more, and, if all else fails, to tough it out. But people who struggle with depression, obesity, hot flashes, or arthritis are not wrong to want to try SSRIs, Ozempic,2 HRT, and Voltaren as well.
“I Felt Free”
And now we can add naltrexone to this list. I recently read Katie Herzog’s excellent book, Drink Your Way Sober: The Science-Based Method to Break Free from Alcohol, not because I have a problem with alcohol (she hastened to add),3 but because I have long been interested in the topic of treating addiction with the help of medication. Herzog’s book combines memoir, history, and self-help and is quick, funny, and informative.
Herzog suffered from alcohol use disorder (AUD) for most of her life and tried repeatedly to quit. But none of the conventional twelve-step treatments managed to end, or even blunt, her craving for alcohol. Then she discovered the Sinclair Method. This method uses the opioid antagonist naltrexone to block the pleasurable effects of alcohol. People take the drug, wait an hour, and then drink. They still experience the unpleasant effects of alcohol—the clumsiness, hangovers, discovery that you bought a round of drinks for the entire bar, etc.—but none of the euphoria. People who practice the method consistently find that after several weeks to several months, they have retrained their brain so that they no longer find alcohol desirable. After nine months, Herzog stopped drinking completely and, as she put it in her first interview on the topic, “I felt free.”
After getting sober, Herzog attended a few AA meetings and was saddened to discover how many people continue to be tormented by constant cravings for alcohol, years or even decades into sobriety. She wrote her book to introduce problem drinkers and their loved ones to a treatment for AUD that eliminates these cravings altogether.
Many doctors remain reluctant to prescribe naltrexone for AUD, courts mandate twelve-step programs rather than medication-assisted treatment, and our culture frowns upon treating addiction with a pill. For these reasons, Herzog’s book is a necessary contribution to the conversation about addiction. Herzog acknowledges that the Sinclair Method doesn’t work for everyone and that twelve-step programs help many people. But she makes a convincing case that naltrexone should be considered not a shameful cop-out but rather a safe, cheap, and effective option for the right patients.
Blame the Puritans
I think our reluctance to embrace medical treatments stems from two beliefs we’ve inherited from our Puritan ancestors, which bias us toward lengthy and difficult struggles.
We believe that our achievements don’t count unless they result from hard work, suffering, and sacrifice. It can feel like medication is cheating, right? Take Ozempic. We’ve all read online comments in which people are quite judgmental about Ozempic. Or they suspect that there has to be a catch, and that perhaps many years from now Ozempic patients will get their comeuppance when we discover that long-term use of the drug has dire consequences. We can sympathize with people who feel this way. Maybe they have spent their lives on restrictive diets, denying themselves ordinary pleasures for years only to regain the weight the moment they let their guard down. And now people waltz in, take a drug, and effortlessly drop the pounds? So unfair!
Similarly, people who have white-knuckled it through twelve-step programs and who successfully overcome their intense desire to drink every day may be suspicious of the Sinclair Method because, as Herzog says in a recent interview,
People have the impression that recovery should be hard. And that oftentimes comes . . . from people who have done it the hard way. . . . It seems like there should be some punishment for the sin. . . . It feels a bit unfair. But addiction is the punishment.
Maybe we should have a corollary to Occam’s Razor. Call it Herzog’s Razor: The simple treatment that frees us from needless struggle is usually the best one.
We believe that we must seek out and resolve the root cause. I once knew a guy who refused to take NyQuil and other OTC medicines when he got a cold because, in his words, “It won’t fix the underlying problem. It just relieves the symptoms.” Well yes! The whole point is to relieve the symptoms! My friend was reflecting the puritanical view that superficial fixes are a dodge, and that we must dig deep to discover and repair our flaws before we can begin to feel better.
But what if there is no fundamental issue causing our problems? No infection to cure, no sin to expiate, no trauma to resolve, no repressed memories to recover? I am not an insomniac because of unresolved trauma or a stressful life. Herzog’s AUD was not caused by stress or childhood trauma either. Therapeutic approaches that focus on digging up and resolving deep-seated issues are irrelevant when there’s nothing there to find. And relieving the symptoms, be they as mild as a stuffy nose or as severe as AUD, is intrinsically good.
Swallow It Down, What a Jagged Little Pill
It can be difficult to acknowledge that there may just be something different about the way we’re made, and that we can’t overcome our challenges on our own, just by trying really hard. Many problems we think of as psychological or spiritual may in fact be genetic.
Insomnia runs in my family. Like me, my dad, brother,4 and son are current or former insomniacs. We may have an inborn melatonin deficit or naturally overactive brains. Some people endure more “food noise” than others,5 and dieting is constant mental torment for them. For these patients, Ozempic is a godsend. Derek Thompson has noted that we have GLP-1 receptors throughout our body. Maybe some of us naturally have more, or more sensitive, receptors than others. Herzog reports that she is descended from, as she puts it, a long line of Irish alcoholics. This, and not a character flaw that needs to be remedied, is the likely reason alcohol is dangerous for her.
It can be even more difficult to question our culture’s assumptions about hard work and root causes and to choose the quick fix instead. But if we swallow down that jagged little pill, it will feel so good. We discover that we don’t have to suffer! And then we can share our stories, as Herzog does in her book and I’m doing here, to encourage others to free themselves from their suffering too.
How about you, readers? What is your opinion of using medications to treat conditions like insomnia, obesity, and AUD? Please share your thoughts in the comments!
The Tidbit
Since we all have the song in our heads now anyway, let’s listen to Alanis Morissette sing “You Learn” with the cast of the jukebox musical Jagged Little Pill. Morissette is so gracious. Watch how she backs away from the mic as she sings. She doesn’t want her great big glorious voice to overwhelm the other singers. Morissette’s joy as she sings is totally infectious!
And speaking of constant cravings, let’s have a bonus tidbit this week!
This is not an exaggeration. My mom tells me that I never, ever napped, not even as a baby, and that as a young child I would snap awake before dawn and be unable to get back to sleep. I’m sorry, mom!
It’s amazing how quickly Ozempic has joined kleenex, xerox, band-aid and other brand names that we use as generic terms.
Although when my husband saw the book in our Kindle library, he said, “Um, Mari? Is there something I should know about?” Tee hee!
When we were younger, my brother once called me up because he had read that the average amount of time it takes someone to fall asleep was only six minutes. He found that so astonishing—and he knew I would too—that he had to let me know.
I am fascinated by “food noise” because I don’t experience it. If it’s not mealtime, I don’t think about food at all, even when there are delicious treats in the house. My family loves to tease me because I have been known to take a bite of cake and then throw away the rest. “You threw away cake?!” they ask, aghast.
I always believed in better living through chemistry. If you can make life better by "cheating" you should cheat, and while doing so can have side effects, there's no law of the universe that they must, and certainly no law of the universe that those side effects must be worse than the alternative.
People have spent forever trying to prove that artificial sweeteners are bad for you because they refuse to believe that you can get the joy of drinking a soda without the calories, or something worse, but it really doesn't seem like there is any basis for it. While it may still be better for you to just drink water, that leaves you stuck just drinking water. Personally, I've always wanted Famine's zero-calorie Food and Meals from Good Omens. Maybe someday.
Somewhere along the line in my total insomniac life I just went with the flow. I get up in the middle of the night and read or do grading of students. Then around 2-3pm I take a nap. I think I sleep about 6 hours in 24 but broken up. And there is biphasic sleep as well--https://www.bbc.com/future/article/20220107-the-lost-medieval-habit-of-biphasic-sleep