Is Intermezzo the Right Kind of Sleep Music?
It's not every day the FDA approves a new drug -- especially a new sleeping pill. Intermezzo is a term that refers to a separate piece that plays in between acts -- especially for a musical performance like opera. And now it's being repositioned to name a "new" kind of sleeping pill -- one to use in the middle of the night.
Yet Intermezzo is not a new drug and may create more of the problem it's supposed to solve.
Old Wine in New, More Expensive Bottles
What is Intermezzo? Nothing more than smaller doses of the old generic sleeping pill zolpidem (ambien.) Zolpidem is very popular -- especially among women -- and is famous for provoking bizarre sleepwalking for those who don't immediately jump into bed.
Intermezzo will come out in two doses -- 1.75 mg -- recommended for women -- and 3.5 mg for men. The lowest available dose of zolpidem is 5 mg. People wanting Intermezzo can just get generic zolpidem from their doctors and cut the pills into thirds. Voila -- an old drug has become a new one -- at what will presumably be far less cost.
Assuming the cost of using is worth it.
How Is Intermezzo Meant to Be Used?
Only in the middle of the night for people who cannot get back to sleep and have four or more hours of expected sleep yet to come.
That's a real problem.
One of the banes of insomniacs is clock watching -- looking at the clock throughout the night. Most insomnia doctors and researchers will tell you that clock watching is a great way to keep people up all night.
Not only do insomniacs who watch the clock keep themselves awake -- through exasperation they make themselves even more aroused and sleepless. And clockwatchers often find themselves waking up in the middle of the night at exactly the same time -- night after night.
They've reset their biological clocks, and caused themselves to wake up.
Use of Intermezzo will pretty much guarantee clock watching -- how else will you know you still "have" at least four or more hours of required sleep to go? (OK, you might program your cell phone in some interesting way, but most won't.) It will also condition people to wake up -- in order to take a pill.
The FDA's four-hour rule is presumably there so too much of Intermezzo (zolpidem) won't be sticking around, sedating people when they wake. Don't expect that rule to be followed in practice.
At least the weird sleepwalking produced by bedtime zolpidem ingestion may prove less troublesome with low dose Intermezzo. People are not as prone to do something besides sleep between 1 and 3 a.m.
Lots of people wake in the middle of the night -- pretty much close to all of us. Most times we don't know that. Sleep itself causes amnesia, and our awakenings are so short we don't recall them. But if you do fully wake in the middle of the night there are plenty of alternatives to taking a pill.
Like reading and music.
Unlike what will occur with Intermezzo, it's best not to look at a clock at night but to set an alarm and treat every moment before that alarm as sleep time. Sleep is non-linear; deep sleep and REM sleep may make you feel far more functional than stage 1 sleep, and your biggest REM period is usually right before you wake.
So if you can't sleep after what you estimate is 5-10 minutes, get out of bed. Go to a different room or at least a chair -- you don't want to condition yourself to staying in bed if you're not sleeping.
Next, read or listen to music. There are many playlists to help you sleep. Middle-of-the-night books should prove neither boring nor enthralling. Poetry knocks out many; history works for more than a few, as do travel books, art history, books on music, autobiographies and memoirs. When in doubt, read a book you should have read in high school -- but didn't.
By encouraging clock watching and drug use during the middle of the night, Intermezzo may provoke people to wake in the night in order to take a pill. That may create more chronic insomnia than it will treat. Low dose zolpidem may work for some, especially shift workers. But there are plenty of alternatives for middle-of-the-night insomnia before you reach for a sleeping pill -- and they're much safer.
Follow Matthew Edlund, M.D. on Twitter: www.twitter.com/therestdoctor