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Why sleepwalk when you can sleepdrive.

Sleep driving, not to he confused with drowsy driving, has been recently added to the lexicon of sleep medicine and phenomena of sleepwalking. This terminology was not established by experts in the sleep field but by the New York Times in an article, March 8, 2006, A New Sleeping Sickness is Haunting Highways. According to this Times article, an ongoing survey by a committee from the Forensic Science Group and the Society of Forensic Toxicologists found that among labs that conduct tests of drivers blood samples for two dozen states, ten of these labs listed Ambien among the top ten drugs found in impaired drivers.

Noteworthy, in the state of Wisconsin, Ambien was identified in 187 arrested drivers for driving impaired from 1999 to 2004. In Washington State, Ambien was found in 78 impaired drivers arrested in 2005, compared to only 56 the previous year. It seems these numbers are probably low considering the number of prescriptions for hypnotics written in the U.S., which is steadily increasing annually. For example, in the year 2001, 19.1 million prescriptions were written for non-barbiturate hypnotics increasing to 31.3 million prescriptions in 2005 with 26.5 million of these prescriptions written for Ambien alone. Moreover, Ambien has 84% of the market with a total of 2.2 billion dollars in sales in the year 2005. With an estimated 70 million Americans suffering from insomnia and the introduction of several new hypnotics on the market, it is conceivable that the number of sleep driving episodes will only increase dramatically as we become more aware of these previously unexplained episodes.

Some of the behavior documented in cases around the country include: driving to the supermarket and not remembering the next day, crashing into a parked car, again with no recollection, awakening in jail after crashing into a parked van, getting into a car wearing only a thin night shirt in 20 degree weather, getting into a fender bender, urinating in the middle of an intersection and becoming violent with police officers when confronted.

It was stated in the article, but somewhat lost in the media frenzy that followed, that many patients with these episodes of sleep driving had taken the hypnotic incorrectly or mixed it with alcohol. Some drivers were found to have supra-therapeutic doses of Ambien suggesting that they had taken more than the usual dose of 10 mgs. or that it was very close to the time the blood was drawn. For example, a shift worker finishing his midnight shift takes the Ambien on his way home in hopes that it would take effect by the time he would get into his bed. Unfortunately in these cases it seemed to work sooner. It was also documented the use and abuse of alcohol combined with Ambien in several cases despite the clear label warning against this practice. It is important as health care providers in sleep medicine that we stress the safety of Ambien and other non-henzodiazepines when taken correctly and under medical supervision. Ambien as the longest non-benzodiazepine in the market has been fairly safe in our collective experience over thirteen years in the United States (over twelve billion nights). Ironically, the success of Ambien may have been in part due to the alleged automatic behavior including sleep violence caused by henzodiazepines, specifically Halcion in the late 1980s and early 1990s.

Unlike other manifestations of somnambulism described many years ago in the literature, for example, hereditary somnambulism in 1898 in Bran Stoker's Dracula, sleep driving may truly be a new phenomena of sleepwalking. The prevalence of sleepwalking may he as high as 17% in childhood with peak age of 8-12 years (another reason riot to decrease the legal age of driving and for that matter drinking alcohol). Sleepwalking usually "resolves" by age 18 but from 1-4% of adults may have episodic episodes of somnambulism. Precipitating factors, among others, include sleep deprivation, sleeping in unfamiliar surroundings, physical or emotional stress, premenstrual period, or the use of psychotropic medications. Ironically, it is for some of these factors that we actually prescribe or take hypnotics. In the future it may he prudent to be careful or somewhat cautious prescribing hypnotics in patients with hyperthyroidism, migraines, head injury, encephalitis, or stroke since these patient populations seem to be more susceptible to sleepwalking and theoretically sleep driving.


Case in point - it was reported by the Associated Press that U.S. Representative Patrick Kennedy (Democrat-R.I.) crashed his car near the Capital on May 4, 2006 at 2:45 am. He told officers at the scene "he was late for a vote". The story goes on to report that Rep. Kennedy had returned to his Capitol Hill home earlier that evening after a final series of votes in Congress and took prescribed amounts of Phenergan which was prescribed for gastroenteritis one day earlier and Ambien which he takes occasionally. The congressman released a statement stating "Some time around 2:45 AM, I drove the few blocks to the Capital complex believing I needed to vote. Apparently, I was disoriented from the medication." The president of the Washington chapter of the Fraternal Order of Police, who was not present at the scene of the accident, stated that the congressman appeared to be intoxicated but no sobriety tests were completed. The congressman had addressed this issue with his initial statement "I consumed no alcohol prior to the incident".

Politics aside and, without disparaging the character and reputation of the congressman based only on the information available this could be a classic case of sleep driving. Remember, somnambulism when described in simple terms is appropriate behavior at the inappropriate time. Rushing to vote is common and a way of life for most elected officials. Furthermore, debating and voting late at night is fairly frequent depending on the importance of the legislation pending on the floor.

On the other hand, it could be a clever legal defense learned from the recent rash of negative stories on the "ambien driver". As this incident takes a life of it's own it behooves the sleep professionals to intervene and educate the general public. It would be very interesting to get more details (obviously without violating the congressman's privacy) on the circumstances leading to the accident, for example sleep debt, other medications, history of previous sleepwalking or family history of sleep disorders. Strangely enough, we know almost everything about this prominent American family including serious medical conditions and psychiatric disorders but nothing about sleeping habits.

Finally, as we counsel patients with parasomnias discussing the importance of avoiding precipitating factors and creating a safe sleep environment we must now add the recommendation of HIDE YOUR CAR KEYS!

by Frank Roman MD JD
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Title Annotation:SLEEP MEDICINE
Author:Roman, Frank
Publication:FOCUS: Journal for Respiratory Care & Sleep Medicine
Date:Sep 22, 2012
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