It was a cool evening in Sydney, the temperature falling to fifty degrees Fahrenheit overnight, but Mairéad was barefoot and only wearing her pajamas. She was normally particular about her appearance, but now her hair was unkempt. The reason was that she was already fast asleep.
She never woke again.
Mairéad walked in her sleep up onto the cycleway of the Sydney Harbour Bridge. Cyclists are possessive of this little piece of turf; pedestrians have a dedicated walkway on the other side of the bridge and cyclists will always bark at stray walkers to get off their side and back where they belong. The CCTV footage of that night shows Mairéad zigzagging along the cycleway; a few bikes slipped past her, but she was oblivious to them and any curt advice they may have sent her way. Soon afterward, Mairéad climbed the chest-high parapet of the bridge, and it was from here that she slipped.
Her landing sixty-five feet below was heard by a homeless man in a bus shelter. A passing nurse tried to revive her, but her injuries were substantial. Had Mairéad been awake, she would have instinctively put her hands out to cushion her landing. But because she was asleep, she didn’t make any attempt to protect herself. The impact showed.
It was not yet ten o’clock. When the police called on Mairéad’s parents several hours later, her mother, Margaret, responded to the news with one word: “Stilnox.”
The toxicology showed no alcohol in Mairéad’s system nor any other drug apart from Imovane. She had no history of depressive or mental illness.
Before long, Siobhán Costigan and her sister, Sascha, had flown to Brisbane to speak with Dr. Geraldine Moses, a clinical pharmacist who was the founder of the Adverse Medicine Events Line, a phone-in service based at Brisbane’s Mater Hospital and funded by the National Prescribing Service. The line began as a port of call for people who were experiencing difficulties with medication. It gives advice but also listens to stories; it has become a significant conduit for the grass-roots experience of consumers to reach the authorities such as the Therapeutic Goods Administration (TGA), who regulate the availability of medicines. A third of the calls made to the Adverse Medicine Events Line report unexpected side effects, many of which have not been described in any official literature.
Dr. Moses grew up with a firsthand understanding of the mystique that can surround medicines, especially so-called wonder drugs. Her father ran a pharmacy in the center of Brisbane, where he became renowned for his hangover cures. After a big night, headsore people, mainly blokes, would make their way into the city from the suburbs in search of Mr. Moses’s ministrations. There was something about the father confessor in Moses’s approach; he kept a special section of the pharmacy where he could sit people down and talk to them.
“Dad’s magic hangover cure was really just codeine,” explains Moses. “But the tablets were red. The customers had confidence in them because of that. Dad said that people believed that all good medicines were red.”
In her own career, Dr. Moses found she had a gift for explaining how medication worked in a clear and accessible manner, cutting through the aura that can hover around those blister packs. In the mid-nineties, she had a popular segment on national talk radio doing just that. It is still a widespread need; Australians take a lot of tablets.
When Dr. Moses started hearing stories about the Z-class drugs such as zolpidem, she initially dismissed them. The reports were too outlandish. Besides, there were plenty of people who loved these drugs and were grateful to them. But the stories just kept coming, each one as improbable as the one before it. Most of them concerned what are known as parasomnias, the name given to things people do when they are asleep that they should only do when awake. Sleepwalking, sleeptalking, sleepdriving, sleepironing, sleepcleaning, sleepsex, sleepcooking, and sleepeating are all parasomnias. So is sleep carwashing. So, unfortunately, are various forms of sleep violence, including violence to oneself.
Here’s a sample. A man got in his car and drove hundreds and hundreds of miles to the house of friends, where he had a cup of tea in the middle of the night. When the friends rang the next day to check he got home safely, he had no recollection whatever of having made the trip. Another man, who slept in the nude, found himself in his car at a service station about to fill up with gas. He then realized he had forgotten his wallet. He had forgotten his wallet because he had forgotten his clothes.
These stories aren’t really funny. A woman needed half her leg amputated after she slipped and broke the leg as she was cleaning her bathtub while she was still asleep. Not even the pain of a broken bone woke her and the angle at which she fell cut off circulation to the leg, killing the limb. When she finally awoke, she was close to a multi-organ collapse. Another woman mysteriously gained almost 95 pounds; her partner confronted her with evidence of her nocturnal cooking extravaganzas and she was dumbfounded. In April 2008, a judge in Sydney accepted that Robert Kingston, who was involved in a traffic accident when he was driving on the wrong side of the road in his sleep attire with a blood alcohol level of 0.105 percent, may have been acting strangely because of the Stilnox in his system. By that point, Australian authorities had received over a thousand reports of bizarre reactions to Stilnox, 10 percent of them related to driving.
Worst of all is an increasing list of people who have managed to kill themselves while asleep. Dr. Moses says that her modest help line has already received many such reports. Once the story of Mairéad Costigan received publicity, another family from Western Australia made contact to talk about a similar tragedy that had befallen a young woman there. These stories do not include the near misses: the man who texted a good-bye message to his family from a beach in the middle of the night and awoke in the hospital; the woman who pointed a gun to her head and was just lucky the gun jammed. The one and only constant in all these scenarios is the presence of a Z-class drug.
Geraldine Moses attributes the problems to the sophisticated manner in which the drugs work. The older generation of sleeping tablets are simply sedatives and help at bedtime by creating calm. But zolpidem actually changes the architecture of sleep. In Moses’s words, it disturbs the great symphony of sleep.
Zolpidem works by stimulating the pathways used in the brain by a hormone called dopamine, produced in the hypothalamus. Dopamine has a job description as long as your arm but helping to organize sleep is part of it. In improving traffic flow for dopamine, zolpidem extends the time a sleeper spends in stage-three and stage-four sleep and delays the onset of REM sleep. It thus alters the natural progression of the sleep cycle and blurs the boundaries between REM and non-REM sleep. For some people, this means an increased likelihood of parasomnias, such as sleepwalking, taking place during a stage of sleep when the body is not paralyzed in the way nature usually arranges to prevent us acting out our dreams. For a significant number of those people, the results have been tragic.
As well as negatives, zolpidem has had some unexpected positives as well. These include a case reported in South Africa of a young man, Louis Engelbrecht, who spent three years in a coma after the bicycle he was riding was hit by a car near his home; he seemed unable to respond to any communication from outside himself. His mother, Seinie, noticed that he had become increasingly restless, tearing at his own bedding, and so his doctor, Wally Nel, prescribed zolpidem for him. A coma is not sleep (a key difference is that sleep is easily reversible), so the idea of giving sleep medication to someone in a coma is not as bizarre as it sounds. Within half an hour, Louis had spoken to his mother for the first time in years. The drug is now being used on a range of people suffering brain injury, with a reasonable level of success. Zolpidem has also been found helpful to patients with Bell’s palsy, Parkinson’s disease, and even restless leg syndrome, all of which is good news. But you do have to scratch your head. All drugs have side effects and are inevitably released onto the market, and become part of millions of lives without the manufacturer knowing everything they do. Indeed, says Geraldine Moses, all kinds of tests are done on new drugs before they are released
, but their impact on sleep is seldom investigated.
Six months after her sister’s death, Siobhán Costigan had given up most of her work as a graphic designer to spend time getting to the bottom of what happened to her sister and to publicize Mairéad’s experience with Z-class drugs. The Costigans were among those who campaigned in February 2008 to have the drug reclassified, meaning that it would be categorized alongside drugs that are much harder to access. The drug wasn’t reclassified, but there was a warning added to the product that advised of “potentially dangerous complex sleep-related behaviors,” ensuring that both patients and prescribers were more aware of its track record. For Siobhán, this was at least a step in the right direction. She points out that the official body in Australia responsible for the reclassification is a government agency funded by the pharmaceutical industry; companies pay fees to have drugs registered.
Sanofi-Aventis has responded to adverse publicity with a poker face. A communications representative said that the company had been inundated with calls from people who had benefited from the drug but that the media wasn’t interested in them. In a statement released in April 2007, the company said that problems with the drug had usually resulted from its improper use, especially taking it with alcohol. This was assuredly not the case with Mairéad Costigan. Consumer information for the drug published in June 2007 included a list of side effects at the beginning and end of which, in bold type, was the following advice: “Do not be alarmed by this list of possible side effects. You may not experience any of them.” The last point on a secondary list of “less common adverse effects” is “sleepwalking or other behaviors while asleep.” Blink and you’d miss it.
In November 2016, Mairead would have turned forty. Her family still grieves for her deeply. Nine years after Mairead’s death, her father says, “I live with the aching memory of several worrying moments when I thought there may possibly have been warning signs about the drug. These were times when I was with her in the car and elsewhere during the last weeks and especially days of her life, when I sometimes drove her to and from the university, where she was lecturing part-time and where I had the use of an office as adjunct professor. I have tried to write about these episodes but the recollections are almost too painful to bear.”
Nine years have brought many more Stilnox stories to the door of the Costigans. They have befriended, for example, the family of Peter Dickson, who was another casualty of the drug. His mother, Jenny, has commented on social media that Peter walked in his sleep from the day he was prescribed this medication until his death six days later. He died in front of a train.
Nine years have also brought some increased caution about the drug in the wider community. It has been banned by a number of sporting teams, and these decisions have received publicity, as has any association of the drug with bizarre behavior, especially in celebrities. A number of doctors are wary of it. But with a few small tweaks, it is still doing great business. Nothing substantial has really changed. For one reason or another, there are plenty of doctors who are sleepwalking right past the warning signs.
Everyone sleeps, even those who claim not to. Sometimes people don’t know they are asleep because, well, they sleep through it. For many years, the record for sleeplessness was held by a Californian teenager, Randy Gardner, who, in 1965, managed to stay awake for eleven days—a grand total of 264 hours. Gardner achieved this feat with the help of friends and a lot of physical activity including walking, using a baseball machine in a pinball arcade, and playing basketball. He got a bit cranky at different times, lashing out at the people who were keeping him awake because he had forgotten why they were tormenting him like this, and he probably had a lot of micro-sleeps, of which people were not yet aware. But the ordeal didn’t seem to leave Gardner with any permanent scars. Once he’d reached the milestone, he slept for nearly fifteen hours. The next night he slept for over ten. After that, he seems to have returned to a normal sleep pattern. Randy was most at risk during the marathon itself.
History is full of famous insomniacs. Some have tried to make a virtue of their affliction. Margaret Thatcher, prime minister of Britain from 1979 to 1990, wrote in her memoirs that she only slept for a few hours a night. She wrote, “There was an intensity about the job of being Prime Minister which made sleep seem a luxury. In any case, over the years I had trained myself to do with about four hours a night.” Thatcher presented herself as keeping vigil over the fortunes of the nation, perhaps not an insomniac so much as someone, like Thomas Edison, who had more important things to do than sleep. As a matter of fact, she didn’t; the belief is a delusion. Voters may have been less impressed if she said she drank heavily but the effects are basically the same as sleeplessness. According to researcher Paul Martin, somebody who has been awake for twenty-one hours will have the same reaction time and cognitive impairment as somebody with a blood alcohol level of 0.08 percent. They shouldn’t be driving a car, let alone a country.
Charles Dickens was a genuine insomniac, and his anxiety concerning bedtime reflected in a curious obsession. He would only sleep in a bed with the head pointing north and the feet pointing south. People have come up with many such rituals, some easier to explain than others. Elizabeth I, for example, always slept with a sword in her bed, perhaps to defend her virginity or perhaps to ward off the armada if it got that far. The purpose of Dickens’s obsession may have been the obsession itself: he was equally fussy about dress and food, although beds had a special hold on him. He always had trouble getting a bed to do what it was supposed to do; at least the direction it pointed was one aspect of its behavior he could control. Dickens’s problems with sleep are evident in his capacity, on occasion, to blur the line between dreams and reality. Ideas for plots sometimes came to him in dreams, and he called the month’s installment, for whatever serialized novel he was working on at the time, “my month’s dream.”
Like Shakespeare, Dickens wrote a lot about sleep. The reason was that, like Shakespeare, he wrote a lot about everything. They both had voracious imaginations; the whole world was not enough to feed it, so they needed to create extra worlds. They made these new worlds by observing the one they already had. They both described sleep apnea, for example, long before the condition had medical credentials. Shakespeare saw it in Falstaff. Dickens saw it in Joe, a character in the book that made his name—1836’s The Pickwick Papers. Joe is introduced as “a fat and red faced boy in a state of somnolency who divided his time into small allotments of sleeping and eating.” Joe is obese; the only thing that rouses him is having his leg pinched and his appearance greeted by the refrain, “Damn that boy, he’s fallen asleep again.” Indeed, in those early days sleep apnea was known as Pickwickian Syndrome. Yet an even better description, one which seems to understand the underlying seriousness of the condition, is found in the character of John Willet, proprietor of the Maypole Inn in 1841’s Barnaby Rudge. Willet’s breathing, when asleep, is likened to the problem of a carpenter trying to get through a knot in a piece of timber. On one occasion, Willet “came to another knot—one of surpassing obduracy—which bade fair to throw him into convulsions, but which he got over at last without waking, by an effort quite superhuman.” Mr. Pickwick experiences insomnia (“that disagreeable state of mind in which a sensation of bodily weariness … contends against an inability to sleep”), while in Bleak House, Volumnia Dedlock is among those legions of people who claim not to sleep when in fact they do. There are descriptions of sleep spasms in the character of Twemlow in Our Mutual Friend and of sleep paralysis in Oliver Twist: “There is a kind of sleep which steals upon us sometimes, which, while it holds the body prisoner does not free the mind from a sense of things around it.” A minor character in Hard Times takes to their bed for fourteen years, something of a Victorian pastime.
Dickens included sleep in all its guises in his literary works—most likely because he so often and so continually battled with it himself. In many respects, his spirit could find rest only in his fiction, a world of
his own wonderful making; reality, on the other hand, was for him a place of profound restlessness, as it had been ever since his childhood. He said, “My own comfort is in Motion”—with a capital M. He was always on the move, an escape artist, a mirror to the world, a gifted mimic, and a generous-hearted man, but one with little capacity for self-reflection. He painted hundreds of vivid characters, his prose using primary colors to subtle effect, but he never portrayed himself, at least not with conviction. The narrative voice in some of his personal writing is among his least sure characterization. Perhaps he knew that if he ever stopped, reality would catch up with him, not least the traumas of his own childhood and its emotional privations. Something was disturbed in his early years that never settled. All his life he was a magnificent observer; he never missed a thing. His imagination was both his blanket and his bed. His books celebrated human entanglement; in private, Dickens was controlling.
Dickens knew one city, London, like few others have known any city. The source for this intimacy was that Dickens knew London at night, in the hours after it took off its makeup. Great Expectations, to take a single example, turns on the moment when the convict Magwitch reenters the life of Pip; that scene rests on its depiction of a wild London night. London was Dickens’s bed partner as well as his quarry; he loved her and needed her chaos to pillow his own. The pair of them spent many restless nights together, tossing and turning. He called London his “magic lantern.”
Because of all of this, it is hardly surprising that Dickens’s remedy for his insomnia was to get out of bed and start walking. Early in his career, in the 1830s, he wrote journalism under the name of Boz. A typical piece recommends getting to know London between three and four in the morning, the time when she gives up her secrets: “But the streets of London, to be beheld in the very height of their glory, should be seen on a dark, dull, murky winter’s night when there is just enough damp stealing down to make the pavement greasy.”
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