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Lack of sleep is 'epidemic' amongst Canadian teens, here's why it has doctors worried

Every morning the bell rings at 8:10 a.m. at Smiths Falls District Collegiate, and herds of weary high-school students stumble into class like zombies.

"We're always tired," Grade 10 student Michelle Norlock says. "It's hard, because you're not focusing and you can't really understand what the teacher is saying."

"My first class, I just want to fall asleep and not really pay attention, because I'm exhausted from the night before," echoes Grade 9 student Angelina Holmes.

Parents of any era know it's often a struggle to coax a groggy teenager out of bed. But two Grade 10 students at SFDC in Smiths Falls, Ont., wondered if their peers are, in fact, chronically sleep deprived.

Elizabeth Horsey and Quin Atkinson asked more than 300 students about their sleeping habits for a recent science fair project. Their questions included a survey known as the Epworth Sleepiness Scale that's commonly used to detect sleep disorders.

It’s recommended that 13- to 18-year-olds get eight to 10 hours of sleep per night, according to the Canadian Paediatric Society. Studies suggest more than half of Canadian teens get less than that. (Duncan McCue/CBC)

The duo found that students slept 7.67 hours on school nights, on average.

What surprised them was that more than a third of students would be classified by the Epworth test as having "excessive" daytime sleepiness, which, in some cases, warrants medical attention.

"Everybody is so stressed with all the work and they're not getting enough sleep," Atkinson says.

"They just have so much on their plate and they're not getting enough time to restore their bodies."

Indeed, national statistics show millions of Canadian adolescents don't get enough shut-eye, which has experts warning of long-term health consequences — unless we start appreciating the importance of a good night's sleep.

'Functioning sub-optimally'

The recommended amount of sleep for 13- to 18-year-olds is eight to 10 hours per night, according to the Canadian Paediatric Society.

Studies suggest more than half of Canadian teens get much less, about 6.5 to 7.5 hours per night, says Indra Narang, director of sleep medicine at Toronto's Hospital for Sick Children.

"We are in an epidemic of sleep deprivation," said Narang, who foresees cumulative effects that can have an impact on everything from health to work performance.

"In 20 years time, we're going to see a whole generation of adults who are functioning sub-optimally."

'We are in an epidemic of sleep deprivation,' says Indra Narang, director of sleep medicine at Toronto's Hospital for Sick Children, who foresees cumulative effects that can have an impact on everything from health to work performance. (Duncan McCue/CBC)

Teenagers naturally function differently than adults when it comes to bedtimes: they don't run on the same inner clocks.

In early adolescence and puberty, teens experience a shift in their 24-hour biological cycles, known as circadian rhythms. This means peak production of the sleep-inducing hormone melatonin happens later in the evening for teenagers, from roughly 11 p.m. to 8 a.m.

Those hormonal changes have long turned many teens into "night owls," but studies over the past few decades show the pervasiveness of sleeplessness is on the rise.

Reasons vary, from late-night use of electronics and hectic after-school schedules, to increased consumption of high-energy caffeine drinks. Some teens also have sleep disorders from being overweight.

"It's not uncommon for me to see teenagers in my clinic who are telling me that on school nights they go to bed at 1 a.m., 2 a.m., 3 a.m. — and get up at 7 a.m. to go to school," Narang says.

"They're struggling to get in to school for the allocated time. They are sleeping in school. They find it hard to do the homework."

When teens don't get enough ZZZZs, the health dangers range from obesity and diabetes, to depression and substance abuse. Narang says public health officials need to better understand the long-term consequences of sleep deprivation.

"What we don't want to do is miss the opportunity to intervene now, rather than have to intervene [later in life] when they have cardiovascular disease or metabolic disease or strokes or, indeed, dementia."

Later school start times?

One of the questions raised by Horsey and Atkinson's science project is whether a later school start time would benefit students.

Some teens worry that delaying start times could have an impact on part-time jobs or after-school sports programs, but many interviewed for this story were enthusiastic about any opportunity to sleep in.

"If school was a bit later, I could get maybe five or six hours [of sleep] … which would greatly help in, like, getting better grades," says Grade 12 student Haze Ketcheson, who sleeps on average four hours per night.

He might be onto something, and it's about more than getting enough sleep to avoid dozing off in class and missing an important lesson.

Some teens at Smiths Falls District Collegiate say they worry that delaying school start times could have an impact on part-time jobs or after-school sports programs, but many interviewed for this story were enthusiastic about any opportunity to sleep longer in the morning. (Duncan McCue/CBC)

Stuart Fogel, a professor at the University of Ottawa's Sleep Research Laboratory, has been looking at what the brain does while we sleep. He's interested in how each day's experiences are moved from the hippocampus, a limited space where we store recent short-term memories, to the prefrontal cortex, the brain's "hard drive" where we store important memories for long-term reference.

Fogel's research indicates that sleep basically cleans up the hippocampus, leaving us ready to take in fresh data — and simultaneously helps convert short-term memories into long-term ones so we can recall them later.

"What's intriguing is that sleep loss will have an impact on your ability to retain anything that you learn that's new," Fogel says.

Narang says studies of American high schools with delayed start times suggest it can lead not only to significantly increased attendance, but also better grades.

However, there can be a host of logistical challenges to changing school start times. In Smiths Falls, for example, where the student population is largely rural, budget restrictions on school bus services resulted in staggered start times at elementary and secondary schools that allow for buses to make two runs. High schools get the earlier start.

"We think they should push it to nine o'clock … all they have to do is switch our bus times with the elementary school kids," Atkinson says.

In the meantime, Horsey and Atkinson's school project on sleep nabbed a gold medal at the science fair, and it has been attracting plenty of interest from students and teachers.

It also caught the attention of Horsey's mother Veronica, who happens to be chair of the school council.

"Unfortunately, most adults don't even understand how sleep deprived we are," says Veronica Horsey. "Can we just look at the bigger picture on how to help our teenagers get more rest?"

She's now working with school administrators to find sleep solutions, including workshops to improve students' bedtime routines and scheduling fewer early-morning tests.


More from CBC

Watch Duncan McCue's story on how important sleep is to learning and forming memories:

Back in 2005, Canadians averaged about eight hours of sleep a night. By 2013, that dropped to seven. Now about 40 per cent of Canadians are dealing with some kind of sleep disorder. Something about sleep keeps our bodies and minds from falling apart. The lack of it has been linked to obesity, heart disease, stroke, diabetes and depression. Researchers are now discovering some fascinating things about how important sleep is to the way our brains store memories and learn things. 11:49

A neurologist answers questions from CBC's audience about how sleep affects a person's health and wellbeing.  12:42

Canadians aren't getting as much sleep as we want, this much we know. In fact, almost 60 per cent of us say we aren't getting the recommended eight hours a night. The National’s health panel talks about the impact of our daily habits on the quality of sleep we get, and answers some of your questions about sleep struggles and what can be done to get a more meaningful rest. 11:55


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Anxiety pills that promise so much leave behind a hidden 'epidemic'

Two weeks after her mother died, Rhonda Assoun-Gritten was looking around the 63-year-old woman's Dartmouth, N.S., apartment, opened the drawer of the night table and discovered receipts for three recent prescriptions. Assoun-Gritten didn't recognize the names of the medications, but stuffed the papers in her back pocket.

The death of Sharon Assoun on Feb. 24, 2016, had been shocking not only in its suddenness, but in its unusual nature. While babysitting that night at her son's home, she had gone down to the fridge, her daughter says, and drank a bottle of his illicitly purchased methadone.

When the toxicology report came back six months later, it pointed to the obvious. The amount of methadone, which is used to treat opioid addiction, had been within the lethal range. But the medical examiner's report also listed two sedatives in the cause of death. A third was found during toxicology tests.

It turned out that Sharon Assoun had for years been prescribed a class of drugs called benzodiazepines for insomnia and anxiety. On a hunch, her daughter showed the prescription receipts she had retrieved from her mother's home to her own family doctor.

"She put her hands on her head and put her head on the desk," says Assoun-Gritten. "'Rhonda,' she said, 'Your mother was so overmedicated she wouldn't have known, awake or asleep, if she was drinking the methadone."

Sharon Assoun, right, had filled prescriptions for three different benzodiazepines leading up to her death. (Submitted by Rhonda Assoun-Gritten)

Benzodiazepines have been used for nearly six decades to treat seizures, anxiety and insomnia. In 2017, more than 26 million prescriptions for benzodiazepines and related drugs were written in Canada. They include diazepam, lorazepam, alprazolam and clonazepam, and go under brand names including Valium, Ativan and Xanax.

But addiction experts have long worried about what they view as the widespread misuse and overprescribing of benzodiazepines. There is a growing push to come to grips with a problem that crosses generations, from seniors hooked for decades to the alarming emergence of Xanax abuse among teens in places like Nova Scotia.

Some are now even drawing parallels to the opioid addiction problem.

"As we start to treat the opioid epidemic and peel back that layer, the extent of the benzodiazepine epidemic that is gripping North America is going to be shown," says Dr. Selene Etches, manager of the concurrent disorder program at the IWK Health Centre, the Atlantic region's largest children's hospital.

This advertisement for the benzodiazepine oxazepam appeared in a 1967 publication of the Journal of the American Medical Association. (Journal of the American Medical Association)

Benzodiazepines were created in 1955 by chemist Leo Sternbach. Hoffmann-La Roche marketed its first version of the drug in 1960 and launched Valium three years later.

The drugs have a number of advantages. They're effective. They also appeared to be safer than barbiturates, a predecessor used to treat anxiety and insomnia with higher risks for overdose.

But they could still be addictive.

The 1966 Rolling Stones song Mother's Little Helper described "running for the shelter" of a "little yellow pill." By the 1970s, some doctors were raising the alarm. Deep concerns about benzodiazepine-prescribing practices remain today.

"I'm as concerned about this as I am about the prescribing of opioids for chronic pain," says Dr. Samuel Hickcox, the physician lead for addictions at the Nova Scotia Health Authority. "I think we're really contributing to a problem, to be frank."

One of the patients he has treated for addiction, he says, has been on benzodiazepines for 58 years, and was prescribed the first one to ever hit the market: Librium.

In Nova Scotia, the prescribing of benzodiazepine and related drugs remains stubbornly above the Canadian average, despite some modest decreases since 2012, according to data from the Canadian Institute for Health Information. Other Atlantic provinces fare even worse. Newfoundland and Labrador is double the national average. New Brunswick's numbers are even higher.

From 2011 to October 2018, benzodiazepines contributed to 313 "acute toxicity deaths" in Nova Scotia. Nearly 80 per cent involved a deadly mix with opioids.

Doctors say benzodiazepines do have a useful role. They can prevent seizures and are an effective treatment for severe alcohol withdrawal. They offer rapid relief for acute anxiety, and can calm a person before surgery or help someone terrified of flying.

But doctors say in most cases, they should only be prescribed for short periods. Long-term use can lead to dependency and addiction. While some patients function just fine for years, for others, the side-effects include cognitive decline, dizziness and drowsiness.

"We know that in the elderly, the chance of falling or having an injury from a fall goes way up when they're on benzodiazepines," says Dr. Connie Leblanc, an emergency doctor in Halifax who is part of a campaign called Choosing Wisely, which aims to curb unnecessary tests and prescribing.

Too often, Hickcox says, benzodiazepines are so effective early on that patients lose the incentive to build resilience against their anxiety. He calls the drugs "alcohol in pill form" because they work on some of the same parts of the nervous system as booze. It's almost akin, he says, to prescribing a beer.

As tolerance to benzodiazepines grows, anxiety can return. One pharmacist told CBC News she has made "grown men cry" by refusing early refills.

Worse yet, getting off them after long-term use is hard. Cold turkey is never recommended and potentially fatal due to seizures. It is more dangerous than opioid withdrawal, experts say.

"It gets me really nervous, as a physician who works in addictions," says Hickcox.

Steve Sepulchre and his wife, Heather Holm, on a walk near their home in Martins Point, N.S. (Alex Lynch/CBC)

For Steve Sepulchre, that moment of reckoning came as he writhed on the floor of his psychiatrist's office, begging for diazepam. He had lost his prescription and no one would give him more pills. Afterwards, his wife, Heather Holm, gave him an ultimatum: If he went back on benzodiazepines, their marriage would be over.

"It wasn't even a threat to leave. It was a statement of reality," she says in an interview at the couple's home in Martins Point, N.S. "Because there was no marriage with those drugs. The intimacy of marriage was not complete with those drugs."

Sepulchre's decade-long slide had started in 2001 when he visited his doctor for insomnia. At the time, he was holding down two jobs, as an aviation regulations consultant for Transport Canada, and teaching French at Acadia University in Wolfville, N.S. He was also being gnawed at by unresolved trauma from childhood.

Different drugs were tried. Later, a psychiatrist prescribed lorazepam, and eventually diazepam.

"The immediate feeling is relief," says Sepulchre, who is now 65. "That's the immediate feeling is welcome relief. It's like, now I can sleep. Huh. Now my problems don't seem so big anymore. Huh. Now I'm getting along easier with the world, the constraints of the world."

Sepulchre says he's found new tranquillity through meditation. (Alex Lynch/CBC)

But as time wore on, the symptoms of anxiety would return. The dosage would rise. The pattern would repeat. His lock on reality was changing. Technical aspects of his contracts became too hard. It was like the people around him were at the bottom of a swimming pool, their voices distorted by the water.

He was becoming apathetic and withdrawn. His spark was gone. Friends noticed. He would write crazy things to relatives. When it all became too much, he would "freak out," sometimes breaking electronics.

After his psychiatrist died, his file was sent to a family doctor in nearby Bridgewater who issued him a blunt assessment. His dosage of benzodiazepines would eventually kill him. A new psychiatrist put him on a tapering program, one of the primary ways to get someone off benzodiazepines.

Two years in, he lost his prescription. It was as if a decade of building tension was uncorked. Images flitted through his mind like banners trailing an airplane: details of meaningless work meetings long forgotten, obsessions from childhood. His heart rate shot up.

Today, he is off all the drugs, including an antidepressant he had also been prescribed. He only takes a small dose of marijuana oil at night to help him sleep. He credits meditation and the support of his wife with saving him. Slowly, incrementally, at times imperceptibly, he says, he's found enough tranquillity to bring himself back in touch with reality.

Oxazepam is one of the benzodiazepines listed in Sharon Assoun's cause of death. (Alex Lynch/CBC)

Concerns about benzodiazepines may date back at least to the Rolling Stones' early days, but the pop culture references hardly end there. The Guardian newspaper in the U.K. called Xanax, also known as alprazolam, "perhaps the most fashionable drug in 2017's rap scene."

This came after American rapper Lil Peep, who had rapped about using Xanax and posted a video saying he had popped six pills, died of an overdose.

Grammy-nominated singer-songwriter and rapper Post Malone spelled out his drug problems in the lyrics of Better Now, released last year: "I did not believe that it would end, no. Everything came second to the benzo." The California rapper Diego Leanos is even known by the stage name Lil Xan.

It was also in 2017 that Etches, the IWK addictions doctor, stepped back and realized something startling. The number of youth she was seeing who were abusing opioids was dropping. Xanax had now become her chief concern.

Many of the young people she treats are snorting and injecting the benzodiazepine in amounts far beyond what would be prescribed. They are self-medicating for anxiety and depression, to relax, sleep, escape trauma in their lives. Others want to get high, but then continue to use to deal with the withdrawal.

Dr. Selene Etches is the manager of the concurrent disorder program at the IWK Health Centre in Halifax. (Richard Cuthbertson/CBC)

Tutorials on the internet outline how to lie to a doctor to get a prescription. Many young people, Etches says, are simply raiding the medicine cabinets at the homes of families and friends. What is even more worrisome, she says, is  counterfeit Xanax is being sold over the internet.

Youth who come to the IWK for addictions treatment have their urine tested. The results reveal fakes are being laced with ecstasy, amphetamines, and deadly opioids like fentanyl and carfentanil.

"We tested one youth's urine and the only benzodiazepine that wasn't present was the one that he thought he was using," she says. Some teens have even obtained take-home kits to test their drugs.

One of things that makes Etches the most nervous is the withdrawal. So significant is the danger of seizures and delirium that she hospitalizes youth going through the process.

"The cravings can last years, especially in adolescence, because the brain is developing so much."

Xanax has been called 'perhaps the most fashionable drug in 2017's rap scene.' (Alex Lynch/CBC)

In October, benzodiazepines were added to Nova Scotia's prescription monitoring program, which can help flag worrisome prescribing patterns or identify patients doctor shopping for drugs.

A hotline staffed by specialists to give advice to doctors and nurse practitioners worried about patients with "problematic relationships to their medications," such as opioids and benzodiazepines, could be up and running by April.

An addictions education mentorship for health-care professionals now has 300 members in Atlantic Canada. And a program launched by two Dalhousie University experts aims to help insomniacs sleep without taking pills.

The death of Sharon Assoun led to investigations by the College of Physicians and Surgeons of Nova Scotia and Nova Scotia College of Pharmacists. (Submitted by Rhonda Assoun-Gritten)

At her family doctor's urging, Rhonda Assoun-Gritten launched a complaint with the College of Physicians and Surgeons of Nova Scotia against the physician who had been prescribing benzodiazepines to her mother.

An investigation showed Sharon Assoun had long been on oxazepam for anxiety and temazepam to help her sleep. But in the months leading up to her death, she had switched from oxazepam to a similar sedative, clonazepam, and then back again as she dealt with "distress" related to family issues.

Her doctor would later tell the college he instructed Assoun not to take the clonazepam once she returned to her old medication. He said he had counselled her and suggested mental-health treatment to help her deal with her issues. She declined. He reported she was coherent, clear and alert, and didn't appear overmedicated.

But not long before her death, Assoun managed to fill prescriptions for all three benzodiazepines. She told the pharmacist she needed that much. He never called her doctor to clarify.

The college of physicians concluded Assoun's family doctor had not been overprescribing. The Nova Scotia College of Pharmacists, which reprimanded two pharmacists involved, saw it somewhat differently. It noted that even using two benzodiazepines at the same time is "not a preferred treatment plan, however, it is not an uncommon prescribing practice."

"I feel really let down by the whole system," says Assoun-Gritten. "It's really sad that one phone call, just one phone call, and my mom would still be here."

If you have a story about benzodiazepines you want to share, contact richard.cuthbertson@cbc.ca  

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CBC | Health News

Diabetes Canada warns of 'epidemic,' calls for national strategy

Diabetes experts say Canada could prevent another million type 2 diabetes diagnoses in the next decade if Ottawa helps to fund something it lacks now: a national diabetes strategy.

Officials with Diabetes Canada were joined by Liberal MP Sonia Sidhu in the National Press Theatre Tuesday morning to ask the federal government to earmark $ 150 million in the next budget to fund a diabetes initiative over seven years.

The charity said its Diabetes 360 strategy, modelled after HIV/AIDS targets, would establish clear milestones to prevent and manage the disease, which affects about five million Canadians.

The strategy would focus on factors contributing to the disease's rise in Canada, such as poverty, poor food security and unhealthy living.

"Canada is facing a diabetes epidemic. Since 2000, the number of Canadians with diabetes has doubled," said Dr. Jan Hux, president and CEO of Diabetes Canada.

"A 20 year old in Canada now faces a 50/50 risk of developing diabetes. For First Nations people, that risk is 80 per cent."

On Tuesday, Diabetes Canada released the results of an Ipsos poll it commissioned which found eight in ten Canadians think the country should be more concerned about diabetes.

"There is a unique opportunity for the federal government right now to take the lead on a nationwide strategy," said Russell Williams, the charity's vice-president of government relations and public policy.

"Diabetes 360 could prevent more than a million Canadians from receiving a diagnosis of type 2 diabetes in the next decade. It could also mean 50,000 lower limb amputations avoided. It could reduce 350,000 hospitalizations," he said.

Williams said any national strategy should include an Indigenous-led component.

The year "2021 is the 100th anniversary of the discovery of insulin," he said. "Canada must have this plan in place … for us to continue the leadership that we once had when it comes to diabetes."

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U.S. officials call teen vaping 'epidemic'

U.S. health officials say teenage use of e-cigarette has reached "epidemic" levels and are calling on the industry to
address the problem or risk having their flavoured products pulled off the market.

The warning from the U.S. Food and Drug Administration on Wednesday marks a stark shift in the agency's tone on e-cigarettes, which have become the most used tobacco product among teenagers.

Since 2017, FDA officials have discussed e-cigarettes as a potential tool to ween adult smokers off cigarettes.

But FDA commissioner Scott Gottlieb says the agency did not predict an "epidemic of addiction" among youth, mainly driven by flavoured products.

Gottlieb says the five largest e-cigarette manufacturers will have 60 days to produce plans to immediately reverse underage use of their products.

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