Sleeping Pill Side Effects

Insomnia refers to the inability to fall asleep when you want to despite being in bed and desirous of sleep, difficulty staying asleep, waking up too early, or waking up after sleeping for a sufficient period of time and not feeling refreshed.

Official definitions of insomnia are not consistent. Some refer only to the sleep patterns being experienced while others require secondary symptoms that interfere with daytime functioning.   Because the criteria used to define insomnia often varies when research is conducted, we don’t know exactly how prevalent insomnia is among the general population. Estimates divide insomnia into two categories, one for long-term or chronic insomnia and the other for temporary or transient insomnia that is referred to as acute insomnia. Between 10 – 15% of adults suffer from chronic insomnia and 25 – 35% experience temporary bouts of insomnia.

A connection between poor sleep and increased illnesses and diseases and premature mortality is well established. Sleep deprivation refers to a situation where someone has not received an adequate amount of sleep. Sleep deprivation can be acute, referring to a total lack of sleep, and chronic, referring to receiving less than sufficient sleep, usually for a period of several days or longer.

Both acute and chronic sleep deprivation have well-established consequences for daytime functioning. The adverse effects include worse mood, decreased ability to remember and focus, irritability, fatigue and sleepiness, apathy, accident proneness, and reduced cognitive function. When sleep deprivation continues over a period of time, it has adverse impacts on cardiac function, increases the risk of diabetes, adverse impacts on immune and digestive function, increased inflammation, and decreased self-control.

When evaluating treatment options, the risks of a treatment should be weighed against the risks of no treatment and alternative treatments that may have a lower risk of side effects.

Sleeping Pill Side Effects

We will describe side effects related to four types of drugs that are prescribed as sleep aids:

  • Hypnotics (Non-benzodiazepine sedatives)
  • Benzodiazepines
  • Barbiturates
  • Anti-depressants

Throughout this article, we will describe the side effect one time and if a subsequent drug has the same side effect, we will name the symptom, but we will not describe the it again.

Hypnotics Sleeping Pill Side Effects

Hypnotics are mandated by the FDA to provide a Black Box Warning on the packaging advising consumers that: Complex sleep behaviors including sleep-walking, sleep-driving, and engaging in other activities while not fully awake may occur with therapy; some of these events may result in serious injuries, including death; discontinue therapy immediately if patient experiences a complex sleep behavior.

Additional risks of all the hypnotics prescribed for insomnia include the following:

  • Potential to worsen symptoms of existing respiratory diseases
  • Symptoms of clinical depression, suicidal thoughts, and completed suicides may increase
  • The ability to function at full capacity the day after taking a hypnotic may be impaired including difficulties associated with:
  • Ability to drive or operate dangerous equipment safely
  • Hand-eye coordination
  • Playing a musical instrument
  • Accurate typing
  • Threading a needle

Amnesia 

Memory loss due to dementia or brain damage

Amnesia involves the loss of memories, temporarily or permanently, as the result of sedatives or hypnotic drugs. Amnesia can occur as the result of the drugs or, if a complication occurs that depresses the Central Nervous System (CNS), brain damage that causes permanent amnesia can occur.

Dizziness and Lightheadedness

Dizziness and Lightheadedness

Dizziness creates a feeling of unsteadiness and can cause you to feel faint, weak, or woozy or a sense that the room is spinning. All of these symptoms can lead to falls and carry the risk of potentially serious injuries.

Headaches

Headaches refer to pain in the head that can be mild to sharp, dull to pounding.

Hallucinations

Hallucinations

Hallucinations can involve seeing things that aren’t there, hearing sounds that aren’t real, and smelling things that don’t exist in reality. Hallucinations can also cause a patient to not see, hear, or smell what is present in reality. They can also involve feeling sensations, such as being touched or bugs crawling on the skin that aren’t there. Hallucinations can cause disorientation and accidents or injuries to self or others.

Increased Risk of Falls

Increased Risk of Falls

Taking hypnotics causes an increased risk of falls and injuries including hip fractures and intracranial hemorrhage; this risk is higher for elderly individuals

The following sleeping pill side effects are specific to Eszopiclone:

Nausea 

Feeling queasy, including the urge to vomit, upset stomach, and sometimes sweating or chills are associated with feeling nauseous.

Abdominal pain 

Abdominal pain 

Abdominal pain can have many sources and the problem with it is that some of those causes can be serious. Inflammation, constipation, gas, stress, muscle strain, and overeating can all cause abdominal pain.

Weakness 

Feeling weak can range from feeling as if your muscles aren’t as strong as they usually are or that they are too weak to support you. You can feel too weak to get out of bed or stand up.

Menstrual cramps 

Menstrual cramps can occur when the woman is not menstruating because of side effects of the drugs.

Eye pain

Eye pain can feel as if it is coming from the surface of the eye, inside the eye, or behind the eye. It can be experienced in conjunction with other symptoms such as nausea.

Sensations on their skin with no apparent cause 

This symptom is a form of hallucination and involves feeling sensations on the skin when there is no cause for the sensation being felt.

Tremors

Tremors are unintentional shaking or trembling that most often occurs in the hands, but can also occur in the vocal cords, legs, or face.

Decreased Level of Consciousness

A decreased level of consciousness makes it more difficult to rouse a patient and responses to stimuli in the environment are slower or nonexistent.

Zolpidem has these side effects in addition to the ones it shares with the other two hypnotic sleeping pills:

Heart palpitations

When you feel as if your heart is beating extra fast, fluttering, pounding, racing, or skipping a beat, you’re having heart palpitations. While heart palpitations can be frightening, by themselves they aren’t usually a sign of danger. If you’ve mixed sleeping pills with other drugs, you should check for drug interactions (this should have been done before you mixed them, but if you didn’t, do it when you experience any side effect – even if your doctor and/or pharmacist knew about the other drug).

Myalgia

Myalgia

Myalgia is pain in your muscles, ligaments, or soft tissue. It can feel similar to the pain you feel after you’ve worked out and your muscles are sore.

Sinusitis

Sinusitis

Swelling or inflammation of the sinus tissues.

Sore throat

Sore throat

Pain, especially when swallowing, scratchiness, and irritation of the throat.

Visual disturbances

Visual disturbances

Visual disturbances can include double vision, partial or total blindness, blurred vision, the inability to distinguish colors, halos, or eye pain. In many situations, visual disturbances are dangerous because of the risk of accidents associated with the inability to see properly.

Rashes

Rashes can occur anywhere on the body. They can be red spots, raised skin, or itchy skin. Rashes can make the skin hotter than surrounding tissues.

Constipation

Constipation occurs when you don’t feel the urge to go to the bathroom or have difficulty having bowel movements. In most cases, constipation is not dangerous but if it continues, it can become serious and life threatening.

Benzodiazepines Sleeping Pill Side Effects

Benzodiazepines also have a Black Box Warning mandated by the FDA:

Concomitant use of benzodiazepines and opioids may result in profound respiratory depression, coma, and death; administer concomitantly when there are no alternative options; limit dosages and durations to minimum required; monitor for signs and symptoms of respiratory depression and sedation.

More: How Many Sleeping Pills Does It Take To Die

In addition, benzodiazepines include the following warnings:

  • May cause drug dependence
  • Central Nervous System (CNS) depression that impairs mental and physical abilities can occur
  • Hyperactive, aggressive, or paradoxical behavior may occur
  • Do not consume alcohol
  • Do not take other CNS depressants
  • May interfere with the ability to drive or operate machinery the next day

Because benzodiazepines have more adverse side effects than hypnotics, and more sleeping pill side effects that can cause serious injury or death, physicians will generally prescribe hypnotics before they try benzodiazepines.

The length of time it takes for the body to flush out the drugs takes longer in elderly individuals and women which can make the sleeping pill side effects last longer and extend the time period when the patient should avoid drug interactions and alcohol.

More: Sleeping Pills and Alcohol

The higher the dose, the more likely patients are to experience side effects.

There are numerous types of benzodiazepines, but there is considerable overlap on side effects. This list of possible side effects is a combined list of side effects from the different types of benzodiazepines prescribed as sleeping pills. Read the package insert from the pharmacy for the specific side effects for the sleeping pill your doctor prescribed.

Functional Side Effects

The functional side effects of benzodiazepine sleeping pills interfere with the ability of the body’s conscious movements because the ability of the body to respond is impaired.

Daytime drowsiness

Daytime drowsiness can occur even if the sleeping pills allowed the patient to sleep a full 8 hours. This may be because they did not obtain a good balance of REM (Rapid Eye Movement) sleep.

Fall risk; especially in elderly patients

The risk of side effects that could cause a fall is long and because it takes elderly patients longer to rid their body of the drug, they are more likely to be effected by those side effects the next day as well as during nighttime waking’s to use the rest room, which are common for elderly patients.

Hungover feeling

A hungover feeling is a combination of symptoms that can include wooziness, sleepiness, thirst, confusion and difficulty focusing, headache, and overall malaise including an upset GI track.

Vertigo

A feeling that you or the environment you’re in is moving when it isn’t moving. The room may feel as if it is spinning.

Slow movements

Slow movements occur when the conscious instructions to the brain to move the body are acted on more slowly than normal. This includes slowed reaction times that could be dangerous when driving.

Unsteadiness

Unsteadiness involves a loss of equilibrium that can cause a sense of falling and can cause stumbling and bumping into objects that would normally be avoided.

Slurred speech 

Slurred speech can give the impression that the patient is intoxicated. The signals to the muscles used when talking do not respond in their normal manner.

Dizziness and Lightheadedness were described in the section on hypnotic sleeping pill side effects.

Side Effects that interfere with Automatic Bodily processes

Numerous side effects of benzodiazepine sleeping pills interfere with automatic bodily processes which can lead to serious complications.

Central Nervous System (CNS) Depression

Central Nervous System (CNS) Depression

The Central Nervous System (CNS) controls your automatic breathing and the beating of your heart. When the Central Nervous System is depressed too much, your CNS can forget to breathe or beat your heart. This can cause death or brain damage.

Convulsions

Convulsions are involuntary rapid muscle contractions that repeatedly contract and relax muscles in a way that is beyond the ability of the individual to control the convulsions.

Diarrhea

When an individual has loose stools more than three times in the same day, they have diarrhea.

Dry mouth

Dry mouth refers to a situation where your saliva glands don’t produce enough saliva to keep your mouth wet.

Heartburn

Heartburn is pain and discomfort in the center and upper part of the chest, the sensation may feel as if it is burning, and may include the neck and throat.

GI complaints

GI complaints involve a wide range of symptoms connected to the gastrointestinal tract. They range from chest pain, abdominal pain, hiccups, nausea and vomiting, gas, bloating, GERD, belching, flatulence, and numerous other complaints related to digestion and elimination of waste.

Impotence

Impotence

The inability of a man to sustain an erection.

Incontinence 

Urinary incontinence is the inability to prevent leakage of urine, usually associated with coughing, sneezing, or lifting heavy objects. During a period of lethargy or decreased consciousness, a patient might not bother to get up to go to the bathroom or have enough awareness that they should.

Jaundice

Jaundice is noticeable when the skin and the whites of the eyes turn yellow as the result of too much bilirubin, which can be due to gallstones, tumors, and hepatitis.

Changes in libido 

Sexual desire may decline.

Menstrual disorder 

Symptoms can be physical, including heavier periods or missed periods and emotional, including uncontrollable mood swings.

Noise or ringing in the ears (Tinnitus)

Noise that is in the ear, not from the environment, which can include buzzing, ringing, roaring, whistling, or hissing.

Difficulty with urination

Reduced bladder function.

Rigidity

Stiffness of the muscles that prevent them from relaxing and can decrease the range of motion.

Increased or decreased salivation 

Dry mouth or too much saliva.

Seizures

Seizures are uncontrolled electrical disturbances that occur in the brain that can affect your movements, level of consciousness, behavior, or feelings.

Vomiting

Regurgitating the contents of the stomach.

Blurred vision, constipation, decreased Level of Consciousness, amnesia, nasal congestion (Sinusitis),

nausea, visual disturbances, and tremors also belong in this category.

Energetic Side Effects

Energetic Side Effects

The energetic side effects of benzodiazepine sleeping pills reduce the energy an individual has to perform tasks, including activities they usually enjoy doing. It can feel as if they are out of fuel.

Fatigue

Fatigue is a mental and physical lack of energy that robs the person of the desire to do things they need to do and want to do.

Lethargy

Someone who is lethargic exhibits a pathological lack of responsiveness and activity. They do not have the energy or enough desire to make themselves take action – even sedentary activities like reading, watching television, or coloring may seem to take too much effort for an individual who feels lethargic.

Weakness and decreased energy are also side effects.

Behavioral Side Effects

Changes in appetite 

A loss of appetite is more common than an increase because depression of the CNS system slows digestion, but appetite could increase due to decreases in inhibition, so it can go either way.

Hyperactive behavior – Restlessness and an Inability to stay still 

Hyperactive behavior refers to activity that doesn’t necessarily have a reason, such as fidgeting and pacing, impulsive actions, difficulty concentrating, and being easily distracted.

Talkativeness 

You could say that talkativeness is hyperactivity of the mouth. Although some people are naturally talkative, this symptom refers to talkativeness that is not normal for the patient.

Emotional Side Effects

Emotional Side Effects

Hostility

Hostility refers to a general demeanor that is unfriendly or worse, such as antagonistic.  In this case, it often refers to unwarranted hostility that occurs with little or no provocation, such as someone who reacts poorly when someone looks at them.

Irritability 

Someone who is irritable overresponds to small stimuli by expressing frustration or becoming upset. Small things, like dropping a spoon on the floor, might make someone who is irritable react in a strongly negative way.

Impaired neurological coordination (gait, speech, eye movements) – Coordination Difficulties

One of the side effects of these sleeping pills is delayed signals through the neurological system that interfere with the ability to walk, speak, and use our other senses the way we do when we are unimpaired.

Physical Side Effects

Bloating

Bloating refers to the feeling that your belly is swollen and is most common after eating, especially a big meal. It can also be related to excess gas production or problems with the muscles in the digestive system performing appropriately. Those muscles are part of the CNS and can be adversely affected by depression of the CNS.

Neuromuscular & Skeletal Weakness

Skeletal muscle weakness is associated with COPD which is often associated with insomnia. The medication can also cause temporary weakness in the neuromuscular and skeletal systems.

Weight gain/loss

Benzodiazepines can cause weight gain and weight loss, partially due to appetite changes as well as lethargy.

Muscle cramps and aches and pains (Myalgia) are also potential side effects of benzodiazepines.

Cardiovascular Side Effects

Cardiovascular Side Effects

Cardiovascular side effects are some of the most dangerous sleeping pill side effects from benzodiazepines. Because benzodiazepines induce sleepiness by depressing the Central Nervous System (CNS) that controls the beating of your heart and breathing, too much depression can cause your heart to beat too slowly or, at overdose levels, to stop beating entirely.

Low Blood Pressure

When the heart does not beat frequently enough due to CNS depression, blood flow slows down. This reduces blood flow to the brain that can cause serious problems. If the CNS is too depressed, it can lead to permanent brain damage or death.

Slow heart rate (Bradycardia)

Bradycardia occurs for the same reason as low blood pressure noted above.

Passing out due to low blood pressure 

When the brain doesn’t receive enough oxygen because blood pressure is too low, it can cause faintness that results in fainting.

Blood dyscrasias (can be fatal)

Blood dyscrasias refers to an imbalance in the amount of blood, bile, lymph, and phlegm in the body.

Tachycardia 

Tachycardia is a disorder of the heart’s rhythm. During Tachycardia, the heart beats faster than normal and is not associated with exercise or a stress response, trauma, or illness.

Sleeping Pill Side Effects that occur in the Brain

Cognitive disorders including Confusion and Disorientation

These include amnesia (especially the inability to remember new information) which is discussed elsewhere and delirium, which involves confusion and disorientation. Cognitive disorders interfere with the ability to remember, learn, solve problems, and can lead to distorted perceptions. Decreased level of consciousness, headache, and hallucinations (auditory, visual, smell, and sensual) are also possible.

Nightmares

Nightmares are dreams that disrupt sleep because they are frightening or disturbing.

Psychological Side Effects

Abnormal thoughts

Abnormal thoughts can be disturbing thoughts that frighten the patient or even thoughts that cause paranoia or they can be thoughts at the other end of the spectrum that bring strong, positive emotions. The problem with abnormal thoughts is that they are distortions. For example, someone may feel convinced that the object of their affection returns their feelings when the person they are focused on is a celebrity who doesn’t know they exist. Terrifying abnormal thoughts can be thoughts that someone is out to harm you.

Aggressive behavior

When a patient exhibits aggressive behavior, it is usually unexpected, impulsive behavior that is an overreaction to the situation. The behavior can be violent and violate social norms as well as the law. If the person had an unexpected reaction to the legal use of benzodiazepines, they might be able to defend against legal charges but if they’ve mixed them with alcohol or taken them not as prescribed, they could be in serious legal trouble after exhibiting aggressive behavior.

Agitation

One way to describe agitation is “not calm.” There is nothing calm about someone who is agitated. They will demonstrate their agitation physically, perhaps by pacing or wringing their hands. Their words will reflect their emotional state and can include annoyance, irritability, biting reactionary remarks, and even anger that all reflect their racing thoughts. They may talk excessively, a form of vocal fidgeting.

Anxiety

At its essence, anxiety involves feeling more stressed than the situation warrants. Someone who is feeling anxious feels worry or fear about situations that wouldn’t bother most people. These fears may be unfounded or simply blown out of proportion. Physical signs can include rapid breathing and heartbeat, sweating, and making themselves tired by the mental exertion of being worried.

Depression onset and Worsening depression including thoughts of suicide and completed suicide

Benzodiazepines can worsen existing depression and can also cause depression. The risk of suicidal thoughts increases.

Disinhibition

Disinhibition refers to someone who doesn’t feel bound by normal socially required restraints relating to their behavior, words, and other actions. They may be highly impulsive, deciding to do things that aren’t socially acceptable or risky without giving thought to the potential consequences. Disinhibition affects the cognitive process the patient uses in decision-making, the emotions they feel, and their choices.

Euphoria

Euphoria is a state of happiness that lacks any sense of waiting for the other shoe to drop. This sense of happiness is intense, described as elation and an overall feeling of high positive energy.

Psychiatric disturbance

Psychiatric disturbances, up to and including onset of psychosis, have been reported as a rare side effects of benzodiazepines. Psychiatric disturbances cause changes in the way you think, how you feel, and your behavior. They can cause disability, and in some cases, loss of freedom or even death.

Nervousness

When your body and mind are stressed, biochemical and hormonal changes occur that produce adrenaline and cortisol. The fight or flight response makes your body ready for action and when you don’t act physically, the energy causes nervousness.

Withdrawal symptoms

It is critical not to stop taking benzodiazepines abruptly and to work with your doctor to stop taking them. Withdrawal symptoms, especially if done abruptly, can cause life threatening symptoms including seizures. Other withdrawal symptoms can include panic attacks, tremors, difficulty concentrating, muscle pain and stiffness, hallucinations, seizures, psychosis, heightened risk of suicide, insomnia, irritability, anxiety, and other cognitive and neurological impairments. Even short time medically supervised users can experience severe withdrawal symptoms.

Withdrawing use gradually reduces the risk of adverse withdrawal symptoms but does not eliminate it entirely.

Sleep Disturbances Side Effects

Rebound Insomnia (when sleeping pills are discontinued)

Stopping the use of benzodiazepines can cause insomnia or cause symptoms of insomnia to return.

Sleep related activities (sleep driving, sleep-cooking, sleep-eating, etc.) may occur 

Patients will sometimes drive, cook, eat, or have sex while they are asleep while taking benzodiazepines. These activities should be immediately reported to the doctor as they can be life threatening. In some cases, the patient doesn’t recall engaging in these activities during their sleep.

Allergic Responses to Benzodiazepines

Allergic reactions including anaphylaxis

Patients have had allergic reactions to benzodiazepines, including reactions that involved swelling of the throat and tongue.

Dermatitis (itchy dry skin or rash)

Dermatitis (itchy dry skin or rash)

Dermatitis refers to numerous skin conditions, from dandruff to dry, flaky patches of skin, swollen skin with a red tint, or even blisters that ooze. Dermatitis will often itch.

Hives

Hives are another reaction your skin can have to allergens. Hives are swollen bumps that are usually pale red, but they can also be plaques or wheals. They generally itch, sometimes almost irresistibly. They can also burn or sting.

Physical Damage from Benzodiazepine Use

Benzodiazepines can cause liver or gallbladder damage and should be monitored by the prescribing physician:

  • Increased liver transaminases (indicates potential damage to the liver)
  • Increase in ALP (indicator of liver or gallbladder problems)

Barbiturates Sleeping Pill Side Effects

Barbiturates also encourage sleep by depressing the function of the Central Nervous System (CNS), which means they have numerous sleeping pill side effects that overlap with benzodiazepines. They are only effective as a short-term solution since they tend to lose their effectiveness in as little as two weeks.

Serious side effects can occur including:

  • Developing an addiction to the drug
  • Depression and suicidal thoughts or actions
  • Dangerous withdrawal symptoms that can include delirium, convulsions, and death

Butabarbital (Butisol)

Hepatotoxicity

Hepatotoxicity occurs when the liver is damaged by chemicals it attempts to clear, such as the chemicals contained in barbiturates.

The more serious side effects are not common, but they are serious and include symptoms described previously in this article including hallucinations, CNS depression, Bradycardia, and Ataxia.

Mephobarbital (Mebaral)

Hyperkinesia

Hyperkinesia can involve uncontrollable muscle movements. It can include hyperactivity.

Hypoventilation

Hypoventilation occurs when respiration is decreased below the level where adequate gas exchange between oxygen and carbon dioxide occurs in the lungs as the result of respiratory depression.

Uncommon side effects that were mentioned previously because they overlap with benzodiazepines include Bradycardia, confusion, hypotension (low blood pressure), Ataxia, CNS depression, nightmares, agitation, impaired neurological coordination, and nervousness as well as non-serious issues such as nausea, constipation, and vomiting.

Pentobarbital Sodium (Nembutal) and Seconal (Seconal Sodium)

Paranoia

Paranoia is a type of abnormal thinking that reflects a distrust of others or thoughts that you are being targeted, persecuted, or watched by individuals with undesirable intentions toward you. Paranoid thoughts are not rational, but they tend to be persistent and difficult to dismiss by someone who is experiencing them.

Numerous potential adverse side effects of these two barbiturates are serious and may result in death. They include decreased breathing due to CNS suppression, suicide, hallucinations, impaired neurological coordination (gait, speech, eye movements), dizziness, memory impairments, anxiety, agitation that were all described earlier. Less severe side effects of these sleeping pills include skin rashes, nausea, vomiting, constipation, and nightmares.

Rare side effects of Pentobarbital Sodium include apnea, hypoventilation, Bradycardia, hypotension, dizziness, hyperkinesia, syncope (fainting from lack of blood to the brain), headache, abnormal thinking, psychiatric disturbance, confusion, nervousness, dermatitis, and, with chronic use, megaloblastic anemia and liver damage.

In addition to the side effects it shares with Pentobarbital Sodium, the following sleeping pill side effects have been reported for Seconal use: impaired mental and physical abilities, hyperactivity, headache, irritability, bleeding, and fever.

Phenobarbital (Luminal)

Nystagmus

This is an eye disorder that makes the eyes make uncontrolled repetitive movements that interfere with depth perception and vision. This condition can lead to problems with balance and coordination that can cause falls and other accidents.

Common side effects described earlier include impaired neurological coordination (gait, speech, eye movements), respiratory depression, dizziness, drowsiness, slurred speech, vertigo, fatigue, headache, irritability, excitement, confusion, depression. Less common side effects include mental dullness, constipation, diarrhea, nausea, vomiting, Megaloblastic (folate-deficiency) anemia. Uncommon side effects include rashes, Hepatotoxicity, and decreased calcium in the blood (Hypocalcemia).

Side Effects associated with using Anti-depressants as Sleeping Pills

Doxepin (Silenor)

Doxepin has a Black Box Warning related to a heightened suicide risk.

In addition to the Black Box Warning, side effects include agitation, panic attacks, irritability, impulsivity, mania, hypotension worsening depression, psychosis, seizures, sleep-driving, sleep-eating, sleep-cooking, sleep-phone calls anxiety, tachycardia, dizziness, paresthesia, blurred vision, Tinnitus, confusion, urinary retention, blood disorders, insomnia, fatigue, weakness, lethargy, headache, dry mouth, nausea, vomiting, sexual dysfunction, sweating, and rashes.

Conclusion

Sleeping pills come with the potential of a wide assortment of side effects, some of the risks are life altering and even deadly. Researchers report that sleeping pills help patients go to sleep about 13 minutes faster than they would without the pill and only increase total sleep time by 11 minutes per night.  Given the serious potential consequences of taking sleeping pills, it seems attempting to improve sleep quality with improved sleep hygiene and increased stress management skills is a better choice from a personal risk management perspective.

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