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“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Wednesday, April 22, 2020

    "I'm having trouble sleeping" is one of the most common complaints I hear from patients. This is understandable, as up to 25% percent of the American population reports occasionally not getting enough sleep (though it seems like more to me). However the percentage suffering from the true definition of insomnia is smaller, about 6 percent. Per the DSM-5 definition, insomnia patients feel impaired from lack of sleep during the daytime; symptoms last at least a month; and are not associated with other medical conditions, substance use or other sleep disorders (restless legs syndrome would be a good example of this).

    Certainly sleep issues are seen most often in the elderly but insomnia can hit at any age. Recently while sorting through a bunch of stored papers I found a literary quarterly published by my university which I had saved for some reason. The theme was "All Night Long" and at least two of the pieces dealt with insomnia... it could have been more, possibly three or four. (These were written by people in their late teens and early twenties, mind you, and they were complaining of insomnia!) There are plenty of factors other than age, however. Sleep problems are often connected to lack of physical activity, especially these days when so many people work sedentary jobs. Daytime naps are also not a good idea as they relieve physical fatigue just enough to make it difficult to fall asleep. And irregular sleep patterns, such as working nights or sleeping late, can also ruin a good night's sleep.

    I empathize with patients as a fellow sufferer. I have had insomnia most of my life, to the point that if I sleep through the night I almost feel cheated. My nighttime awakenings are my "me time," when I ponder my work schedule, to-do lists and various deep thoughts. Certainly I need sufficient sleep to function, at least six hours. Back when I was a medical resident I realized that I was usually very depressed the day after being on call. It took a surprisingly long time for me to figure out the connection between my mood and lack of sleep.

    The basic recommendations:

    • Regulating your sleep pattern is a big one. Yes, you have to become one of those boring people who goes to sleep at the same time every night. 
    • Don't go to bed too early. If you go to bed at eight-thirty, you won't sleep through the night unless you have to get up at four-thirty every morning - or even earlier than that. 
    • Limit alcohol and caffeine. Alcohol can really screw with your sleep. No caffeine after noon. 
    • Don't go to bed until you are ready to go to sleep. I once had a friend, a fellow MD, who stated that if he had his way every bedroom in the US would be deprived of its television. Likewise, no reading or crossword puzzles in bed. You should do these fully dressed and in a separate room until you are ready to go to bed. 
    • Keep the bedroom cool, dark and quiet. 
    • And now that we have computers and smartphones, the same applies. Don't grab for your phone if you awaken in the middle of the night. You don't want to be looking at a glowing screen. 
    • Do try to get some physical activity in, it will tire your body and you will sleep better. 
    • Don't use sleep medications if you can possibly avoid it. 
    And now we come to the crux of the matter... the request for sleep medication. Many insomniacs resort to the antihistamine diphenhydramine (AKA Benadryl in the US) as it is sedating and readily available. Not to mention that if you have allergy-related postnasal drip at night, it will solve that problem as well. Pretty much every nonprescription sleep medication is a combination of diphenhydramine and either acetaminophen or aspirin. Does it work? Yes, as I can vouch from firsthand experience; I have used it myself. However it can interact with other medications and has side effects, most often associated with the elderly population, who of course are the ones most often requesting sleep medication. 

    Then there are the natural options: Camomile tea, valerian and melatonin. Also meditation. I recommend all of these options, but you can always identify a hardcore insomniac by the death glare they give you when you suggest melatonin. Also melatonin is not recommended for pregnant women, and the jury is out on valerian and pregnancy (I have seen articles saying both that it is OK and that it should be avoided). 

    And then there are the prescriptions. Sleep specialists recommend not using benzodiazepines (aka "nerve pills") for sleep, even though they work. They are also potentially addictive, and sudden discontinuation after years of heavy use can cause lifethreatening withdrawal. (A favorite saying of addition specialists: Narcotics withdrawal makes you wish you were dead; benzodiazepine withdrawal makes you actually dead.) It's easy to develop benzo tolerance with regular use, meaning you need to keep increasing the dose to get the same effect. 

    Non-benzo hypnotics are considered safer, and generally are. However, we still don't recommend using these on a nightly basis as development of drug tolerance is still a problem with this group. Examples of these drugs include zaleplon and eszopiclone. Keep in mind that any sedative, no matter which drug group we are dealing with, is dangerous to mix with alcohol or other sedation. In the elderly sedatives can cause confusion and they also increase the risk of falls and injuries. 

    Sleep specialists recommend not prescribing these medications; however, we live in the real world and I do prescribe sleep medication, because sometimes you just need it. When I do, I always emphasize that it should not be used nightly and I track patients' refill requests to see how often they are using it. I suggest using it not more than three times per week, to prevent the problems of relying on the drug and developing tolerance. 

    Not to mention that patients are missing out on the benefits of searching your soul and making to-do lists at three in the morning. 

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