Testosterone Therapy Part I: ‘I’m On an Opiate [buprenorphine, Suboxone, methadone, morphine, etc] and My Mood and/or Libido are blah’

Testosterone Therapy Part I: ‘I’m On an Opiate [buprenorphine, Suboxone, methadone, morphine, etc] and My Mood and/or Libido are blah’

by Natan Schleider, M.D.

August 19th, 2018

While the USA suffers through another opiod use epidemic (yes, we’ve had them before but I’ll give you the history lesson another time), the focus of press and medical/government powers that be are appropriately focused on preventing overdose and death. Far less attention is paid to adverse effects of chronic opiate use.

Whether used for pain management or for Medication Assisted Therapy (MAT) [IE using buprenorphine or methadone to manage Opiod Use Disorder formerly called opiod dependence] here is an important medical fact: if you are taking any opiate, you are at risk for testosterone deficiency. While not life threatening directly, common signs and symptoms of testosterone deficiency are decreased libido, depressed mood, lack of energy, diminished muscle mass/trouble gaining muscle size and strength at the gym, increased body fat, erectile dysfunction, and infertility.

Opiates reduce leuteinizing protein (LH) and follice-stimulating protein (FSH) production at the brain’s pituitary gland. LH and FSH tell the testicles to make testosterone.

In my practice, 50% to 75% of my male patient’s on opiods have low testosterone and half of them have some of the symptoms listed above.

I would argue that suffering the above symptoms poses risk of relapse to illicit opiod use and should be investigated and treated when indicated.

The good news about testosterone supplementation: it can help many of the symptoms above. The bad news: testosterone supplementation increases risk of prostate disease, prostate cancer, blood clots, and possibly heart disease (depending on the study).

Testosterone is broken down/destroyed by the stomach if swallowed so it has to be supplemented via transdermal gel (that goes on the skin daily) or by injection into the muscle (usually the gluteus) weekly to monthly. A few formulations I am not that experienced with as I can rarely get them covered are available: buccal (melts in the mouth) Striant, intransal gel (Natesto) [has to be given 3 times daily–annoying].

Most of my patients prefer the injectable formulations being least expensive and allowing for the patient and I to optimize how frequently to give the shot. I find weekly injections the best as if given less often, testosterone levels tend to peak for several days after the injection and wear off faster than the manufacturer suggests.

I would love to hear your experience or horror stories or opinion about testosterone therapy in opiate users via Twitter.com @DrSchleider or Facebook or Instagram.

Thanks for reading and stay tuned for part II, testosterone supplementation in women and transgender patients.

A Family Doctor’s Visit to See a Cosmetic Dermatologist for Sun Damaged Skin Part I: Poikiloderma of Civatte

A Family Doctor’s Visit to See a Cosmetic Dermatologist for Sun Damaged Skin Part I : Poikiloderma of Civatte

By Natan Schleider, M.D.

Dr. Natan Schleider’s Forehead. Note what appears different color tones which was diagnosed a poikiliderma.

I don’t wear skinny jeans. I wear flip flops whenever I can which apparently are out of style. And while starting to go bald–which I’ve decided to ‘own’ rather than pursue hair plugs or the ever popular toupee, the sun-damaged skin on my forehead has been bothering me (only when I look in the mirror).

Having spoken to my regular dermatologist, Dr. Roy Seidenberg (great, brilliant physician), he suggested a cosmetic dermatology consult for possible laser treatment.

Now I’ve had laser treatment before in my early 30s: laser hair removal on my back and chest. After 18 months of treatment every 6-8 weeks for a total package deal of about $3500, my back and chest were about 60% improved but I learned one valuable lesson: as I aged new hairs began to sprout on my back and chest (not to mention my ears, yikes!). So what I presumed–and is often advertised as a ‘permanent’ fix–not the case with me.

Friends have raved about various laser treatment for skin as the definitive cure while many patients of mine love Retin-A, a prescription cream or gel FDA approved for anti-aging (improving fine lines and sun spots). I tried Retin-A for a few weeks but realized I was soon forgetting to apply it at night (when I was negotiating with my 5 year old daughter Elie on the benefits of tooth brushing, a nightly debate).

Treatment for this would not be ‘one and done’ but would require a ‘series’ of treatments–the doctor would not commit on even a ballpark number but I would surmise 5-10 treatments. lasting ‘minutes’ after a numbing cream was applied. The stronger the laser each session, the better/faster the final results (meaning the more sun-damaged blood vessels are destroyed). If the laser is put on mild, minimal downtime, skin feels slightly sunburned, you can work same day. If laser is put on high power, skin is very red and inflamed and downtime expected to be 1 week. The cosmetic dermatologist suggested an in between setting.oping for a ‘one and done’ laser treatment to leave my forehead smooth and uniform in color, I saw a cosmetic dermatologist yesterday.

I tried to get a price idea on these laser treatments before the consult but found no great source?

Anywho, while I do have a few sun spots medically called solar lentigos, my primary problem in poikiliderma, a benign discoloration of blood vessels brought on by sun exposure underlying the skin leaving colors darker and lighter.

Treatments would occur about once a month and I ultimately got a price of $450 per treatment (which I think is low in the NYC area as it is a small region of skin being zapped as opposed to chest or neck where poikiloderma occurs more commonly.

The staff seemed surprised when I declined treatment at this time. Given this would be a long expensive process with best outcomes (based on my research) about 75% improvement, I paid my $200 consult fee and told them ‘I’d think about it’ which I will do.

The treatment would involve some type of laser which would take ‘a few

Any comments or experiences with cosmetic dermatologic treatments appreciated via Twitter.com or Facebook.com or Instagram.com.

Thanks for reading and I’ll keep you posted if I go back for laser treatment.

 

 

 

Medicine Changes It’s Mind Every 10 Years, Case in Point, Vitamin D Supplements No Longer Advised

Medicine Changes It’s Mind Every 10 Years, Case in Point, Vitamin D Supplements No Longer Advised

By Natan Schleider, M.D.

August 13th, 2018

Having been in practice 13 years now, I’ll let you in on a secret: fifty percent of everything you learn or read about in the news regarding health and medicine will be obsolete or wrong, sometimes even harmful, within 10 years or so. Does that mean I should ask for 50% of my money back from my medical school, hmmmm?

Case in point: In the 2000s, a lot of interest in Vitamin D testing and supplementation ensued with the consensus being, take Vitamin D if you don’t get enough sun, have low levels (my lab says low levels are less than about 30 ng per ml), are elderly and at fall risk, have mood disorder such as depression, are at risk for heart attack…the list went on.

Less than a decade later, recommendations have shifted 180 degrees, that is, studies in recent years show no benefit to taking Vitamin D for all the disorder above unless your levels are below 12-20 ng per ml making you Vitamin D deficient. If you are deficient in Vitamin D or your diet lacks the needed 600-800 IUs recommended daily, take Vitamin D (FYI most multivitamins have about 200-400 IUs of Vitamin D).

I’ve stopped supplementing with Vitamin D and plan on checking my levels in a month or two.

If you have been prescribed Vitamin D but are not in fact deficient and have questions or comments, speak to your doctor or contact me on Twitter. Facebook, Instagram, etc.

SOURCE: AMERICAN FAMILY PHYSICIAN V.97 NO.4 FEB 15th, 2018

What to Bring BEFORE You Go To The Emergency Room to Keep You Sane

What to Bring BEFORE You Go To The Emergency Room to Keep You Sane

By Natan Schleider,  M.D.

July 29th, 2018

One Horse Power Ambulance (Circa 19th Century)

Having gotten a call that my 5 year old daughter had just fallen at the playground in camp and was complaining of right wrist pain, I hustled down to pick her up. While crying inconsolably, the ice pack on her wrist already warm, she said ‘I can’t move my fingers and I want to go to the doctor–but I don’t want a shot.’

The wrist was swollen and very tender to the touch so with nothing but my wallet, smart phone on 40%, and keys, I picked Ellie up and went to the Pediatric Emergency Room directly, panicked, not thinking, unprepared. As doctor who has worked in the emergency room (ER), I should have known better: bring the stuff you need when going to the emergency room as if you were going on a camping trip or off to boot camp.

The ER was packed and we were ushered into a bed outside multiple rooms where the screaming of tormented children rang louder than the ambulances outside.

Long story short, we got there at 1:30 pm and were discharged at 2am and my daughter ultimately left with a cast in a sling having fractured her distal forearm. Hospital staff did not want me leaving my daughter unless I had to use the bathroom because the orthopedist and x ray transport would be here ‘any minute but no promises.’

My personal experience is that the average ER visit lasts 6-12 hours and here is the irony, the less sick you are, the longer you wait for care as heart attacks get prioritized over sore throats in a setting which is almost always understaffed.

While I credit the hospital staff for being polite and professional–they don’t make the rules in the ER nor control how busy it is–I know of no modern emergency room where you are greeted at the door with a handshake or smile, offered a glass of water, or a ‘welcome packet.’

As emergency rooms are losing business to urgent care centers, valet service (at hospitals, not the ER), a coffee machine and crackers, and a single chair for the parent are the latest in luxury amenities.

I was given a computer/tablet about a dozen times to sign consent forms–not to watch Netflix during the prolonged wait (seems like a reasonable idea doesn’t it).

Moving forward when going to the ER, may I suggest/note:

  1. You not go as only 10-30% of the time is it a true medical emergency…get a good doctor who can triage you same day and picks up his/her phone.
  2. Bring snacks, ear plugs, ear buds to listen to music or watch movies or whatever on your mobile device, a good book, a portable phone charger, beverages, a change of clothes, your toiletry kit, a portable chair or cushion, and your medicines.
  3. Learning to meditate because you’re gonna be there at least twice as long as your are initially quoted.

I would love to hear about any emergency room experience or wisdom via Twitter, Instagram, of Facebook!

Over and Out,

Natan Schleider, M.D.

PS–Being a health care provider does NOT afford you any special or speedier care unless you’re on staff in that ER or are a super famous doctor or specialist.

Cosmetic Medicine Part 1: What A Doctor Does for Prevention and Treatment of Sundamaged Skin

Cosmetic Medicine Part 1: What A Doctor Does for Prevention and Treatment of Sundamaged Skin

by Natan Schleider M.D.

July 23rd, 2018

Now that I am 42, those blissful days at the beach when I casually remembered to add SPF sunblock occasionally are catching up. Suddenly my skin in looking like it has some age spots, wrinkles, and my forehead has pigment changes.

I realize I’m no male model but when ‘liver spots’ appear I start worrying that shuffleboard all day and dentures are on the way so let’s nip this in the bud in the most cost effective way possible.

Natan Schleider MD sun-damaged skin on foreheard
Natan Schleider MD sun-damaged skin. Note two dots on back of my hand.

I’ve been using Retin A Micro Gel 0.06% for about a few months and see no results so I’m considering other options.

According to John Hopkins these are my treatment options:

  • Botulinum toxin type A. An injection of botulinum toxin (a complex type of protein) into specific muscles will immobilize those muscles, preventing them from forming wrinkles and furrows. The use of botulinum will also soften existing wrinkles.
  • Chemical peels. Chemical peels are often used to minimize sun-damaged skin, irregular pigment, and superficial scars. The top layer of skin is removed with a chemical application to the skin. By removing the top layer, the skin regenerates, often improving its appearance.
  • Soft tissue augmentation or filler injections. A soft tissue filler is injected beneath the skin to replace the body’s natural collagen that has been lost. There are multiple different kinds of fillers available. Filler is generally used to treat wrinkles, scars, and facial lines.
  • Dermabrasion. Dermabrasion may be used to minimize small scars, minor skin surface irregularities, surgical scars, and acne scars. As the name implies, dermabrasion involves removing the top layers of skin with an electrical machine that abrades the skin. As the skin heals from the procedure, the surface appears smoother and fresher.

    A gentler version of dermabrasion, called microdermabrasion, uses small particles passed through a vacuum tube to remove aging skin and stimulate new skin growth. This procedure works best on mild to moderate skin damage and may require several treatments.

  • Intense pulsed light (IPL) therapy. IPL therapy is different from laser therapy in that it delivers multiple wavelengths of light with each pulse (lasers deliver only one wavelength). IPL is a type of nonablative* therapy.
  • Laser skin resurfacing. Laser skin resurfacing uses high-energy light to burn away damaged skin. Laser resurfacing may be used to minimize wrinkles and fine scars. A newer treatment option is called nonablative* resurfacing, which also uses a laser as well as electrical energy without damaging the top layers of skin.

*Nonablative dermatological procedures do not remove the epidermal (top) layer of the skin. Ablative procedures remove the top layers of skin.

I’m leaning toward the laser because I am inpatient and want fast results but the price in New York City may be $1,000-$2,000 so I may need to go with something else?

I recommend my dermatologist who isa brilliant and has a great bedside manner: Dr.Roy Seidenberg [https://www.laserskinsurgery.com/Dermatologists/Roy-Seidenberg-MD

To be continued after consult…how exciting!

HAVE COMMENTS? PLEASE SEND THE TO MY TWITTER ACCOUNT @DrSchleider or my Instagram!

Thx for reading!

How to Prevent Excess Sweating Like Sweaty Armpits- Treatment Options for Hyperhidrosis

How to Prevent Excess Sweating Like Sweaty Armpits- Treatment Options for Hyperhidrosis

by Natan Schleider, M.D.

June 23rd, 2018

Vintage Advertisement for Treating Sweaty Smelly Armpits (Circa Early 20th Century)

With temperatures on the rise here in New York City now that summer is here (and special thanks to climate change), I find myself sweating profusely. While this may be normal, when shirts, armpits, and back are sticking to your shirt, I feel quite uncomfortable. This may be due to dehydration but frankly, seeing patients with sweat dripping down my brow and back, I feel unprofessional to say the least.

While excess sweating is known to cause ‘social, emotional, and work impairment’ (American Family Physician Vol 97 Number 11 June 1st 2018), up to 3% of the United States population may suffer from hyperhidrosis (the fancy medical word for sweating beyond which is normal).

To stay cool and dry when your antiperspirant deodorant isn’t cutting it, here are  management and treatment options from a medical doctor’s perspective. (I will leave natural remedies to any naturopathic doctors but would love to hear if you have any natural or herbal remedies that work (other than a recycled paper towel):

  1. First line treatment for sweaty underarms is aluminum chloride (Drysol) 20% applied to affected skin nightly or every other night depending on how much you sweat. Note this may cause skin irritation and I would not use this on the face. For the face (craniofacial hyperhidrosis) your pharmacist can compound (mix) topical 2% glycopyrrolate cream applied every one to three days.
  2. Iontophoresis (passing of water through the skin by electrical current–sounds like quackery to me but data supports this apparently) for hyperhidrosis of palms of hands and soles of feet.
  3. Botulinum Toxin like onabotulinotoixnA (aka Botox) can be first or second line treatment and can be injected into the skin of axillae (armpits, palms, and soles and lasts 6-9 months. I have had trouble getting this covered by insurance but the stuff works.
  4. If you don’t like the idea of smearing cream on regularly ot getting injections, two oral prescription medicines are available: oxybutinin 2.5 mg to 10 mg daily and glycopyrrolate.
  5. Noninvasive microwave zapping of sweat glands in the armpits is relatively new with at least 2 treatments needed to reduce sweating by about 50%.
  6. Fractionated microneedle ablation (another way to zap and kill sweat glans) using local anesthesia can work well with at least 1-3 treatments required in general.
  7. If all else fails for hyperhidrosis, we turn to surgery which can be done: liposuction curretage; endoscopic thoracic sympathectomy (very small incisions in skin of chest) cutting the nerves to the problematic sweaty areas.

If you don’t like the above, stay inside, relax if a cool air-conditioned room if available, and take your Vitamin D as you won’t be getting sun exposure indoors (although some UV sunlight does come through windows but that’s a different topic.

Any questions, comments, idea, critiques, I’d love to hear them on http://www.twitter.com or http://www.facebook.com.

 

 

Top 20 Medical Studies of 2017 Reveal that LESS IS MORE

Top 20 Medical Studies of 2017 Reveal that LESS IS MORE

By Natan Schleider, M.D.

June 3rd, 2018

The Doctor, by Jan van Staveren after Gerrit Dou, 1650-69, Dutch painting, oil on copper. Doctor holding a bottle against light to examine a patient’s urine.

As long as I’ve wanted to be a doctor (some 30 years now) it was a veritable fact that Type II diabetics not on insulin should routinely check their blood sugar at home.

Wrong! Or so says the recent American Family Physician of May 1st, 2018 Vol 97, No.9 P.584. A 1 year study showed patients were less happy checking blood sugars at home nor did they have any improved HbA1c levels (a long term marker of blood sugar). They did not get more low blood sugar. And doctors ‘did not seem to respond’ to the home blood sugar tests patients brought in. Get rid of the test strips and painful fingersticks and if you (or your doctor) tell want to monitor home blood sugars, might as well just taste your urine (or rather have your doctor taste it. Seriously. When blood sugar rises above 180-200, the urine tastes sweet and you may be getting into trouble. See how much modern medicine has learned! I bet the diabetes testing companies are bummed out.

Medicine notoriously changes its mind every 10 years or so but some of these studies are real shockers and made me laugh:

  • Sterile gloves do not lower risk of infection for minor procedures like suturing skin lacerations or removing small lumps and bumps. Hand washing and irrigating the wound with regular tap water work just as well.
  • Cortisone injections for arthritis of the knee are not beneficial and may be harmful-don’t do them-plus they hurt like hell in the wrong hands.
  • When discussing cancer screening with older patients, doctors should use the right lingo. Don’t say since you’re probably gonna die soon, you don’t need this screening cancer test, skip the mammogram and go take you grandkids for ice cream. Better to say ‘This test will not help you live longer.’

Something I have been advocating for years is using a statin like Lipitor for primary prevention of heart attacks, strokes, and artery clogging. So if you are 40 or over and have any significant risk factor like smoking, diabetes, high blood pressure, etc, take a statin. I take atorvastatin 80 mg daily and have hypertension and my LDL (bad) cholesterol is great in the 70s!

Conversely, another study found that if you are 65 or older and have no cardiovascular disease, a statin will not be helpful and after age 75, may be harmful. Bottom line: take a stating from age 40-65 to keep arteries clear and then you can stop them if you have not had a heart attack, stroke, peripheral vascular disease, etc.

The American College of Physicians discerned that taking any medicine for back pain is more harmful than helpful. Good for them. When my low back hurts I am still going for Tylenol or Advil–call me weak, I have a low pain threshold.

These are some highlights from the academic world of medicine in 2017. In 10 years medicine will likely change it’s mind when these studies are repeated. but for now as a basic rule in medicine as my mentor told me: ‘Patients get better 95% of the time despite what the doctor recommends.’

If you have any questions or comments, please let me know on Twitter (@DrSchleider) or find me on facebook.

 

Thanks for reading!

Dr. Natan Schleider, M.D.

‘I Want To Stop Drinking Alcohol NOW But I Can’t’: Alcohol Abuse and Alcoholism

‘I Want To Stop Drinking Alcohol But I Can’t’: Alcohol Abuse and Alcoholism

By Dr. Natan Schleider, M.D.

July 29th, 2017

‘I need you over here quick doc, I want to stop drinking alcohol NOW but I can’t.’

Among the most common house call requests I get is from the loved one or family member of an alcoholic–and sometimes the patient themselves–who needs to quickly sober up. While the drinking has been heavy for years, a situation has presented itself where the patient is ready and willing to stop drinking alcohol but cannot.

Why after years of drinking is the patient asking for treatment so quickly?

The answer is simple: fear of going into alcohol withdrawal. This is the fancy medical terms for signs and symptoms related to cessation or reduction in use of drinking alcohol after heavy use characterized by sweating and high heart rate, hand tremors, insomnia, nausea or vomiting, anxiety, and, when things get bad auditory and visual hallucinations and seizures.

Of note, you may have heard the term delirium tremens or ‘DTs.’ This is somewhat synonymous with the later stages of alcohol withdrawal, normally occurring days 3-5 after the alcoholic has stopped drinking.  Imagine not sleeping for 3-5 days and being deprived of your alcoholic elixir. Mix in some nausea, vomiting, and dehydration. I give you the perfect cocktail for psychosis ready to happen, meaning the alcoholic will literally begin to hear and see things, act nuts, and start shaking or trembling–hence the term delirium tremens.

Now since alcohol withdrawal happens within hours for most alcoholics, time is of the essence to treat the patient or risk of relapse to drinking alcohol is high. In fact, even with treatment and appropriate alcohol detoxification, the sad truth is, the majority of alcoholics with less than one year sober will return to drinking alcohol, regardless or the medical treatments, twelve step programs, and other resources available.

That said, even the longest road toward recovery and long term sobriety begins with a single step. That First Step of Alcoholics Anonymous (AA) is “We admitted we were powerless over alcohol–that our lives had become unmanageable.” Being an addiction medicine doctor, I am a big advocate of 12 step programs like AA. The ‘Big Book’ of Alcoholics Anonymous has a lot of good stuff and even if you don’t believe in all that God-Stuff, it is full of information that is relevant in 2017, despite the fact that it was written in 1939.  Another fundamental point made on p.30 4th edition of the Big Book is “We learned that we had to fully concede to our innermost selves that we were alcoholics. This is the first step in recovery.” I n my experience, those patients who readily admit that they are alcoholics and say they are alcoholics have a higher chance of recovery than those who have called me just to sober up for a while so they can drink like a gentleman or a lady. As they say in AA, ‘once a pickle, never a cucumber.’  That is, once your drinking of alcohol has spiraled out of control, the chance of returning to normal drinking is extremely low.

While advocating for AA, from a medical and practical standpoint, small chance that an alcoholic who is trembling and vomiting in alcohol withdrawal will delve straight into any sort of non-medical treatment program or 12 step program like AA until their alcohol withdrawal has been safely treated.

So what to do if you can’t stop drinking, the craving are bad, and as soon as you try to stop on your own, you start feeling anxious, shaky, sweaty, and crave alcohol?

Good question. The answer is alcohol detoxification also called alcohol detox or just detox. I often get asked for intravenous (IV) fluids to rid the patients body of all the evil chemicals that have accumulated from heavy drinking of alcohol. While it is true that heavy alcohol abuse can damage the liver and cause certain compounds in the blood to accumulate which we find on blood tests like elevated liver functions tests (LFTs) or elevated bilirubin, the value of IV fluids is highest if the patient is dehydrated and/or cannot eat or drink. While I am a spiritual doctor and do believe in God, I do not know of any evil spirits or toxins that accumulate as a result of drinking alcohol. So to eliminate the confusion, when we detox a patient, alcohol is the actual toxin–or poison so to speak–that the addiction doctor is addressing and treating.

Now I suppose the hardcore alcoholics have succeed in locking themselves in a room or being chained to a bed. Others may have found success going to some ‘dry’ region and I’m not talking the desert. I mean going or flying somewhere where alcohol does not exist–yes there are such place, even counties and towns in the USA in which  it is illegal to buy and sell alcohol dating back from prohibition-era America.

If you are trying an at home detox without help and hunted around on the internet for home  remedies, you have probably read that you should taper down you alcohol use, perhaps by using beer in lesser amounts. While I should admonish you as a physician, let’s be real. Addiction medicine doctors use tapers all the time to wean patients off other habit forming drugs and substances of abuse. While I do not condone this, if you are going to do this on your own, I would take a multivitamin, Vitamin B Complex, and Thiamine (which is Vitamin B1). Do your best to stay hydrated, eat nutritious foods, and go to an AA meeting as soon as possible.

If you are seeking medical help, what to expect? Well, the mainstay of therapy for treatment of alcohol withdrawal are the benzodiazepenes (the family of Valium medicines also called ‘benzos’). That’s right, addiction medicine doctors substitute one habit forming medicine for another. Unfortunately, these are the best tool in out tool box and they work.

While many benzodiazepene exist, chlordiazapoxide (Librium) is FDA approved for treatment of alcohol withdrawal. Lorazepam (Ativan) is one of my favorites to use as well. Why? Both are short-acting and allow flexibility of dosing. Sometimes I need to improvise if the patient is vomiting and cannot swallow pills in which case some orally dissolving formulation of clonazepam and alprazolam are available.

Remember that the most serious symptoms of alcohol withdrawal like seizures (and death can occur as a result) occur at days 3 to 5 typically so the treatment course needs to last a good week or so before the patient is physically in the clear, in general. One must consider variables as to how long and how heavily and how much the patient was drinking but this is general consensus.

Time for me to wrap up my blog for now as I have to give my 4 year old daughter breakfast but I wanted to add an important note on alcoholism. There is a lot of press about the opiod epidemic in recent years but let’s realize the current statistics:  an estimated 88,000 American died in 2015 as a result of alcohol related deaths [Source: National Institute on Alcohol Abuse and Alcoholism https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics] while the 33,000 Americans died from opiod related deaths in 2015 [Source: Center for Disease Control and Prevention https://www.cdc.gov/drugoverdose/index.html].  I’m not trying to diminish the opiod epidemic as deaths are rising at an alarming rate and I will likely be writing about this in the future; however, I did want to emphasize the toll that alcohol continues to take and even though alcohol kills more Americans by a rate of nearly three to one, our treatment goals need not be focused nor eclipsed by the current opiod epidemic. Let’s keep a view of the big picture people.

Thanks for reading and comments welcome.

Diary of a Insomniac Physician aka What to Do If You Can’t Sleep and Suffer Insomnia: Part 2

Diary of a Insomniac Physician aka What to Do If You Can’t Sleep and Suffer Insomnia: Part 2

By Dr. Natan Schleider, M.D.

July 17th, 2017 3:49 AM

Can’t sleep? Join the club. 5.5 million Americans visit their doctor every year for treatment of insomnia and I’m one of them.

Having tried proper sleep hygiene techniques discussed in my blog post yesterday, I visited the drug store.

Sleepy time tea was tried. No effect. Melatonin 1 mg was tried. Nothing. Incidentally, melatonin generally needs to be taken nightly and with regularity to take effect. I increased the dose to 3 mg nightly. No effect. Then 10 mg. Still I tossed and turned.

Next I tried some sedating anti-histamines for my trouble sleeping, namely diphenhydramine better known as Benadryl. This usually comes as 25 mg tablets or capsules at the pharmacy and it is approved by the Food and Drug Administration for short-term treatment of insomnia at doses up to 50 mg nightly taken 30 minutes before bed. [I have some patients that swear by Zzzquil which is actually just diphenhydramine as well].

So how did the diphenhydramine (Benadryl) work? Not at all for me. It made me groggy (and did help my allergies) but did not put me to sleep. Some of my patients find this stuff as sedating as a horse tranquilizer but not me.

Ultimately I went to my doctor where a medley of prescription medicines were tried. He finally pointed out that what was keeping me awake was my increased stress of being on call and the fact that my cell phone my ring at any time in the middle of the night.

So I decided to change the nature of my medical practice and unless I had a patient in the hospital or had a particular patient I was worried about, I now turn my cell phone to silent most nights so I can sleep. This has helped more than all the pills; however, for the sake of thoroughness let’s go over some of my preferred medicines for treating insomnia.

Below is a list of Dr. Natan Schleider’s prescription medicines to consider when you cannot sleep:

  1. If you have trouble falling asleep, controlled release melatonin or Ramelteon. These are not habit forming so they are a good place to start. If these do not work, there are a family of medicines called “Z-drugs.” These are drugs like Ambien and Lunesta and are habit forming. Being an addiction medicine doctor, I caution against these. If you can take them sparingly, that is, one or two nights weekly, your chances of becoming dependent are lower but not impossible. Unlike the melatonin and Ramelteon, the immedate release forms of Z-drugs can be taken IF needed while the melatonin analogs must be taken nightly.
  2. If you have the type of insomnia where you cannot stay asleep consider doxepin (Silenor), an ‘oldy but goody’ in the family of tricyclic antidepressants also FDA approved for insomnia. This is also a nice option if you are diagnosed with depression.
  3. Suvorexant (Belsomra) is a reatively new medicine for treating insomnia which I have zero experience with but for the sake of being thorough I am including this in the list. It is FDA approved for treating insomnia but is a controlled medicine meaning it is habit forming so caution with use. On a personal note I tend not to prescribe the newest medicine to hit the market. A lot of new medicines are recalled like Bextra and Vioxx, rememebr those? Better to go with medicines with a good safety profile in my opinion.
  4. The following medicines are commonly prescribed by psychiatrists for insomnia (and even by me once in a while) although admittedly, the evidence for them is lacking but my patients say they work: trazodone and Seroquel.

Well, there are a lot more medicines out there that are sedating and I’m no sleep specialist, just an insomnia specialist. I’m gonna try to get an hour of sleep before getting my daughter ready for school. Over and out.

Diary of a Insomniac Physician aka What to Do If You Can’t Sleep and You Suffer Insomnia: Part 1

Diary of a Insomniac Physician aka What to Do If You Can’t Sleep and You Suffer Insomnia: Part 1

By Dr. Natan Schleider, M.D.

July 16th, 2017

It is 2:08 am on Sunday July 16th, 2017 and for no particular reason, I cannot sleep. I did not drink any caffeine today. I am practicing good ‘sleep hygiene’ [we will get to that later but that is the fancy doctor jargon meaning all the stuff you are supposed to do when you sleep, for example, go to bed at the same time every night).

This month’s journal of the American Academy of Family Physicians, American Family Physician (Volume 96 Number 1, July 1st, 2017 p.29-35) has an article which I read: ‘Insomnia: Pharmacologic Therapy.’

Given that my 4 year old daughter, Ellie, keeps kicking me in the head as she tosses and turns at night in my bed (and refuses to use her toddler bed), I thought I would add my personal knowledge and experience with insomnia. Ok, now I realize I am not practicing proper sleep hygiene but kicking your toddler to the curb so you can sleep simply is not in the medical textbooks (and you parents out there can now say ‘I told you so’ and warn me of the dangers of letting children sleep in your bed but Ellie says “Daddy I’m afraid of monsters in the dark and want to sleep in your bed.” Yet I digress.)

So who is more likely to suffer insomnia?

  1. Women get it twice as often as men, especially if pregnant or post menopausal
  2. Older adults
  3. Patients with chronic medical conditions like heart and lung disease and psychiatric conditions like depression, anxiety, substance abuse, and posttraumatic stress disorder.
  4. People who are grieving death of a loved one
  5. People separating or divorcing
  6. People of lower socioeconomic class
  7. Patients withdrawing for alcohol and opiates

As a family physician and addiction medicine doctor, I see a lot of patients for insomnia, I mean, it is up there for the primary purpose of the visit with high blood pressure and sore throat.

Having been on call for a medical practice where patients and the hospital can call at all hours of the night, my insomnia has worsened over the years. Maybe I am becoming one of those ‘older adults’ that gets less sleep? Maybe now that I’m a single parent I ‘sleep with one eye open’ which, as most single parents will attest to, means we don’t get much sleep?

Here are Dr. Schleider’s sleep hygiene techniques or ‘behavioral interventions’ as the journal article liked to put it that I use to try to get to sleep. These work most nights:

  1. I go to bed around 8pm every night with my daughter, even on Saturday and Sunday (yes, I’m boring but I value my sleep).  I wake up around 3am to 4am every morning. A regular sleep schedule gets you body used to falling asleep on time.
  2. Caffeine is a luxury item I cannot afford and I drink coffee or tea or diet coke maybe twice a week and only in the morning.
  3. The human body likes a cool, quiet, dark place to sleep so keep the lights out and the room chilly. I use a face mask and ear plugs and white noise from a fan and an air conditioner in summertime for the double bonus of keeping me cool and the ambient white noise.
  4. Avoid naps which can mess with my sleep cycle.
  5. I am not supposed to read or watch TV in bed according to the American Sleep Association but here I am guilty by proxy, that is, Ellie makes me watch My Little Pony with her as her ‘white noise’ is the television which she needs to fall asleep. This is a real problem for me…
  6. I do not drink alcohol or smoke tobacco or drink any energy drinks as these interfere with sleep.
  7. I try to exercise before 12 noon. Exercising before going to sleep, while better than no exercise at all, can release neurotransmitters and hormones (IE endorphins and adrenaline) which can keep you awake. The verdict is out in my mind on vigorous sexual activity before bed but my advice is: go for it,  enjoy it while it lasts unless it really affects you sleep cycle in which case maybe you and your partner can switch to morning intercourse.
  8. I try to keep busy until I am so tired, I fall asleep. This is contrary to other advice which suggests mediation and baths and scented candles before bed but that just doesn’t work for me.

Well, that’s pretty much it on ways to get to sleep without medicines or supplements, at least in my personal and professional experience. Please add any comments or suggestions you have as it is almost 3am here in New York City and I should try to get back to bed!