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!