If I’ve heard it once, I’ve heard it a thousand times… “Dr. Speight, I can’t sleep and I’m going crazy! It’s been weeks since I had a decent night’s sleep and I just can’t take it anymore!”

We’ve all been there at least once, whether it was the kids, too much coffee, an argument; something kept us up! For some however it is a way of life and oh so difficult to handle. Insomnia can be so regular for some folks, that they’ve actually forgotten what it meant to have a real restful night’s sleep. This week, we’ll try to shed a little light on insomnia.

There are a number of different types of sleep disorders. Insomnia is the one we recognize the most. However some causes of poor sleep have their own category of classification and have insomnia as a byproduct. These would include Restless Leg Syndrome, Teeth Grinding or Bruxisim, Anxiety, Bipolar Disorder, Depression, and Bed-Wetting. There are other sleep related disorders, but we’ll focus primarily on insomnia and associated illnesses.

An important point to determine is when does the problem with sleep occur. Is it a problem falling asleep or staying asleep? For those who have trouble falling asleep, using a short acting sleep medicine that helps you get to sleep is the best way to make a restful night’s sleep a reality. For those who can’t stay asleep there may be other options.

Typical medications that are helpful in inducing sleep include Halcion, Ambien, and Sonata. Halcion has the shortest half life and can really help you get to sleep early. A short half life means the drug goes to work fast and get’s cleared from your system in a very short amount of time. It in technical terms is the amount of time it takes for ½ of the drug to be cleared from you body.

The problem is that these drugs can be somewhat habit forming. They usually do not leave you with a hangover, but if you have a chronic problem with insomnia, these are probably NOT the drugs to use. Rather, these drugs work better when your body is reeling from a change in time zones, like a long trip to China or when you’ve started working third shift and have to have help falling asleep in the morning. They in general should be short term options.

Other drugs that are helpful for people who may wake up in the middle of the night in addition to having trouble falling asleep include the antidepressants. Folks who are suffering from the loss of a loved one often have trouble with sleep. These people do well with a medication like Elavil This is a tricyclic antidepressant and while it is helpful with depression, it is one of the most potent sleep inducers I know. Most people will get to sleep and stay asleep with 50 to 100mg at night. The problem is, it can leave you feeling groggy the next morning, give you dry mouth, constipation, and impair your ability to charge into the day. If you are depressed and want a drug approach to your depression, Elavil can be helpful, but other SSRIs like Prozac and Zoloft may help as well.

A more recent medication for sleep known as Lunesta is thought to interact with GABA receptors in the brain. These receptors help induce a relaxed state and Lunesta has been helpful for some in finding sleep and staying asleep. It generally is not felt to be habit forming and is a wonderful potential tool for some in their quest for sleep.

Another fatty acid metabolite known as gamma hydroxybutyrate seems to quickly help some people fall asleep. This drug is a liquid and goes by the trade name Xyrem. It has been used to help with another condition known as cataplexy, but in those who just can’t get to sleep with anything else, they may find relief with Xyrem. It is however quite expensive and other sleep options should probably be pursued prior to Xyrem.

Lastly, a drug known as Rozerem ( Ramelteon) binds to the areas in the brain that typically melatonin binds to so it acts in many ways like melatonin would. Some people experience rebound insomnia, headaches, and fatigue when this drug is withdrawn however.

I have seen good results in giving three medications in low doses. Together they form a synergy that is hard to beat for the person who struggles with sleep the most: 1) Doxepin in 10mg doses which is quite low 2) Neurontin 100mg , and 3) Klonopin .5mg. When all three of these are taken at bedtime this sleep cocktail can be lifesaving in terms of restful sleep. If you’ve tried everything else, you might want to ask your doctor to add these three in low doses to see if you can achieve restful sleep.

If you have anxiety or depression, treating the primary disorder often takes care of the insomnia. In the same way, people with Restless Leg Syndrome (RLS) can also benefit from treating the primary issue. Restless Leg Syndrome is a disorder in which a person’s legs seem to move frequently at night. Keeping them “at rest” is almost an impossibility in some cases. It is thought in part to be related to a problem with proper dopamine control in the brain, however a common cause of RLS can be iron deficiency. If you or someone you care about has this disorder and can’t sleep, suggest that they see their doctor and have an iron panel as a screen for their RLS. In those people who have iron deficiency as a cause of their RLS, they’ve often seen return to restful sleep after this condition has been cared for properly.

What if I don’t want to take medication to sleep. Is there a “natural” way to do this? In fact there is. I see many patients with anxiety and depression. Inevitably, over half of them have problems sleeping. We often use amino acid therapy to treat their illness with good results. This involves giving the amino acids Tyrosine and Tryptophan or a metabolite of tryptophan known as 5HT to induce restoration of proper neurotransmitter balance. While these amino acids are helpful in improving mood, it is also helpful in restoring sleep. We’ll review this in more detail over the next few weeks.

In summary:

If you’re having trouble FALLING asleep consider

  • Trying exercise regularly 3 to 4 times weekly for at least 30 minutes.
  • 50 to 100mg of 5HT at bedtime may be helpful.
  • Sonata or Ambien for short term treatment of insomnia.
  • Do you have good sleep hygiene habits? i.e. are you eating in bed before going to sleep, doing other things in the bed beside sleeping or being intimate: reading, watching television, etc. Stop those other extracurricular activities.
  • Check your medication list for any medication that might have insomnia as a side effect. This is very typical with decongestants.
  • Don’t have coffee or other caffeinated beverages after 2PM
  • Turn the lights off! If there is excess amount of light at night, your melatonin response does not kick in as well as it normally would leading to difficulty with falling asleep if the lights are on.

If you’re not experiencing restful sleep ask your spouse or partner whether you snore or stop breathing. If so, please ask your doctor to consider ordering a sleep study to see if you have sleep apnea which can prevent you from getting into deep sleep.

If you’re having trouble STAYING asleep, consider

  • Trying longer acting medication such as Elavil or Desyrel.
  • Consistent use of amino acid therapy using L-tryptophan or 5HT a metabolite of L-tryptophan.
  • Consider a trial of Lunesta. Your doctor can provide this for you
  • Consider having your doctor adding low dose amounts of two or more drugs that have a synergistic effect such as Doxepin, Neurontin, and Klonopin.

To Your Health!

Dr. Neal

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