Drugs for Insomnia

Since our July 6th issue includes an article on Drugs for Insomnia, we have invited our Contributing Editor, Carl W. Bazil, MD, PhD, to be our guest blogger this week. Dr. Bazil is Director of the Epilepsy and Sleep Division of the Department of Neurology at Columbia University Medical Center. In addition to clinical care of patients with sleep disorders and epilepsy, his research interests include the pharmacology of sleep disorders and the impact of sleep disorders on neurological diseases, especially epilepsy and Parkinson’s disease.

From Carl W. Bazil, MD, PhD…

Insomnia is a nearly universal problem; almost everyone has occasional nights where sleep just won’t come, or when thoughts invade in the middle of the night and sleep won’t come back. When it is isolated and there’s an obvious cause, there is no need for treatment. But for the millions of Americans that suffer from frequent or chronic insomnia, treatment is essential not only to avoid drowsiness, but also to improve immune health, concentration, and memory function. Many insomnia sufferers will turn to websites, apps, or folklore for treatment; some of these can be useful for learning ways to improve sleep. Others may try over the counter sleep aids; these have scanty evidence of effectiveness in most cases but could work (and even if it is a placebo effect – who cares?). But many patients will turn to their physicians – and many of those will leave with a prescription for medication.

In general prescription sleeping medications are best used as just one tool toward improving sleep. None will force sleep, nor will any correct bad habits that perpetuate insomnia. Prescriptions for insomnia fall into several classes, and the correct choice will take into account the overall health of the patient and the individual characteristics of their sleeping problems. Many insomnia patients, for example, have mood disorders (depression or anxiety) contributing to their insomnia and so may benefit more from classes that also treat these. Others may have an element of a circadian rhythm disorder, such that a melatonin agonist is more appropriate. For the majority, the non-benzodiazepine hypnotics are used; these differ mainly in terms of half-life. The most popular, zolpidem, has a short enough half-life that it is less likely to produce morning drowsiness if used appropriately but any drug in this class can result in confused behavior if taken before getting into bed, or if the patient is awakened for any reason while under the influence of the drug. A new addition, an orexin antagonist (suvorexant), was just added to this roster, promising a different mechanism to help sleep. Keeping track of all these options, and matching the drug to the patient is ever more daunting.

So for patients and their physicians (and for physicians with insomnia!):

  • DON’T CHEAT ON SLEEP! Remember it is at least as important as exercise and nutrition for your health.
  • If you have insomnia, first look at your habits. Make sure you have a proper environment for sleep, avoid caffeine late in the day, give yourself time to unwind before bed. And turn off those smart phones and tablets!
  • Incorporate behavioral techniques to help you relax. You can use meditation, self-hypnosis, progressive relaxation, or guided imagery – whatever works for you.
  • AND: if you or your patient need prescription sleep medication, choose the one suited to the whole patient, and his or her individual sleeping problems. Use them to retrain healthy sleep habits, then back them off. And as the field is complicated, familiarize yourself with the options through a reputable source of drug information.

Sleep well!

Carl W. Bazil, M.D., Ph.D., has disclosed that he serves as a consultant for UCB Pharma, and offers research support for NeuroPace.

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