#(DO NOT use my antihistamine usage as a guide. I take very high levels as directed by my doctors)

[tj-crochets]

Another weird question for y'all: If you are moderately allergic* to a thing and had been eating it anyway for years because you didn't know, and then when you figure out what you're allergic to you quit eating it at all, can you lose your ability to tolerate even a little bit of it? *a phrase which here means "probably severely allergic but can tolerate small amounts when on antihistamines"

[pharmacyforthemasses]

Sleep and Sleep Medications

So, sleep. There are two kinds of sleep: REM and non-REM. NREM is further broken down into four stages. During REM sleep, the brain is very active. During NREM, things tend to slow down. NREM sleep is affected by the neurotransmitters GABA and adenosine. REM sleep is “switched on” by cholinergic cells. Both types of sleep are necessary.

Insomnia is a very common problem, affecting around 30-50% of the population at some point in their lives. Primary insomnia is insomnia that is not caused by another disease. Secondary insomnia is a symptom of another disorder. For example, insomnia is common in people with depression and anxiety. There are also different ways that people experience insomnia. Some people can’t fall asleep, some people wake up early and can’t get back to sleep, some people are lucky enough to experience both. Personally, I’m an early-waker.

How insomnia is managed depends on a few factors. First, treatment varies based on whether insomnia is transient, short-term, or chronic. Treatment will also vary based on frequency of insomnia, effect on daytime functioning, and cause of insomnia (if one is identified).

Okay, so you’ve decided to talk to your doctor about the trouble you’ve been having with sleep. The first thing they’re going to do is rip apart your sleep hygiene habits. Let’s be real. We have terrible sleep hygiene habits. I’m playing on my phone basically up until the moment I close my eyes to sleep. I take naps as often as possible. I have the barest hint of a sleep schedule. After listening to you explain your sleep hygiene, the doctor will make something along the following recommendations:

Establish regular times to wake up and to go to sleep (including weekends). Sleep only as much as necessary to feel rested. Go to bed only when sleepy. Avoid long periods of wakefulness in bed. Use the bed only for sleep or intimacy; do not read or watch television in bed. Avoid trying to force sleep; if you do not fall asleep within 20-30 minutes, leave the bed and perform a relaxing activity (eg, read, listen to music) until drowsy. Repeat this as often as necessary. Avoid blue spectrum light from television, smart phones, tablets, and other mobile devices. Avoid daytime naps, and my personal favorite, schedule worry time during the day, do not take your troubles to bed.

Who schedules their worry time?

If you’re like most people, you’ve done a Google search before going to the doctor and you’ve already probably tried most of these things. Let’s pretend your doctor actually listens when you tell them this. Thus, it’s time to move up to the next tier of treatment, level 2: herbal and over-the-counter remedies.

I’m not too informed about herbal remedies. Melatonin has shown efficacy for some sleep disorders, but not primary insomnia. Valerian root has some evidence supporting its use. Anything else, though, I’m not sure.

There are a ton of over the counter sleep aids. Tylenol PM, Advil PM, ZZZquil, Unisom. Here is a secret: they’re all the same thing. The ingredient in all those OTC options that puts you to sleep are older antihistamines, usually diphenhydramine (Benadryl). This stuff is effective if you have transient insomnia but taking it long term isn’t the greatest because you can develop tolerance and need higher doses. High doses of diphenhydramine have some unpleasant side effects, so if you have insomnia that’s more frequent than a day or two a month, you need something else.

You tell your doctor, “I heard from my pharmacist that those OTC medicines aren’t good for long term use. I have insomnia almost every night. What other options are there?”

In a sane world, you would then be bumped up to the next level of treatment:, level 3: benzodiazepine receptor agonists (BZDRA), a class of drugs that contains benzodiazepines along with the “z hypnotics” zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). These medications are generally safe and effective, though they do have some side effects to watch out for: daytime drowsiness, rebound insomnia when discontinued, and tolerance. However, studies about long term use support their usage for chronic insomnia.

However, we do not live in a sane world, so the odds of being a prescribed a BZDRA are low. These drugs are all classified as schedule iv narcotics by the DEA, a classification which means “this drug carries some risk of physical dependence, some-to-high risk of psychological dependence.” Doctors are reluctant to prescribe controlled substances (something I’m sure many of you are aware of) these days because the DEA is breathing down their necks about the opioid crisis. So instead of getting a generally safe, effective medication with solid evidence backing its use, you’re much more likely to get bumped into an alternative track of treatment, which we’ll call 3A: antidepressants.

Antidepressants have shown efficacy in treating insomnia…in depressed patients. There’s not really evidence supporting using them in non-depressed patients, but doctors do it anyway because they’re “safer.” Except they’re not, really; these drugs have significant side effects like weight gain, daytime drowsiness, cardiac conduction abnormalities, and others. Common antidepressants used to treat insomnia are trazodone, mirtazapine, nortriptyline, and doxepin. I have had personal experience with mirtazapine, doxepin, and trazodone. I’m currently taking trazodone because it’s the least awful one I’ve tried.

There’s one more medication worth mentioning, but it doesn’t really fit into the “tracks.” It is called Suvorexant. This drug is kind of cool, because instead of inducing sleepiness, it turns off your body’s wakefulness signaling. So once you’re asleep, you stay asleep. Obviously this is more effective for people who have trouble staying asleep rather than falling asleep.

So that’s it for the sleep medication guide. I could write a whole post about how ridiculously hard it is to get a prescription for a BZDRA, and I might in the future—I could also talk about how hard it is to get stimulant ADHD medications, if anyone’s interested. If you want some tips on talking to your doctor about insomnia, I’m always happy to roleplay so you can be more prepared.