I’ve been busier than I like, and haven’t had as much time for posting.  But I spend a lot of time answering emails from my patients, and some of my responses may be useful for others.  Below I’ll share my answer to a patient who has been unable to get quality sleep.  Next week I’ll find another answer to share with readers.

This patient asked whether her insurance would cover Lunesta.  She wrote at 2 AM that she is up most of the night tossing and turning. She now takes 10 mg of Ambien, and wrote that it ‘stopped working’.  She doesn’t think 20 mg of Ambien would be covered by insurance (although Ambien is very inexpensive when purchased for cash).  She takes gabapentin for a pain condition and wonders if increasing it would help with sleep.

My response:

Before getting into a discussion about insurance I want to make sure you have a good understanding about the issues you’re facing when you take sleep medications.  Most sleep medications are subject to tolerance, and some share ‘cross tolerance’.  Lunesta (s-zopiclone) and Ambien (zolpidem) act at the same receptor and have the same actions, so if a person is used to one, she is used to the other.  The situation is analogous to opioids, where a person tolerant to a significant dose of oxycodone will find little effect from morphine.

I have taken Lunesta but stopped it for the same reason you are unhappy with Ambien:  it just didn’t do much.  Lunesta also causes a very bitter taste in the mouth, not from the pill touching taste buds, but from the drug circulating in your bloodstream.  The taste is unpleasant but goes away aftef a few weeks in most people.  If you are not responding to Ambien, you won’t likely respond to Lunesta.

Some people change from an ‘ultrashort’ to a benzodiazepine, typically temazepam.  That change will often offer some benefit, but tolerance will eventually match the effects of temazepam just as with the shorter medications.  Patients often ‘chase’ tolerance higher until their doctor refuses to prescribe larger amounts.  The exercise only deepens the plight of the insomniac, making it harder and harder to sleep without medication.

What is your current dose of gabapentin?  Pain docs sometimes taper that drug up to a total of 3 grams per day, and higher doses cause some degree of sedation.  But again, step back and look at the big picture.  With any sedating substance, including gabapentin, you are only  addressing the short-term.  Your body will adjust to any dose of sedative, just as with opioids, and you will eventually need to address the same symptoms on even higher doses of sedatives.

I am willing to look at the gabapentin, but understand what you are up against.   Patients tend to focus on the short-term at 2 AM.  My job is to know that you will be around for years, even decades!  I often see new patients whose doctor prescribed benzodiazepines for years, repeatedly raising the dose.  At some point the patient ran out too early, prompting discharge.  At that point there is little to be done for such patients beyond helping them through several weeks of severe insomnia caused by benzodiasepine withdrawal.  Sometimes questiapine, clonidine, or hydroxyzine will help patients find some restless sleep while lowering their tolerance to benzodiazepines, but that sleep is usually poor in quality and associated with significant daytime sedation.

My best advice:  When taking sleep medications, the most important point is to NEVER ‘double up’.  If you take two tablets instead of one of any medication, you will never get the same benefit from taking one again.  You will only run out early, and the doctor, pharmacist, and state will all prevent early refills  The second point is that newer sleep meds will not just make a person fall asleep.  For the first few nights a new medication might feel more potent, but over time, the best thing a sleep med will do is HELP a person fall asleep.  Patients must do everything else correctly, including sleep hygiene measures such as using a dark, somewhat cool room, using white noise to help the mind avoid focusing on creaking boards or other noises, avoiding significant alcohol use, avoiding caffeine after noon, avoiding eating or smoking right before bed,  calming down at the end of the day (some people can’t  sleep if they exercise late in the day), dimming lights, avoiding watching football right before bedtime, etc.

If you do all those things, a sleep medication will help ease the transition to sleep.   But the shorter meds like Lunesta and Ambien work best when they take effect in people who are in bed already, working on getting to sleep.  People often make the mistake of taking a sleep medication and wating to go to bed until they feel sleepy.  The newer sleep meds don’t cause the sleepiness that came with the older drugs, and they don’t last near as long.  Waiting ‘until they work’ can also cause amnestic behaviors like sleep-eating, sleep-sexting, sleep-driving, and worse.

Give these issues some thought and tell me the amount of gabapentin you take.  Beyond the controlled substances, consider trazodone or clonidine, two medications that work differently than benzodiazepine and Ambien.

The best sleep, of course, is found in the unmedicated condition desiged by evolution.  Evolution is not fast enough to keep up with changes in communication and the social media phenomenon, so it is often useful to think about the sleep environment of our ancestors, 40,000 years ago.  If I knew how to use twitter, I’d hashtag ‘sleep like a caveman.’


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