Complementary and Alternative Treatments for Sleep Disorders. Learning Objectives

Transcription

1 Complementary and Alternative Treatments for Sleep Disorders Ellen Hughes MD, PhD Learning Objectives Overview of CAM use in US CAM therapies used for sleep disorders Herbs and supplements valerian, kava, melatonin Mind-body therapies meditation Resources No conflicts of interest

2 40% US adults use CAM in 2 large population samples Greater use in some parts of the country CAM = big business 11% of all out-of-pocket health-related spending was for CAM in 2007 ($40 billion) Ten Most Used Therapies 2007

3 Insomnia = 10 th Most Common Reason People Used CAM in 2007 Who Seeks CAM and Why? Typical user is well educated Dissatisfaction with conventional health NOT independent predictor of CAM use Most patients combine CAM with conventional medical care because they believe the combination is superior Eisenberg DM et al Ann Intern Med 2001;135:344

4 The Communication Gap Many patients who use CAM and aren t talking to us about it Less than 40% CAM therapies are disclosed to conventional practitioners Why? Gardiner P et al Altern Ther 2007;13:22 Eisenberg DM et al Ann Intern Med 2001;135:344 Reasons for Not Discussing CAM With a Doctor The doctor never asked 42% Didn t know I should 30% Not enough time during the office visit I didn t think the doctor knew about CAM 17% 19% The doctor would be dismissive or tell me not to 12% %

5 Many Claims... But What s the Evidence? What s the Evidence? Majority of CAM research <1990 not good quality NIH Center for Complementary and Alternative Center is trying to change this >1500 studies at >200 institutions That said, 90% of Cochrane systematic CAM reviews still conclude inadequate data or no benefit

6 Big Picture Many of your patients are using CAM for their sleep disorders, but not discussing it with you Some CAM therapies have been shown to be effective for insomnia and circadian rhythm disorders No CAM therapies have been shown effective for OSA, but 20% of patients with OSA reported using alternative therapies Sood A et al. J Clin Sleep Med 2007;3:575 Dietary Supplements 48% US adults take one or more supplements 1in 6 patients taking prescription medications takes 1 or > supplements 71% would continue to take their favorite supplement even if the government reported it wasn t effective! Something from the supplement cart? Kaufman et.al. JAMA 2002;287:337

7 Use of Herbals Botanicals have been used medicinally for thousands of years by virtually every culture Traditional healers grew, harvested and prepared local plants they were familiar with Now we just pick something off the shelves at the drug store Regulation of Herbs and Supplements 1994 Dietary Supplement Health and Education Act classifies herbs, supplements, minerals, amino acids, etc. as nutritional supplements No pre-market testing required for safety or efficacy

8 Buyer Beware: Consumers Can t Trust That Plant was accurately identified Potency will be same Product is pure Product is safe Product is effective New FDA manufacturing standards have the potential to change this Herbs and Supplements Herbs Valerian Kava Hops Passion flower Skullcap Lavender Supplements Melatonin Tryptophan 5-HTP Many sleep products = combinations of herbs and supplements

9 Relaxation Beverages Melatonin, valerian root and/or tryptophan added in small amounts to bedtime drinks Lullaby Lemon Snoozeberry Berry Berry Tired Valerian Root Used as sedative and anxiolytic for > 2000 years Active ingredient unknown, but products standardized to valerenic acid Early studies showed it improved sleep latency was well tolerated > efficacy over time (4-6 weeks) had no major drug-herb interactions 2007 systematic review of 37 studies: safe but not effective, but improved sleep quality in 2011study of postmenopausal women with insomnia Taibi DM et al. Sleep Med Rev 2007;11:209 Taavoni S et al. J North Amer Meno Soc 2011;18:951

10 Kava Roots used to make ceremonial drink in the South Pacific Shown to reduce anxiety, so included in some sleep products Early trials showed efficacy for anxiety up to 6 months with no dependence Case reports of liver damage caused it to be taken off the market in Europe and Australia Sleep Supplements Most are in the synthetic pathway for melatonin Tryptophan 5-OH-tryptophan Melatonin

11 Melatonin Melatonin Evolutionarily old molecule found in plants and all animals Made in the pineal gland in response to light in humans

12 Melatonin Daytime = 2-10 pg/ml Nighttime = pg/ml OTC doses ( mg) raise blood levels to 3-60 X normal peak values Doses < 5 mg generally considered safe Dosages up to 300 mg or 1 g daily for 30 days resulted in no negative side effects Vijayalaxmi et al. Int J Rad Onc Biol Phys 2004;59:639 Melatonin and Light We evolved to sleep in the dark Outdoor light pollution Indoor light pollution Even ordinary levels of indoor lighting can suppress melatonin for up to 90 minutes after the lights turned off Gooley JJ et al. J Clin Endocrinol Metab 2011;96:E463

13 Wavelength Also Matters Synthesis of melatonin influenced by wavelength, as well as intensity of light Older bulbs emit > red Suppress melatonin LESS Newer bulbs emit > blue Suppress melatonin MORE F.Lux = free ap that gradually adjusts the warmth of your computer screen in the evening Melatonin More Than Just Sleep? Melatonin found in many other tissues (GI tract, retina, bone marrow) Receptors for it found on many cells Multiple mechanisms of action Anti-oxidant Anti-inflammatory Immune modulator Some supplement manufacturers marketing it as an anti-aging product

14 How To Get the Most Out of Your Supplement Choose a high quality product Look for a Seal of Approval

15 Use Information from Independent Testing Laboratories ConsumerLab.com Learn As Much As You Can ODS: ods.od.nih.gov Medline: CAM on PubMed ncbi.nlm.nih.gov/sites/entrez Subscription required naturaldatabase.therapeuticresearch.com naturalstandard.com Subscription required

16 Mind-Body Therapies 24/7 accessibility makes unwinding at the end of the day a challenge Average # electronic devices in a teenager s bedroom = 7! Relaxation practices and CBT already part of sleep behavior therapy Many Paths to the Relaxation Response Meditation Biofeedback Imagery Hypnosis Diaphragmatic breathing Progressive muscle relaxation Yoga, Tai chi, Qi gong Prayer Exercise Music, etc..

17 Two Most Studied Forms of Meditation Transcendental Meditation Mindfulness Meditation Mindfulness Meditation Mindfulness = non-judgmental, moment-to-moment awareness Based on Vipassana meditation Jon Kabat-Zinn stress clinic established at U Mass >30 years ago 8 week group program (MBSR) now offered at >250 US sites Ludwig DS and Kabat-Zinn J JAMA 2008;300:1350

18 MBSR Efficacy >80 NIH-funded studies (half RCTs) report trend towards improvements in physical and psychological health Best data: chronic pain, anxiety, depression Some evidence may also be useful for sleep problems Rosenzweig S et al. J Psychosom Res 2010;68:29 Borwn CA and Jones AK Pain 2010;ePub ahead of print Brain Changes Seen After Just 8 Weeks! 16 subjects underwent MRI scanning before and after 8 week Mindfulnessbased Stress Reduction program Meditators showed significant growth in areas of brain associated with Learning and memory Empathy and compassion Emotional regulation Previous study showed a decrease in gray matter in amygdala (center of fear and stress) Holzel BK et al. Psychiatry Res: Neuroimaging 2010;ePub ahead of print

19 Advantages of Mind-body Practices Relax, Reflect, Accept Easily taught Inexpensive Safe Effective Can be done anywhere Complement other therapies Sleep Industry Is Big Business Could technology become a new form of alternative medicine?

20 Products to Help You Fall Asleep Ecotones Duet Sleep Sound Free iphone and Android app Ear Plugs White Noise Generator Cooling Options CoolGelMat PolarPillow

21 Products to Help You Stay Asleep Anti-snore Pillow SnorePro Products To Help You Nap Sleep Pods The Sleep Box

22 Sleep Cycle Alarm Clock What s in the Pipeline? A decrease in frontal lobe metabolism is linked to falling asleep Cross-over study of a cooling cap in 12 subjects with primary insomnia and 12 healthy controls showed frontal cerebral thermal transfer (FCTT) improved sleep latency and efficiency! Nofzinger EI and Buysse DJI Abstract at 2011 Sleep Meetings

23 Wish You Could Sleep Like a Baby Again? 8 healthy male volunteers fell sleep faster and experienced deeper sleep during a 45 nap on a gently rocking bed Bayer L et al. Current Biol 2011;21:R461 Wake N Bacon

24 Summary Many of your patients may be using CAM to improve their sleep, and not telling you Herbs and supplements are most commonly used: best evidence is for melatonin Mind-body therapies effective ways to manage stress and improve sleep Quality of research still limited