The Use of Sleep Aids in Our Society Today

Transcription

1 The Use of Sleep Aids in Our Society Today Kathryn Hansen, BS, CPC, CPMA, REEGT Integration Consultants, LLC Sleep Education Partners Executive Director Kentucky Sleep Society Executive Director Society of Behavioral Sleep Medicine

2 What Do People Take to Try to Improve Their Sleep? Alcohol 1 Herbals 2 Dietary supplements 2 Homeopathic preparations 3 Melatonin 2 OTC sleep aids 1 Sedating antidepressants 4 Sedative-hypnotics 5 Marijuana Opioids 1. Ancoli-Israel S, Roth T. Sleep. 1999;22(suppl 2):S347-S Larzelere MM, Wiseman P. Prim Care Clin Office Pract. 2002;29: Neubauer DN. Clinical Cornerstone. 2003;5:16-27; 4. Wagner J et al. Neuropsychiatry. 1998;32: Mitler MM. Sleep. 2000;23(suppl 1):S39-S47.

3 Behavioral aspects of medication treatment for insomnia Medications for insomnia: A brief review Medications as a form of behavioral intervention What the patient brings What the provider brings Take home points

4 How to treat insomnia: Practice guideline from the American College of Physicians Recommendation 1 ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. Grade: strong recommendation, moderate-quality evidence Recommendation 2 ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. Grade: weak recommendation, lowquality evidence Qaseem, Ann Int Med, doi: /m

5 Insomnia: What patients say I feel fatigued all the time. I can t sleep. I take forever to fall asleep, but once I m asleep I m fine. I lie awake all night long. I can fall asleep, but I keep waking up? I don t feel rested in the morning.

6 Medications: What patients say This medication doesn t work. I don t like the way it makes me feel. Thanks, doc. This stuff works great. I think I need a higher dose. Medications have the opposite effect on me. My medication stopped working. I dropped some in the toilet. Can you call in some more?

7 How do we treat insomnia? Treatment for Insomnia Behavioral Pharmacologic

8 Behavior: A function of the patient-provider interaction Behavior

9 Behavioral aspects of pharmacotherapy: What the patient brings Suffering Frustration Beliefs and attitudes Regarding sleep I want 8 hours of sleep like everybody else. I read about sleep deprivation in the newspaper and I don t want to die. Regarding medications I just want something to knock me out. I should be able to sleep without medications. Other medications, illnesses Life circumstances All of these can affect if and how patients take medications

10 Behavioral aspects of pharmacotherapy: What the provider brings Evaluation knowledge Patient education Ability to personalize treatment Specific instructions Follow-up on treatment

11 Education 1: Sleep Nature and regulation of sleep Voluntary/ involuntary Homeostatic and circadian (2-process model) Realistic expectations Normal and not normal (e.g., sleep duration) Sleep as a behavioral alternative

12 Education 1: Sleep Nature and regulation of sleep Voluntary/ involuntary Homeostatic and circadian (2-process model) Realistic expectations Normal and not normal (e.g., sleep duration) Sleep as a behavioral alternative

13 Education 2: Medications Realistic expectations Sleeping pills vs. general anesthesia Modest effects The Olympic Sleep Team Characteristics of medications Pharmacokinetics Effects Side effects Therapeutic level

14 Personalizing treatment Classes of medication Benzodiazepine receptor agonists: Pros and cons Sedating antidepressants: Pros and cons Others (antihistamines, melatonin, alcohol) Frequency of administration Every night Intermittent: Targeted, intermittent

15 Instructions Who: The patient What: Medication Types Dose When, where: Time and place of administration Too early, too late At home How: Details Food, Alcohol Other medications How long (duration)

16 Behavioral aspects of pharmacotherapy: Timing is key

17 Follow-up Therapeutic effects Sleep Wake Side effects Challenges, difficulties, and questions Education regarding long-term use Daily Targeted, intermittent Discontinuation

18 Take home points Taking medication is a behavior The best pharmacotherapy involves behavioral therapy Both the patient and the provider bring something to successful (or unsuccessful) pharmacotherapy Key talking points with patients Sleep is an involuntary biological process influenced by behavior and medication Sleep is not a behavioral alternative to wakefulness Reasonable expectations re: sleep, medications Appropriate timing

19 Deprescribing Medications Rationale should be clear Tapering plan should be negotiated Discuss evidence risks of ongoing BZRA use potential benefits of discontinuation therapeutic effects might be lost within 4 weeks (receptor changes) mild, short-term withdrawal effects can be expected during tapering Adapted from Pottie, Thompson, Davies, et al. 2018; Can Fam Physician, 64(5(:

20 Clinicians and patients choices in evidence-based medicine 1 Clinical state and circumstances Clinical expertise Patients preferences and actions Research evidence 1 DaCruz, BMJ 2002;324:674.

21 Does Marijuana Help Sleep? Prevailing view: yes Study - University of Michigan concluded that depending on how frequently an individual uses marijuana, it may not help them sleep at all. It may actually worsen their sleep quality. The study recruited 98 subjects who were divided into three groups: daily marijuana users, non-daily marijuana users, and a non-user control group.

22 Marijuana and Sleep Researchers found: that that the daily-use group had higher levels of insomnia (almost 40 percent) compared to non-daily users (10 percent) and the control group (20 percent).

23 What happens if you quit? Sleep worsens during a withdrawal period if they attempt to quit using the drug or use it less frequently. Limitations of study: amount of marijuana was not measured Note: When controlled for anxiety and depression, the difference in reported insomnia levels disappeared.

24 Summary Many sleep aids are used Effectiveness impacted by behavioral factors

25 Thank you???