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Sweet dreams: Insomnia options appear elusive

By Jason Poquette, BPharm, R.Ph

William Shakespeare appears to have understood the discomfort of chronic insomnia when he wrote “O sleep! O gentle sleep! Nature’s soft nurse, how have I frighted thee that thou no more wilt weigh my eyelids down?” But you don’t need to be a poet to appreciate the value of a good night’s sleep. According to information provided by the National Institute of Health, depending on your definition, upwards of 30% of adults have some degree of insomnia.

And a lack of sleep is more than just a simple annoyance. Insomnia often result in numerous other serious consequences. Studies have linked insomnia to increased motor vehicle accidents, poor cognitive performance, heart disease, diabetes and depression.

But in spite of its prevalence, and even though we have numerous medications indicated for the treatment of insomnia, strong evidence is still lacking which would point us in the direction of 1 option over another. In a recently published (Feb 2017) article in the Journal of Clinical Sleep Medicine the authors review studies and data on 14 agents (both prescription and non-prescription). While they are able to provide some suggestions which lean toward the use of certain drugs and lean away from others, the lack of comparative trials prevents a strong recommendation in any one direction.

According to a review of the article published online in Pharmacy Times, “the guideline does not recommend one drug over another since few comparative efficacy studies have been conducted among these agents.” A sampling of some medications reviewed in the report include prescription drugs such as suvorexant (Belsomra®), eszopiclone (Lunesta®), zolpidem (Ambien®), diphenhydramine (Benadryl®), melatonin and valerian.

In general, based upon available studies, the authors tended to lean toward some of the prescription options indicated for insomnia, and away from the over-the-counter treatments.  But again, the evidence was not nearly as strong as they would have liked.

Of course, the lack of evidence supporting the use of any one medication for insomnia is a good reminder that drugs are generally not the first line of treatment when it comes to dealing with sleep problems. Patients with chronic sleep difficulty (either falling asleep or staying asleep) should see their doctor and discuss this concern. I also highly recommend keeping a sleep journal as a tool to help diagnose the type of sleep problem you may have.

Most often the best first approach for treating insomnia, assuming it is not being caused by something else (we call that “secondary” insomnia) is some form of behavioral therapy and possibly some changes in basic sleep hygiene. These include developing new habits, when appropriate, about our sleep patterns such as going to bed at the same time, limiting the use of caffeine or alcohol, and avoiding “screen time” prior to bed.

A quick online search will provide a long list of similar recommendations which may be useful to try when preparing to talk to your physician about insomnia.

As a pharmacist I am frequently asked about melatonin, since it is readily available, reasonably affordable and considered a natural approach. While the evidence isn’t overwhelming, I think there is enough to warrant trying melatonin before moving on to more potent (and potentially habit-forming) prescription medication. Melatonin is a hormone naturally secreted in our brain when we are falling asleep. I recommend starting with a low dose (like 0.3mg or 1mg) rather than the higher doses (like 3mg or 5mg). Some studies suggest smaller doses work better. Patients should also know that recent studies have shown that manufacturers haven’t all been very good at providing a consistent and reliable dose.

And so, while millions are still at odds with “nature’s soft nurse” I hope that patients struggling with insomnia will at least pursue getting additional help from their doctor and maybe the pharmacy. Treatment options are available.  Sweet dreams!