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Sleep

We spend about one-third of our lives sleeping.  Sleep is an important component of human behavior and provides emotional and physical restoration for the body.  There is a wide variability in how much sleep each person needs per night, ranging from 4 to 10 hours. Most people function far better after a full 8 hours than after less sleep. An occasional poor night of sleep should not be a concern.  However, when sleep is disturbed on a regular basis, quality of life is affected.

Alcohol, stimulants (such as caffeine), and nicotine should be avoided by patients with insomnia.  Although alcohol enhances sleep onset, the sleep is disturbed and fragmented.  Individuals with insomnia are sensitive to the arousal effects of mild stimulants and should avoid all caffeine-containing products and chocolate for at least 8 hours before bedtime.

Measures for Good Sleep Hygiene 

  • Establish a regular time to wake up and go to sleep (including weekends).

  • Sleep only as much as necessary to feel rested.

  • Avoid long periods of wakefulness in bed.  Use the bed only to sleep; do not read or watch television in bed.

  • Avoid trying to force sleep.  If you do not fall asleep within 20 to 30 minutes, leave the bed and perform a relaxing activity such as reading, listening to music, watching television) until drowsy.  Select relaxing books recordings or programs, not once that excite you. Repeat this as often as necessary.

  • Avoid daytime naps.

  • Exercise routinely (e.g. three to four times weekly), but not close to bedtime as this may cause arousal.

  • Create a comfortable sleep environment by avoiding temperature extremes, loud noises, and illuminated clocks.

  • Discontinue or reduce the use of alcohol, caffeine, and nicotine.

  • Avoid excessive fullness or hunger at bedtime.

  • Avoid drinking large quantities of liquids in the evening to prevent nighttime trips to the restroom.


Medications

If insomnia is a severe, continuous problem, your doctor may consider placing you on a medication to help you to sleep.  There are several classes of medications available, with many choices in each group.

Two types of antidepressants are useful in managing insomnia.  These are trazadone and the tricyclic antidepressants.  The doses used to aid sleep are markedly lower than the doses used to treat depression.

Trazodone is an antidepressant at doses of several hundred milligrams.  Low (50-150 mg) help most people get to sleep and do not cause tolerance or dependence. This medication can be useful in most types of insomnia experienced by chronic pain patients.   

Tricyclic antidepressants (amitriptyline [Elavil], desipramine [Pertofrane, Norpramin], others) are actually analgesics for a particular type of nerve pain (neuropathic pain) and these medications also help patients get to sleep.  They usually are appropriate in neuropathic, not muscle (myofascial) pain. Trazodone is preferred to aid sleep for most patients who do not have neuropathic pain.  These medications also do not produce tolerance or dependence.

Benzodiazepines are useful for short term or occasional sleep problems.  They are not preferred agents for long-term or nightly treatment of insomnia, because they can cause dependence.  Examples include temazepam (Restoril) 15-30 mg and diazepam (Valium) 2-5 mg

Zolpidem (Ambien) 5 mg - 10 mg - is a benzodiazepine-like medication that works well for some patients, but does produce dependence and is very expensive.  Like benzodiazepines, it is indicated primarily for short term or occasional use.

Some other, newer sleeping medications are now available.  Most new medications are more expensive than older ones. 

Antihistamines are useful for short-term or occasional treatment of insomnia.  They commonly lose their effectiveness is used chronically.  These agents are available over-the-counter or without a prescription, but are sometimes prescribed by a physician.  It is important to check with your physician or pharmacist before using these agents to make sure you do not have any contraindication for use.  Common examples are:

Diphenhydramine (Benadryl, in Tylenol PM, others) 25 mg - 100 mg

Doxylamine (Unisom) 25 mg - 100mg

Melatonin is a herbal product that has been marketed as an all natural way to restore sleep.  A common misconception is the dose.  The most appropriate dose is 1.5 mg - 3 mg about an hour before going to bed.