Pharmacists can be key in sleep disorder counseling

by Denise Wagner on July 4, 2012

Recent estimates put the number of persons in the United States reporting some degree of insomnia at one-third to one-half the population. And according to a noted sleep specialist, pharmacists can perform a valuable service to these patients simply by being especially judicious in their dealings with them. In fact, he said, pharmacists might in some cases be doing patients a valuable service by not always complying with their requests for over-the-counter sleep remedies.

Hormoz Ashtyani, M.D., director of the sleep physiology laboratory at Bergen Pines County Hospital, Paramus, N.J., said that pharmacotherapy is not the only answer to sleep disorders. He suggested that pharmacists keep this in mind when counseling patients who have a sleeping problem.

When patients are self-medicating insomniacs, he explained, pharmacists should question them as to the duration of the problem. They should try to ascertain whether there’s some underlying medical condition causing sleeplessness and be alert to potentially dangerous patterns of sleep-aid use.

Selected Use: Ashtyani considers the use of medications to promote sleep appropriate only in selected circumstances–and for only a limited number of nights. Speaking at a recent symposium on sleep disorders, he said, for example, that one of the situations in which pharmacotherapy might be appropriate is in “transient insomnia.” That’s a condition in which a normally good sleeper is having trouble due to some acute, passing, external stress–jet lag, for instance, or anxiety over a scheduled hospitalization.

In such cases, “it’s perfectly OK” to give patients “a few days’ worth” of a sleep-inducing drug, he said. In fact, if such patients aren’t helped to sleep at least temporarily, their sleep cycle might be thrown out of whack, he noted, turning a one- or two-nigh problem into a long, drawn-out sleep disturbance. As Ashtyani explained it, if these patients toss and turn all night, they’re almost sure to fall asleep sometime the next day, resulting in their not being able to sleep again at night, and so on.

It’s a different story altogether when dealing with more chronically insomniac patients, he continued. More often than not, their sleeplessness is only a symptom of some other medical (or psychiatric) condition, and they should be evaluated by a physician.

What’s more, if patients with chronic insomnia take medication night after night, the drug will eventually stop inducing sleep and will, in fact, negatively affect whatever sleep the patient gets. All sedative and hypnotic drugs, according to Ashtyani, produce “poor quality sleep”: They deprive the patient of deeper phases while expanding the light phases.

He contended that “the great majority” of health professionals are unaware of the “intimate relationship” between sleep and a number of medical conditions. Thus, sleep disorders with treatable organic causes can go untreated or be improperly treated.

Some medical conditions are naturals for causing sleep disturbances. It stands to reason that conditions that cause pain–arthritis, for instance–or those associated with itching will interfere with sleep. Other conditions that don’t openly manifest their sleep-disturbing propensity, Ashtyani noted, include lung disease, fever, neoplasms, infections, vascular disorders, cardiac disease, gastrointestinal disorders, and such endocrine and metabolic disorders as diabetes.

A wide array of pharmaceuticals, too, can cause sleep disturbances, according to Dr. Jack Rosenberg, director of the International Drug Information Center, Brooklyn, N.Y. He said that’s often overlooked in treating insomnia, and that pharmacists can play a key role by helping determine whether a sleeping problem is related to drug therapy. Just some of the drugs, said Rosenberg, are antiasthmatics, appetite suppressants, belladonna alkaloids, beta-blockers, caffeine-containing products, diuretics, narcotics, NSAIDs, reserpine, and systemic and topical sympathomimetics.

The consensus: Ashtyani believes strongly in moderate use of prescription drugs for insomnia. In his estimation, only patients with transient insomnia should receive therapy with hypnotics of any kind. Most experts, on the other hand, while they have urged caution in the selective application of hypnotics, view their role in the treatment of insomnia somewhat more liberally.

In a consensus conference report issued by the National Institutes of Health, a panel of experts outlined treatment strategies for each of the three types of insomnia: transient, short-term, and long-term. They agreed that bezodiazepines are the “preferable” hypnotic agents when pharmacotherapy is indicated for sleep disturbances, recommending that patients receive the smallest dose of an agent that will do the trick, for “the shortest clinical necessary period of time.”

For transient insomnia, the majority of NIH panelists recommended a small dose of “a rapidly eliminated” benzodiazepine–unless sustained sedation would be indicated–for up to three nights. Some, however, questioned the propriety of administering any hypnotic; they suggested that patients simply observe good “sleep hygiene” or manage to tolerate their temporary lack of sleep.

Short-term insomnia was characterized by the NIH experts as lasting for up to three weeks and usually associated with some “situational stress,” such as problems related to a job, family life, or a serious illness. For this type of insomnia, patient education relative to “desirable sleep routines” is particularly important.

In addition to good sleep habits, the concomitant use of a hypnotic “may be desirable,” they concluded. If so, the panelists said that a drug with a short half-life may be preferable to avoid daytime sedation–if patients aren’t “significantly” anxious. Otherwise, they said, a more slowly eliminated drug may be chosen.

In either case, however, they recommended intermittent use of the hypnotic–skipping a dose altogether after every one or two good nights’ sleep. And overall, they noted, the drug shouldn’t be used for more than three weeks.

There’s a great deal of controversy surrounding the treatment of long-term insomnia with drugs. Some experts say, as does Ashtyani, that hypnotics have no place in the condition. He suggested that patients suffering from insomnia of months’ or years’ duration have an underlying medical or psychiatric condition, can’t sleep because of chronic drug or alcohol abuse, or suffer a circadian disturbance. And in any of the above, he contended, hypnotic therapy would be inappropriate.

Although the NIH panelists agreed in part, they stressed that the treatment of psychiatric or medical disorders may “still leave a need” for treating associated insomnia’s with hypnotics. And some insomniacs, they pointed out, simply aren’t attributable to other causes. For such long-term insomnia patients, the panel recommended a combination approach, utilizing behavioral therapy and the adjudicative use of hypnotics.

Citation Reference:

John P. White, Drug Topics

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