When to Treat Insomnia With Prescription Medication

Peter L. Salgo, MD: If people are trying all these over-the-counter medications, and they’re not having the result they want and they tell you: “I really kind of cleaned up my act and I don’t need my iPhone in bed or my other kind of phone in bed,” let’s not demonize iPhones per se—and they continue saying, “I don’t take naps, I don’t have coffee, and I don’t drink alcohol, and I’ve tried these over-the-counter medications and they’re not working.” When do you move from there to more prescription medications in the elderly?

Sanford H. Auerbach, MD: One of the things that we left out of this equation here is the distress of the patient. A lot of things we do—sleep hygiene is wonderful—but you have to measure it against the distress of the patient at that moment as to what you’re going to do. And I think that some things take longer to do, and that all has to go into the equation. I think that’s the first step. We’ve talked about all these various options, and there’s a time factor involved, there’s the acceptance of the patient. Part of these herbals is also a little placebo effect built into it, which you can’t discount, that is probably good. We have to keep all of that in mind. When you’ve exhausted those options, and now you’re confronted with a situation in which in the clinician’s judgement you need to do something else to help this patient out, because they’re not going to believe you when you say to just make all these changes in your life. That’s when you would start considering other medications.

Peter L. Salgo, MD: OK. I’ve always been kind of a therapeutic nihilist myself. If we don’t have to use medication at all, let’s not. It sounds to me the key core of what you were saying is the distress of the patient.

Sanford H. Auerbach, MD: Well, and the acceptance of the patient. I have patients who come to see me and they say, “I just want a pill. I’m not going to listen to anything else.” I have other patients who come to me, like the therapeutic nihilist here, who say, “No pills, no medications, never, nothing.”

Peter L. Salgo, MD: Where’s the middle ground?

Sanford H. Auerbach, MD: And there are people in the middle, people who do both. People may start off with some medication and do the other things as well. To me it’s a matter of judging it, dealing with the patient.

Peter L. Salgo, MD: The other thing I hear from all of you is that this can be terribly distressing and that patients who have, almost by definition, if they have insomnia they’re unhappy, and it’s affecting them in some deleterious way. So the question is what is the urgency of treating this? It takes time if you’re going to do sleep hygiene, clean up your act, stay in bed, try this. Now you’re talking days and weeks, maybe try over the counter medications, now it’s weeks and months, and still the patient’s not doing well. Is there a point where you say let’s do something else? This is an urgent situation. Does it ever get there?

Sanford H. Auerbach, MD: Urgent?

Peter L. Salgo, MD: Urgent.

Sanford H. Auerbach, MD: Well, again, that’s dictated by the patient. I don’t know if it has anything to do with the time. There are some people who may be having insomnia for a few weeks and they’re desperate. People come in and say, “Well, you know, it always took me 2 hours to fall asleep and I sort of get by, but now it’s starting to get a little worse and it’s been going on for years.” So time is not the issue here. I think again it’s the matter of dealing with the patient at hand. That’s what dictates it.

Karl Doghramji, MD: Can I say one thing, Sandy? Don’t you think also it’s a matter of how impaired the patient is during the day? In other words, insomnia’s gotten to the point where the patient is not functioning well, or is functioning less well and with behavioral therapy. I think you need to do something to help them function, get back quickly. One of the advantages of pharmacologic therapy is that it works rapidly. Whereas, behavioral therapy takes a while to work.

Peter L. Salgo, MD: That’s what I’m saying, it takes a while.

Karl Doghramji, MD: So, if you need rapid improvement, the patients’ symptoms are significant enough. I had a patient the other day, he had insomnia for a year-and-a-half, horrible, debilitating sleep. The man could not work. He needed to get back to work right away. He was going to lose his job. We needed to do something very rapidly to get him there. CBT [cognitive behavioral therapy] would have taken weeks, maybe months to work. I think it’s a matter also of how impaired the patient is, how quickly you’d like to expedite therapy. Quite frankly, one of the other issues is availability. In some parts of the country there are no cognitive behavioral therapists available, so pharmacology is the only going thing. Those practical issues are also problematic.

Sanford H. Auerbach, MD: And there’s one other thing. I think that there’s a socioeconomic factor here. We see a large number of people who come to us who are illiterate, where this kind of cognitive behavioral therapy is a very foreign concept to them. And assuming you can get somebody who can do it in their native language. It’s nice to go through these things and have these ideals of how to manage patients, but you have to be practical.

Peter L. Salgo, MD: Before we launch into a discussion of some of the prescription drugs, I caught something that you said earlier, which is you’ve got to watch it in older patients, that what may be safe in a 20-year-old has some consequences in older folks that we might not like. What, for example?

Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: We’ve talked about falls, but I’ll put a for instance with the anticholinergics, such as diphenhydramine, where an older gentleman has an underlying prostate disorder, enlarged prostate.

Peter L. Salgo, MD: May I just interject? When I hear this, ouch!

Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: Yes, right? The tipping point for urinary retention that led to urosepsis. And really, the tipping point was the use of the diphenhydramine at higher doses for sleep. So really, looking at that interaction between their coexisting medical conditions and how those medications might be the tipping point, and so for them to have an exacerbation of that problem. I think the threshold and our ability to readjust, especially if we have a fall, and I think these medications are not without the implications on falls. And it might be because of the sleepiness but also because of the blurred vision, making them more confused, and they’re falling more. I think it’s really just being cognizant of that risk and benefit exchange.

Peter L. Salgo, MD: I’ll bet we’ve all gotten the phone call. I have gotten 2 or 3 from a family member saying, “My husband, my dad, had a cold, and now he can’t pee, and he’s going to the hospital because he’s in agony.”

Karl Doghramji, MD: Right.

Peter L. Salgo, MD: That’s what you’re talking about.

Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: Exactly.

Peter L. Salgo, MD: And that’s not going to happen to a 20-year-old.

Karl Doghramji, MD: Absolutely.

Peter L. Salgo, MD: It’s important to recognize this.

Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: And people just do not recognize the safety implications of over the counters.