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The drugs that keep us up at night

How well are you sleeping at night? It's not uncommon to have difficulty falling or staying asleep, but certain medications and substances may either help or inhibit proper rest. From a pharmacist’s perspective, it’s essential to address the root cause and determine the best course of action.

Insomnia is the most common sleep disorder and among the top psychological health issues. It has been estimated that 1 in 3 people in the United States and 50% of people worldwide have difficulty with sleep.1One study found that 30% of the people surveyed experienced short-term insomnia and up to 10% of adults experienced a longer-term or more chronic version of insomnia.2 Another study showed that an estimated 4% of adults over the age of 20 used some type of prescription to address sleep issues during the past month. The resulting impact of sleep disorders on an individual as well as our collective society is enormous.3

Over-the-counter medications

A common over-the-counter generic medication used for sleep is diphenhydramine, commonly known as Benadryl. Its main purpose is to be used for allergies as an antihistamine, but many people turn to it as a short-term solution for insomnia as its side effects can cause drowsiness. Many drugs marketed over-the-counter in their ‘pm’ versions contain diphenhydramine. While it can help with sleep initiation, it does not necessarily help with sleep maintenance. And for children, diphenhydramine can have the opposite effect — resulting in hyperactivity or vivid dreams. As with many medications, if substances are used on a longer-term basis, it may be necessary to use a schedule to taper these off rather that abruptly discontinuing their use. This will help minimize or mitigate withdrawal symptoms.

Natural supplements

While proven sleep hygiene techniques are recommended for quality sleep, there is also a great deal of interest in natural sleep products and substances like a melatonin supplement. As one of the more popular products on the market, melatonin is a hormone produced in the body that helps individuals fall asleep and stay asleep. The sleepy feelings of drowsiness that arise just before falling asleep are the result of natural melatonin produced by our bodies.

Interestingly, there is a connection between melatonin and our circadian rhythm. When it is light outside, our melatonin levels are decreased; when it gets dark, melatonin levels increase. On average, melatonin levels peak in adults is between 11:00 p.m. and 3:00 a.m, but levels are often influenced by the seasons. In addition, the production of melatonin is linked to age. The peak production of melatonin occurs during the toddler years and remains high in young adults. However, levels of melatonin decrease as people age, with people in their seventies producing about 75% less melatonin compared to a young adult. Over-the-counter melatonin supplements can help with both sleep onset and maintenance. They can also help shift your circadian rhythm, therefore some people find them helpful when traveling overseas or experiencing jet lag. If you decide to take melatonin, it is important to be aware of the dosage and always consult your physician or pharmacist with questions.

In addition to melatonin, many people take valerian root, a popular substance found in herbal teas. While there is still much to be learned and evidence is limited, one study found that people taking valerian had an 80% greater chance of improved sleep than those taking a placebo. However, people should be aware that natural substances can interact with other prescriptions or drugs. For example, valerian is metabolized through the liver and can interact with other drugs that are metabolized in the liver. This can decrease excretion leading to higher amounts of the substance or drug in the body. It is important to remember that a natural substance does not automatically translate into a safe substance, so consult your doctor or pharmacist before taking or combining drugs with natural substances.

Another popular substance used for sleep is cannabis, which has been found to alter the sleep cycle and increase the production of melatonin. However, similarly to valerian root, more research is needed and studies are inconclusive as to its effectiveness. Cannabis is not for everyone and can have the opposite effect — leaving some people anxious and agitated before bedtime.

Healthy sleep habits

A comfortable, dark room is recommended as part of a good sleep hygiene regime. Blue light from the sun can decrease melatonin and interfere with sleep. Similarly, tablets and mobile phones at bedtime can also produce blue light and inhibit sleep so be sure to tuck those away before you get ready for bed.

While many habits can help promote sleep, there are also substances we ingest often that can negatively impact sleep. Caffeine is one of the most well-known examples of a substance that can make sleep more difficult. The longer and more consistently someone ingests caffeine, the faster that person will build up tolerance to its effects. To achieve the same effect, people can unknowingly increase their caffeine intake to levels that endanger their health. To avoid this, some people find it beneficial to reduce the amount of coffee they drink and replace it with some type of decaffeinated tea. Ideally, caffeine should be discontinued four to six hours before bedtime.

While caffeine is a well-known stimulant, alcohol is a popular depressant. Some estimate that up to 10% of the population uses alcohol to sleep. However, alcohol has been shown to disrupt sleep and cause people to feel unrested. There are four stages to the sleep cycle and it is important to get the proper amount of sleep in each stage. Alcohol can cause a person to skip through the first two stages and fosters sleep in stages three and four. The result is waking up feeling unbalanced and groggy as opposed to feeling well rested.

Insomnia is often associated with chronic pain, depression and anxiety. Often, prescribers try to treat multiple conditions with a single agent, but it is important to monitor these situations closely. Some antidepressants used for neuropathic pain can produced unintended side effects. In these cases, alternative pain management techniques and counseling may be worth consideration.

In summary, sleep is not to be taken for granted and it is important to practice and develop good sleep habits. Should lack of sleep become a problem, it’s important to consult a physician or pharmacist to address the root cause and determine the best course of action. Over-the-counter drugs and natural substances may be effective alternatives, but they can interact with other medications and produce unintended side effects if not taken properly. The good news is we can rest easy knowing help is available.

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