Roxy asked
I am a nurse and I should know better, but the stress of my job has caused severe sleep disturbances over the last two years. I started with two Benadryl tabs to sleep (50mg) . Then when that didn’t work I added Xanax to the mix (I was on it for anxiety attacks) one to two tabs daily. The sleepless nights continue so I asked my doctor for help. I was then prescribed Ambein CR 6.25 which worked for about 6 months. I could fall asleep but for only a few hours. I have tried sleep hygiene, cutting out caffeine, etc. Now I am not sleeping at all. I have another appointment to see my doctor but not for another couple weeks. I am losing sleep and calling off work. I need help.
Answer
The most beneficial thing you can do to combat your insomnia is to treat the underlying condition, which in your case is stress. Seeing a counselor or therapist in regards to your problem is most likely going to be your best therapy. We recommend that you speak with your current doctor regarding referrals or alternative treatment options.
If there is any consolation, it is that your not alone in suffering from insomnia. Data suggests that nearly 1/3rd of people living in the United States experience insomnia. The first-line treatments for insomnia should typically be non-pharmacologic interventions, as you have tried.
You mentioned you have tried sleep hygiene, which is one of the first steps to try and combat insomnia. You should try to specifically focus on stress relief and be sure to follow some basic sleep hygiene guidelines such as avoiding napping, cutting caffeine, having appropriate lighting etc...
In addition to your stress levels, there could be additional road blocks to you having a good nights sleep. Participating in a sleep study may be beneficial for you to have your sleep properly evaluated. You may have underlying conditions or disturbances in your sleep you are not aware of.
The last line of treatment is often pharmaceuticals. Drugs like Benadryl and Xanax, while often beneficial initially, tend to lose effectiveness over time. In addition, long term use of Xanax for the treatment of insomnia typically isn't recommended. It has a relatively high chance of causing dependence and sleep insomnia may rebound after stopping use.
Aside from what you are taking now, there are a variety of other treatment options we can touch on that you should discuss with your doctor.
Antidepressants
These may beneficial to treat underlying stress, anxiety and depression as well as providing effective treatment for insomnia. Options include:
- Doxepin
- Mirtazapine
- Trazodone
Although only Doxepin in the list above is the only FDA approved for the treatment of insomnia, the others are used commonly off-label for that purpose. They typically decrease the time needed to fall asleep (i.e. sleep latency) and increase the total time you stay asleep (i.e. sleep maintenance). Due to your stress, antidepressants may be an option to look into with your doctor.
Non-Benzodiazepine Insomnia Drugs
There are many options here:
- Lunesta (Eszopiclone)
- Rozerem (Ramelteon)
- Belsomra (Suvorexant)
- Ambien (Zolpidem)
As mentioned in your question, you have tried Ambien. They do make an Ambien CR 12.5 mg dose which may be more beneficial than the 6.25 mg dose. Lunesta is very similar to Ambien and typically wouldn't provide any more benefit if you have failed on Ambien.
Rozerem is different than both Ambien and Lunesta. It works by agonizing melatonin receptors in the body. One of the best aspects of Rozerem is that studies indicate that it does NOT interrupt REM sleep as benzodiazepines do (e.g. alprazolam). That often can lead to someone feeling more rested.
Unfortunately, Rozerem doesn't quite produce the fast onset of action and level of sedation that other medications do. For that reason, in those who have previously tried Ambien or benzodiazepines, the effects often feel underwhelming.
Lastly is a new drug known as Belsomra (suvorexant). It is unlike any other available and works via a novel mechanism of action... it is classified as a orexin receptor antagonist. Orexin neurotransmitters in the body are thought to be a key component in promoting wakefulness. Antagonizing those receptors induce drowsiness and sedation. It may be an option to try having failed other medications for insomnia.
The key to treating insomnia is to treat the underlying condition. Medications can work for a time, but may lose effectiveness and you still have the underlying problem. Please speak with your doctor regarding your best options moving forward.
