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Help! I can't get a good night's sleep!

Help! I can’t get a good night’s sleep!

Are you experiencing insomnia?

First, a disclaimer. This article was not written by a medical doctor and should not be considered a substitute for medical advice or medical care. If you are experiencing difficulty sleeping that persists for more than two weeks, see a medical doctor right away for a complete physical check-up. For some people, sleep problems can be caused by worries about something going on in life, anxiety, stress, or simply too much thinking. However, insomnia can be a medical condition which requires medical treatment, or it can be a symptom of a medical problem that needs attention. Sleep problems can be caused by a serious or even life-threatening illness, and should be thoroughly investigated by a medical doctor.  And many people have trouble sleeping due to physical pain or other physical symptoms that can be successfully treated with pain medication or other medical treatments.  Your doctor can advise you or prescribe medication or medical treatment if appropriate.

Three common types of sleep problems

Millions of people have trouble sleeping, either occasionally or every night. Some people have trouble “initiating sleep,” a term doctors use to describe having trouble falling asleep at night. Other people have “middle insomnia,” just a fancy way of saying they wake up in the middle of the night and have trouble falling back to sleep. And some people have “early morning awakening,” which is exactly what it sounds like: waking up a few hours too early, usually after having only four to six hours of sleep. Some people have the misfortune of having all three problems, which one of my clients dubbed “the evil three-headed dog from hell,” and they generally have the most difficult sleep problems to solve.

The reason doctors make these distinctions is that these three types of insomnia often have different causes and different solutions. At the risk of oversimplifying  a vast spectrum of very complex sleep problems, here are a few examples. Trouble initiating sleep is often caused by anxiety, too much coffee, steroids or other stimulants too late in the day, traumatic brain injury, or physical pain, all of which make it difficult to relax enough to fall asleep. Middle insomnia is often experienced by people who drink too much alcohol relatively close to bedtime, because the alcohol starts to be metabolized during the night and wakes them up. Middle insomnia can also be caused by anxiety and stress, as someone might wake up during the night and start worrying about something going on in their life and not be able to get back to sleep.

Early morning awakening also has multiple causes, but among the most common are chronic pain syndromes like arthritis, lupus, fibromyalgia, or migraine headaches. Most people with these pain conditions take pain medications, muscle relaxants, or anti-inflammatory drugs throughout the day to manage their pain. But even though they have usually taken a dose of their medication at bedtime, by 4:00 AM, or at some point before morning, the medications have worn off, so their pain worsens and wakes them up. And in many pain syndromes, the pain is worsened by inactivity, so lying in bed sleeping for several hours (rather than walking and moving around as they would during the day) tends to make the pain worse, eventually waking them up.  

The other most frequent cause of early morning awakening is clinical depression.  It is not clear why people suffering with depression tend to wake up a few hours early, after only sleeping for four to six hours. Scientists believe this is related to lowered levels of a neurotransmitter (a type of chemical messenger in the brain) called serotonin, which is a feature of biochemical depression. Because early morning awakening is sometimes a cardinal symptom of depression, if you experience this type of insomnia, it is important to see your doctor as soon as possible for an evaluation.

Doctors and sleep researchers have warned that sleep deprivation, regardless of the cause, is an epidemic that causes billions of dollars in lost productivity at work, as well as many workplace accidents, and thousands of car accidents due to slowed reaction times, impaired judgement, or falling asleep at the wheel. Research indicates that chronic lack of sleep contributing to many illnesses including heart disease and diabetes. And, insomnia creates untold misery for anyone suffering with this very painful problem, disrupting their careers, home life, relationships, and quality of life.

Insomnia and so-called “sleep hygiene”

There are lots of websites and books giving advice on how to get a better night's sleep, so this article will just give you the short list. Traditional sleep advice covers a range of behaviors called “sleep hygiene,” a strangely obnoxious term that includes things like going to bed at the same time every night, getting up at the same time every morning, not drinking coffee after 12 noon, and avoiding too much alcohol, getting enough physical exercise during the day. They also advise not watching TV or being on your computer or phone for a few hours before bedtime, because the type of light, called blue light, in these screens stimulates you to stay awake. Another guideline suggests if you can’t fall asleep after 20 minutes of lying in bed, get up and read for awhile and then go back to bed when you feel sleepy. For some people, following these steps significantly improves their ability to fall asleep and stay asleep.

Sleep problems are very personal and individual

However, most people find that insomnia is a very individual demon, and each person has a different experience with struggling to sleep well. As a result, many people practice these “sleep hygiene” behaviors religiously, but find that this does not improve their sleep. Many other people            try all the sleep hygiene behaviors and discover that one of these guidelines actually does help their sleep, but the rest don’t make much difference.

For instance, one client told me she tried everything, but nothing actually helped except getting more exercise. “I started taking an exercise class at the Y three times a week, and I noticed that on those three nights I was sleeping more soundly and getting at least one hour more sleep per night. So I started running and biking for at least a half-hour on the other days of the week, and now I sleep better every night. None of the other stuff helped me at all. For instance, I can drink coffee all day long and drink whiskey all evening, and it doesn’t affect my sleep at all. But if I skip a few days of exercise, I only get four hours of sleep those nights.” Another client found that going to bed at the same time every night and getting up at the same time every morning actually did help him sleep more soundly and get more sleep, but none of the other “sleep hygiene” guidelines seemed to make any difference. “I go to bed every night at 10:30 PM and set the alarm for 6:30 AM, and try to stick to that seven days a week. I used to get so exhausted from being awake in the middle of the night that I would sleep late whenever I could. But that just got me even more off-kilter with my sleep. Now I get up at 6:30 even if I am tired, and it seems to re-set my body so I can sleep a lot better most nights.” 

A third client discovered that he slept much better if he only drinks coffee early in the morning, and sticks to de-caf coffee the rest of the day. “I used to drink coffee all day, and it never bothered me. Since getting a little older, coffee seems to affect my sleep. So now I drink three cups of coffee in the morning, and then drink only de-caf in the afternoon. Whenever I make the mistake of drinking real coffee in the afternoon, I can’t get to sleep until 1:00 AM and then I wake up frequently throughout the night.” Another client says, “I tried all that sleep hygiene stuff even though I thought it was a bunch of nonsense. And none of it made any difference except the thing about TV. I love watching TV shows and movies in the evening to relax after a long day at work. But unfortunately, if I watch them late at night, I am overstimulated and cannot get to sleep. I had to change my habits so now I watch TV or movies earlier in the evening, and quit at least an hour before bedtime. And I listen to an audiobook for about 45 minutes before going to sleep.”

So the take-home message is: DO try modifying your behavior and following these sleep guidelines that are recommended by all the sleep gurus and doctors, and evaluate the effectiveness (or lack thereof) of each one.  Changing one or more of these behaviors does help many people, so give them a try.

Different Strokes for Different Folks

There does not seem to be any “one size fits all” insomnia solution. If you find that these universally dispensed sleep guidelines listed above don't work for you, don't despair. There are a lot of other options. It seems to be a very frustrating and time-consuming “trial and error” process for most people.

If you have seen a doctor and have ruled out any medical cause for your insomnia, it is possible that the cause is anxiety and overthinking. Modern life is extremely hectic and stressful, and it can be very hard to “put your worries to bed” and feel safe and relaxed enough to get a decent night’s sleep. Whether you are facing serious crises, or simply trying to manage the normal stresses of life in our crazy modern world, learning to let go of the worries of the day and settle into sleep can require a learning process.

Some people find that doing meditation, self-hypnosis, or deep breathing exercises, either before bedtime or when they get into bed, helps them fall asleep and sleep more deeply. Many people listen to relaxation CD’s or downloads, or guided imagery or hypnosis CD’s or downloads, to relax their bodies and minds so they can fall asleep. Or they use these CD’s or downloads if they wake up during the night, to help them fall back to sleep.

One relaxation exercise that some people find helpful is called Progressive Muscle Relaxation. This just means deliberately tensing up each set of muscles and then relaxing them, starting with your toes, ankles, calves, and working your way all the way up to your face and jaws. Some people find this focuses their mental and physical attention on relaxation enough that they can get sleepy and fall asleep. Other people find it annoying and say that it only makes them feel more agitated and awake. Give it a try and see whether it works for you.

If you feel that your insomnia is caused by stress and worrying about things going on in your life, talking things through with a counselor may help you feel calmer and/or help you formulate plans and take action on the things that are bothering you and keeping you awake at night. Cognitive-behavioral therapy can help you change your thinking in order to avoid obsessing about problems. Another option: some people have found a few sessions of hypnosis with a professional hypnotherapist can help reduce their anxiety and make it easier to fall asleep at night and sleep more soundly.

What about sleeping pills and other medications for insomnia?

Our society in general, and the medical community in particular, seems to have a very conflicted and contradictory relationship with the idea of taking pills to get to sleep. All of the sleep experts, books, websites, and doctors advise against taking sleeping pills or tranquilizers. However, the reality is that millions of prescriptions area written every year by doctors for Ambien, Restoril, Remeron, Lunesta, Sonata, Trazadone, Ativan, Xanax, and many other medications for sleep problems.  And there are plenty of “over the counter sleep aids,” available without a prescription, that usually contain some type of antihistamine such as Diphenhydramine (Benadryl). Antihistamines are used for colds and sinus congestion, but they that cause drowsiness as a side effect, and many people find them effective as a sleeping pill.

Any of these drugs can be extremely useful for insomnia, but can also be extremely dangerous and should only be taken in collaboration with a medical professional, and with a complete understanding of the both the potential benefits and hazards.

DON’T MIX SLEEPING PILLS AND ALCOHOL

These drugs should NEVER be taken in conjunction with ALCOHOL, as this will suppress your heart rate and respirations. Translated into plain English, this means you could stop breathing and die if you drink alcohol and take any of these drugs together. You have certainly read many stories of movie stars such as Judy Garland and Marilyn Monroe, rock stars, and normal everyday people who have died from this toxic combination of drugs and alcohol.

Many people do successfully use small amounts of alcohol to help them fall asleep, such as one 8-ounce glass of wine or two ounces of hard liquor such as bourbon or vodka, and that is perfectly safe as long as you are not a recovering alcoholic or taking other medications that may interact with alcohol. However, under NO CIRCUMSTANCES should you ever drink alcohol and take any type of sleeping pill, pain pills, or tranquilizers, as this can lead to coma, brain damage, and even death. If your doctor gives you a prescription for any type of sleeping pill or tranquilizer, make sure she is aware of any other medications you are already taking for any other medical condition, as many other drugs can have dangerous and potentially lethal interactions with these medications.

Sleeping pills can be habit-forming, and can lose their effectiveness over time

Some people take these drugs occasionally when they have a really bad night, or take them once or twice a week when they know they have a long work day ahead of them. Others take them every night and find that they cannot get a decent night’s sleep without medication.

Some of these medications can be habit-forming, in other words you can become addicted to them. Even worse, these drugs will become ineffective if taken too much or over a long period of time. If taken regularly, over time you will build up a tolerance and the drugs will no longer put you to sleep. Some people alternate them to avoid become addicted and to keep them from losing their effectiveness. For instance, some people take a sleeping pill such as Ambien one night, a tranquilizer such as Ativan the next night, and an antihistamine such as Benadryl the next night, and then back to Ambien the next night.

Talk to your doctor and see if this type of medication is appropriate for you. Never take any kind of medication, especially sleeping pills or tranquilizers without a prescription from your doctor, and never take more than the recommended dose.

A special concern is not taking sleeping pills or tranquilizers too close to morning, as these drugs can affect you for over eight hours. If you wake up during the night and make the mistake of taking an Ambien, for instance, at 2:00 or 3:00 AM, the drug will still be in your system in the morning and may impair your ability to safely and effectively drive a car, operate machinery, cook, concentrate, or be responsible for children. A general rule of thumb is that you should only take these drugs if you do not have to drive, work, or have other serious responsibilities for at seven hours after taking them. This will give the medication time to wear off enough that you can be a responsible adult without mental or physical impairment. This can sometimes be a very tough call. If you are lying awake at 2:00 AM, you may agonize over whether you will be more mentally and physically impaired in the morning if you take an Ativan or Restoril, or if you DON’T take anything and have to drive to work and actually do your job after only getting three or four hours of sleep. Because of this exact dilemma, a low-dose form of sublingual Ambien was developed, called Intermezzo. Intermezzo can be taken in the middle of the night by placing it under your tongue. It is a much lower dose, and it takes effect much faster than Ambien pills, and wears off much more quickly. However, even Intermezzo should NOT  be taken unless you have at least 4 hours to sleep before you have to get up and be a grown up and do anything requiring real alertness.

Medical Marijuana and insomnia

Since the advent of medical marijuana and the legalization of cannabis in many states, numerous cannabis products have been developed for treating insomnia. Even more than any other sleep solutions, cannabis is extremely idiosyncratic. This is a medical term that just means that each person’s response to various marijuana products and blends is extremely individual and unpredictable. And some types of pot are very stimulating, usually those strains that are primarily sativa, while some are more sedating, usually those blends that have mostly indica. However, even all-indica types of pot can produce a stimulating effect on some people, keeping them awake rather than putting them to sleep. For instance, one client who suffered from life-long insomnia found very effective relief through smoking a particular type of indica cannabis blend. However, his wife found that this same type of pot made it even harder to fall asleep. Some clients have found that cannabis cookies or tinctures that are taken by mouth are much more effective for them than smoking pot. However, edible cannabis takes much longer to take effect, and should be taken at least one hour before going to bed, preferably 90 minutes or more before you hope to fall asleep.

Cannabis seems to be most effective for two types of sleep problems:

1)      “Middle insomnia” or waking up in the middle of the night, and

2)      Insomnia or sleep disruptions caused by physical pain. 

 As discussed earlier, middle insomnia” means waking up in the middle of the night and lying awake for an hour or longer before being able to get back to sleep. For someone with middle insomnia, smoking or eating cannabis one hour before bedtime often will help them sleep more soundly through the night. And if they do wake up during the night, they usually find it much easier to fall back to sleep. However, DO NOT smoke or eat any cannabis product WHEN you wake up in the middle of the night. Otherwise, you are likely to be very stoned when you wake up in the morning and experience impaired physical and mental functioning. Some cannabis products are more long-acting than others, but most will affect you for several hours, so using them when waking up in the middle of the night is usually not optimal.

Chronic physical pain is a growing problem that affects millions of people. Chronic pain can be caused by past injuries, back problems, arthritis, diabetes, migraine headaches, fibromyalgia, endometriosis, multiple sclerosis, neuropathy, HIV, cancer, or other medical conditions. People suffering from chronic pain syndromes often have moderate to severe insomnia, finding it very difficult to fall asleep, often waking frequently during the night, and sleeping very lightly rather than having a sound, restful sleep. Many people with chronic pain sleep much more soundly if they use some form of cannabis about one hour before bedtime. CBD is a particularly useful cannabis product for insomnia caused by chronic pain, but there are many other types of cannabis that can help people who are experiencing sleep disruption due to physical pain.

Many people suffering with pain find that their sleep is improved significantly through a combination of cannabis and an anti-inflammatory medication such as Aspirin, Naproxen (Alleve) or Ibuprofen (Motrin), or a muscle relaxant such as Baclofen or Flexeril at bedtime. Pain relief, and sound sleep, can often be enhanced by utilizing a mild pain medication, anti-inflammatory, or muscle-relaxant with marijuana. As always, talk to your doctor to ascertain whether it is safe for you to combine these medications. Many anti-inflammatory medications, even “over the counter drugs” such as Aspirin and Motrin, can thin your blood, cause nausea and vomiting, internal bleeding, and other serious side effects, especially in conjunction with other medications. So it is very important to make sure your doctor knows what drugs you are taking or considering taking, so she can advise you appropriately about safety and effectiveness.

If you decide to utilize marijuana for your insomnia, it is imperative to talk to a doctor or medical professional with expertise in cannabis. The vast majority of doctors have no training or knowledge about cannabis, so it is imperative that you see a specialist who can advise you on whether cannabis is likely to be effective for your particular sleep problem, and can prescribe an appropriate type of pot as well as an effective dosing schedule. In addition to having a knowledgeable doctor, it is important to patronize a reputable marijuana dispensary in your community. Cannabis dispensaries vary greatly in their commitment to providing high-quality products as well as excellent patient care. And there is a very wide range of knowledge and education among cannabis professionals working in dispensaries. Talk to a number of staff members until you find someone who has expertise in cannabis products for insomnia, as this will significantly increase the likelihood of finding the most effective treatment for your sleep problem. Some dispensaries have excellent information on their websites about various blends and products for specific medical problems, and some post reviews from patients who have had success in treating their medical conditions with a specific product.

And while we are on the subject, there are a large number of other non-cannabis herbal products being marketed for insomnia. Many people do find some relief from insomnia through herbal remedies.  However, herbs are not regulated by the Food and Drug Administration (FDA), as they are considered “supplements” like vitamins rather than drugs. But herbs are very powerful medications, and should not be taken without seeing a trained and reputable herbalist, and taking herbs only as prescribed by an herbalist. Many herbal blends being peddled in health food or vitamin stores for insomnia are useless or even harmful.  Many herbs have many side effects and may interact negatively with other medications you are taking. Be especially cautious about taking any herbal remedy made outside the US, as manufacturing standards are generally lower and the risk of contamination or dangerous ingredients is higher.

Another option: check out a podcast:  www.sleepwithmepodcast.com

Many people struggling with insomnia have found that listening to a podcast called www.sleepwithmepodcast.com helps them get to sleep and stay asleep, and helps them fall back to sleep if they wake up during the night. What is this podcast and how does it work?

It is disarmingly simple, just a really nice guy recording an hour-long podcast three times a week in his closet in his apartment in Alameda, California, that lulls people to sleep. His name is Drew Ackerman, who goes by the nickname Scooter, and he is a life-long insomniac who has always had problems sleeping. He discovered somewhat by accident that he has a talent for putting people to sleep with his voice. For the past three years, he has been making these hour-long podcasts where he tells very long, rambling stories in a very soothing voice. His warm, welcoming, but dull delivery tends to engage your mind just enough to distract you from whatever may be keeping you awake, whether that is stress, anxiety, physical pain, noise, an uncomfortable or unfamiliar environment, a snoring partner, or other problems.

The trick seems to be that his stories are just interesting enough to keep you listening, but boring enough that they don't keep you awake. As he says himself, “When you listen to me droning on on the podcast, your mind tells you, 'this guy is s goofball, he’s not saying anything that important, I don't have to listen to him or pay attention, so I can fall asleep now.' I'm like a boring friend sitting at the edge of your bed telling bedtime stories until you fall asleep.” He apparently is onto something, as he has literally hundreds of thousands of listeners who download his podcasts and listen to them every night, falling asleep somewhere between the five-minute introduction and the ending of the story over an hour later. Over 600 episodes of the podcast can be downloaded for free, but thousands of people voluntarily subscribe to the podcast by sending monthly pledges through Venmo or Patreon. Many people have sent testimonials which appear on his website, claiming they had tried every other insomnia cure without relief, and that the podcast really helps them sleep. If you want to check it out, go to www.sleepwithmepodcast.com.

And I hope by the time you have read through this whole article, you are so bored that you have fallen asleep! Wishing you good luck with solving your sleep problems.

Kathy Labriola,
Counselor/Nurse

www.kathylabriola.com

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