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Cannabis use in patients with insomnia and sleep disorders: Retrospective chart review As medication experts, pharmacists are best suited to consult on the therapeutic applications of Can’t Sleep? Learn about insomnia solutions to help you fall asleep and stay asleep including sleep aids, OTC supplements, and sleep hygiene practices.

Cannabis use in patients with insomnia and sleep disorders: Retrospective chart review

As medication experts, pharmacists are best suited to consult on the therapeutic applications of cannabinoids. Insomnia is highly prevalent and with the rise of cannabis use, this research is a necessary first step to providing sound care. We want to ensure our patients are using any medication safely and effectively.

Abstract

Background:

Medical cannabis has been increasingly used in Canada after being sanctioned by Health Canada in 2001. Insomnia and sleep disorders are among the most common conditions for which patients report using cannabis. Current research shows cannabis may have a beneficial effect in sleep disorders and may improve patient-reported sleep scores.

Methods:

A retrospective chart review was conducted at Hybrid Pharm community pharmacy in Ottawa, Ontario, and included patients who were interested in, or already using, medical cannabis for sleep disorders. A qualitative, exploratory approach was taken to evaluate the descriptive efficacy and safety of medical cannabis when prescribed for insomnia or comorbid conditions. The comprehensive data collection also involved investigating the impact of cannabis on other medication used for insomnia.

Results:

A total of 38 patients were identified as having adequate follow-up documentation to assess the impact of medical cannabis. At time of data collection, 15 patients (39%) were able to reduce or completely discontinue a prescription medication indicated for sleep. On follow-up, 27 patients (71%) reported a subjective improvement in their sleep or related condition. Only 8 patients (21%) reported any adverse effects from medical cannabis use, and these were manageable and did not require discontinuation of cannabis.

Conclusion:

This study highlights the importance of a pharmacist’s role in the management of cannabis-based therapy, including ongoing supportive care, follow-up and medication management. Can Pharm J (Ott) 2022;155:xx-xx.

Introduction

Cannabis has been used in Canada for medical purposes since being sanctioned by Health Canada in 2001 under the Medical Access Regulation Act. 1 Data on the potential impact of cannabis to treat insomnia remains equivocal, however, with a recent meta-analysis by Bhagavan et al. pointing out that while there are data to show a positive effect of cannabis on outcomes in patients living with insomnia, it is still low quality because of small sample sizes and short treatment periods. 2 Indeed, sleep disorders are one of the most common reasons individuals report using cannabis for medicinal purposes, alongside chronic pain and mental health–related disorders. 3

Sleep is essential for health and involves factors such as quality and duration, 4 and recent research has shown that later sleep timing and greater variability in sleep are associated with adverse health outcomes such as increased risk of depression 5 and cardiovascular diseases. 6 -9 Despite advances in pharmacotherapy and psychotherapy, insomnia and sleep disorders remain a significant burden to society. Cannabinoids are gaining acceptance for use as medicines in the treatment of insomnia. Patients often report using medical or recreational cannabis to treat multiple symptoms 10 ; patients may be using cannabis for a primary sleep disorder (e.g., insomnia) or secondary to another medical condition or psychiatric condition (e.g., depression, anxiety, chronic pain, fibromyalgia, etc.). 11 Currently, the available pharmacologic treatments for insomnia and sleep disorders include H1-antagonists, benzodiazepines and hypnotics (e.g., zopiclone, zolpidem, etc.). Other medications are used off-label for sleep, including antidepressants (e.g., trazodone, mirtazapine) and second-generation antipsychotics (e.g., quetiapine). 12 However, many of these medications have unwanted adverse effects, including dizziness, cognitive impairment, daytime sedation, weight gain, metabolic syndromes and the potential for addiction and dependency. Many patients who seek medical cannabis for sleep and related disorders have often tried many of these medications and have experienced undesirable side effects.

The cannabis flower contains more than 120 different phytocannabinoids, with delta-9 tetrahydrocannabinol (THC) and cannabidiol (CBD) being the most studied cannabinoids of interest. 12 Cannabis, specifically with strains containing higher levels of THC, is known to have a dose-dependent effect on sleep. 13 THC acts on the CB1 receptors in the central nervous system and can yield a biphasic effect on sleep 14 such that THC, at lower doses, can reduce sleep onset latency and has been associated with greater ease of falling asleep, increased slow-wave sleep and increased total sleep time. 15 -17 At higher doses, THC-predominant cannabis has demonstrated a reduction in total rapid eye movement (REM) sleep and REM density. 18

CBD, the second most abundant cannabinoid found in cannabis, has been shown to have a dual effect on sleep latency. At lower doses, CBD can have a stimulating effect; however, at higher doses, it can have more of a sedating effect. It can increase total sleep time and decrease the frequency of arousals during the night. Overall, cannabis may have a short-term benefit on improving sleep time, where evidence has shown reductions in sleep onset latency. 19

Based on the available evidence, THC and THC derivatives, used either alone or in combination with CBD, have been shown to improve self-reported sleep scores. 20 Because of the preliminary evidence from small-scale randomized controlled trials suggesting cannabis can provide treatment benefits in sleep disorders, along with the downfalls of current pharmacologic therapy, it is reasonable to conduct a review of patients using cannabis for sleep and assess their sleep scores, along with other measures of improvement or adverse effects of cannabis use.

Methods

The primary objective of this chart review was to evaluate the descriptive efficacy and safety of medical cannabis in patients with insomnia. The secondary objective was to identify specific medical cannabis products used for the treatment of insomnia and observe their effects on the utilization and discontinuation of other prescription medications in patients.

Design

A retrospective chart review of patients who indicated they were interested in using, or already using, recreational or medical cannabis for sleep or related disorders was conducted at Hybrid Pharm. The data collection was conducted through a comprehensive chart review of patients seen at Hybrid Pharm community pharmacy in Ottawa from January 2019 to July 2020, and who indicated they were seeking cannabis for insomnia and had received a medical document for cannabis.

Patients (inclusion/exclusion criteria) and recruitment

The inclusion criteria included patients who had received a medical cannabis document either from a clinician at Hybrid Pharm or from another prescriber. Patients were identified by investigators to be included in the analysis if there was adequate follow-up documentation regarding their cannabis use. Patients excluded from this study consisted of recent patients with a short duration of use, defined as less than 3 months of medical cannabis use from date of consultation at Hybrid Pharm. Further exclusion criteria included inadequate documented follow-up to assess efficacy and safety or patients who were not seeking cannabis for insomnia or sleep conditions.

Outcomes

The primary efficacy endpoints were subjective patient-reported improvements in sleep and a reduction in prescription medication use for sleep disorders. Secondary endpoints included adverse effects of cannabis and types of medical cannabis products used.

Follow-up

Patients were reassessed by a nurse practitioner 3 months after starting medical cannabis, once their initial medical document had expired. Pharmacists also conducted follow-up appointments with the patients to assist in medication counselling, including product selection, dosing, side effects and drug interactions. Electronic databases, consisting of patient questionnaires and charts, community pharmacy patient profiles and health care professional documentation found in Kroll Pharmacy Management Software, AdvancedCare and CannScript, were all used to collect information. Self-reported diagnosed conditions on initial intake questionnaire can be seen in Table 1 . The patient onboarding questionnaire contained in the AdvancedCare platform was a descriptive form completed individually by the patient. It included the Insomnia Severity Index (ISI), which was used to determine baseline insomnia severity as well as assess improvement, medical conditions and general open-ended questions regarding previously tried therapies and impact on quality of life. The ISI is a validated 7-item self-report with adequate psychometric properties that captures the nature, severity and impact of insomnia. 20

Table 1

Self-reported diagnosed conditions on initial intake questionnaire from Hybrid Pharm (N = 38)

Condition n
Anxiety/stress disorders 18
Depression 12
Chronic pain 13
Sleep disorders 11
Migraines 7
PTSD 6
Cancer 4
ADD/ADHD 4
Fibromyalgia 3
Psoriasis 3
Eating disorders 1
COPD 1
IBS 1
Spinal cord injury/disease 1
Crohn’s disease/colitis 1
Epilepsy 1
Arthritis 1

Patients were able to select more than 1 condition. PTSD, posttraumatic stress disorder; ADD/ADHD, attention-deficit disorder/attention-deficit hyperactivity disorder; COPD, chronic obstructive pulmonary disease; IBS, irritable bowel syndrome.

Upon renewal, patients report on a recall period of “last month” using a 5-point Likert-type scale with the following dimensions: severity of sleep onset, sleep maintenance and early morning awakening problems, sleep dissatisfaction, interference of sleep difficulties with daytime functioning, noticeability of sleep problems by others and distress caused by the sleep difficulties. As indicated by Bastien et al., “The total score is interpreted as follows: absence of insomnia (0-7); sub-threshold insomnia (8-14); moderate insomnia (15-21); and severe insomnia (22-28). 20 Ethics approval for this retrospective chart review was obtained from the Research and Ethics Board at the Children’s Hospital of Eastern Ontario (CHEO).

Results

At the time of data collection, a total of 159 patients had indicated on the patient intake form that they were seeking cannabis for insomnia. Of 159 patients, 38 were identified as having adequate follow-up to assess the impact of medical cannabis ( Table 2 ).

Table 2

Documentation of patients self-identified as interested in seeking or already using cannabis for a sleep disorder

Documentation n
Adequate follow-up to assess endpoints 38
Inadequate documentation to assess endpoints 21
No follow-up documented 73
No medical document for cannabis or follow-up 27

Patient demographics

At the initial point of contact at Hybrid Pharm, 39% of patients were taking a prescription medication indicated for sleep disorders when they began using medical cannabis ( Table 3 ). At baseline, the mean ISI score was 15.4 (±5.2), which is indicative of moderate insomnia.

Table 3

Baseline characteristics of patients included in the retrospective chart review (N = 38)

Baseline characteristics n
Currently taking prescription medication indicated for sleep disorders 15
Reported using specifically for insomnia 7
Reported using primarily for depression or anxiety 5
No indication specified 3
Number of patients reporting that sleep disorder and/or related medical/psychiatric conditions were affecting their life daily 33
Previous cannabis use 23
Recreational cannabis 14
Medical cannabis 9
Cannabis naïve (no previous cannabis use) 13

Patients could be identified with multiple baseline characteristics. Recreational cannabis = cannabis used without a medical document authorized by a prescriber; medical cannabis = cannabis authorized by a prescriber and purchased from a Health Canada–licensed producer of medical cannabis products.

On the initial patient onboarding questionnaire, 87% of patients reported that their sleep disorder affected their daily routine, affecting quality of life. Patients were often seeking alternative therapies, including medical cannabis. Of the 38 patients included, 23 patients had reported previous or current cannabis use, either obtained recreationally or from a prior medical cannabis document from a licensed producer. Recreational cannabis was defined as use of cannabis not obtained directly from a licensed producer with a medical document. Medical cannabis was defined as cannabis authorized by a prescriber with a medical document and obtained from a Health Canada–licensed producer. Thirteen patients indicated they had never tried recreational or medical cannabis before and were therefore cannabis naive.

The average duration of follow-up was 100.9 ± 60.4 days (data not shown). Upon follow-up with either a pharmacist or nurse practitioner at Hybrid Pharm, 21% of patients reported being able to reduce their prescription medication use, while 18% were able to completely discontinue prescription medications used for sleep or related comorbid conditions. These included benzodiazepines, benzodiazepine receptor agonists (i.e., zopiclone) and antidepressants (i.e., trazodone). Patients also reported using medications such as benzodiazepines and trazodone less frequently for sleep. Benzodiazepines are often associated with adverse effects, including the development of tolerance, risk of abuse and cognitive impairment, especially in older adults. 5 Eleven patients reported taking antidepressants such as trazodone, mirtazapine, doxepin or quetiapine for a concurrent diagnosis of depression or anxiety or, more commonly, for sleep.

The types of medical cannabis products used were based on the data collected, either from self-reported patient information during follow-up or recommendations made by the pharmacist or nurse practitioner: 34% reported using a CBD-only oil, while 21% of patients reported using a combination product of a THC:CBD oil, of varying concentrations. Many patients were using multiple medical cannabis products, with high-concentration CBD oil during the day and a THC:CBD (1:1) oil at night. Approximately 29% reported using at least 2 different types of cannabis oils, although this number may be higher, as a confirmed list of all products patients were using was not available. This included a high-CBD oil and a combination THC:CBD oil. Patients were often recommended to start CBD oil initially for use at bedtime if sleep was the main indication. Although smoking was discouraged, 3 patients reported that rapid onset via inhalation was more beneficial before sleep, where they reported using inhalation methods such as vaporization, dabbing and shatter ( Table 4 ). These patients were typically cannabis experienced and often used vaporization and alternative methods in addition to regularly dosed cannabis oils.

Table 4

Medical cannabis products used by patients at Hybrid Pharm (N = 38)

Results n
Cannabis oil products used:
CBD-only oil 13
Combination THC-CBD oil 8
≥2 different cannabis oils 11
Routes of administration:
Ingestion (oils) 37
Smoking/vaporization 3
Concentrated dosage forms (e.g., dabs, shatter) 1

Patients were exposed to multiple products and routes of administration.

Based on follow-up documentation from the health care practitioners, 71% of patients reported subjective improvement in their sleep or related medical condition with cannabis, which was a primary efficacy endpoint. The degree of improvement varied, with some patients reporting a mild improvement, such as taking less time to fall asleep or sleeping longer through the night. Moreover, 26% reported a very significant improvement in their sleep or comorbid symptoms. Thirteen percent of patients reported that their symptoms and sleep level were the same and had no change with cannabis use (see Table 5 for efficacy and safety endpoints). Upon follow-up, based on anecdotal evidence, these patients were taking a dose that was too low to provide benefit for sleep or the medical cannabis product was inappropriate. Some patients reported their concurrent medical conditions, such as chronic pain, were improved with cannabis; however, their sleep may not have been affected to the same degree. This was often due to improper dosing and may have been improved with additional counselling and patient education. In addition, 2 patients reported worsening of sleep with medical cannabis. One of these patients was cannabis naive. The other patient reporting a worsening of sleep had previously smoked and vaporized recreational cannabis daily while also using a concentrated THC resin. They reported that the medical cannabis products recommended did not provide the same effect on pain relief and insomnia as the recreational product did.

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Table 5

Efficacy and safety endpoints identified in patients using medical cannabis for sleep disorders (N = 38)

Endpoint n
Efficacy endpoints
Subjective improvement in sleep or related medical condition with cannabis use 27
Very significant subjective improvement in sleep or related medical condition with cannabis use 10
No change in sleep disorder or related medical conditions with cannabis use 5
Worsening sleep disorder or medical condition with cannabis use 2
Reduced prescription medication use 8
Discontinued prescription sleep medication 7
Safety endpoints
No adverse effects reported 25
Mild adverse effects 8
No data of adverse effects 5

Patients were assessed for the development of any adverse effects from cannabis during follow-up appointments. Of the 38 patients included, 66% reported no adverse effects from their cannabis use. Twenty-one percent of patients reported mild adverse effects, including diarrhea and acid reflux with cannabis oil, increased anxiety with higher THC concentrations and “brain fog.” These adverse effects were often manageable with either a change in cannabis product, adjustment of THC:CBD concentrations, alternative dosage formulations or a dose reduction. While some patients chose to discontinue cannabis use for other reasons, no patients specifically discontinued medical cannabis due to an intolerable adverse effect.

Discussion

Sleep-related disorders represent one of the most common uses for cannabis products. Our review of patients using cannabis products for sleep showed that 71% of patients reported a subjective improvement in their sleep, with 39% of patients reducing and/or discontinuing prescription therapy. Twenty-one percent of patients experienced manageable dose-dependent adverse effects, which did not result in discontinuation of medical cannabis therapy.

Most patients we identified during this chart review indicated they had been diagnosed with an anxiety/stress disorder. Anxiety can often affect a patient’s sleep, and both anxiety and stress often occur concurrently. Indeed, anxiety and sleep are top conditions cited by patients as indications for their cannabis use, along with pain 14 ; the current findings dovetail with this previous research, as many of the patients in this chart review reported using cannabis for sleep, anxiety and chronic pain. Many patients reported reduced anxiety at night, which helped them fall asleep. Not only did this retrospective investigation demonstrate a subjective improvement in patients’ quality and quantity of sleep and related symptoms, but it also demonstrated that many patients were able to discontinue prescription medications previously taken for sleep and anxiety. This had other improvements in their overall health, such as reduced side effects of medications and improved psychological well-being. Importantly, this review of chart data demonstrated that patients presenting to a pharmacy for treatment are able to completely discontinue insomnia medications, or reduce their use from nightly administration to as-needed administration, with the use of medical cannabis.

Adverse events and clinical implications

There were few adverse effects reported by patients, with only 21% of patients reporting any. None of the side effects reported were intolerable, and they often responded to therapy modification. Pharmacist and practitioner interventions were able to improve the efficacy and ameliorate the adverse effects of cannabis. These recommendations included titrating to an appropriate dosage or switching to an alternative product. Most of the adverse effects reported responded to a change in dose or product. For some patients, high concentrations of THC were reported to activate states of anxiety, euphoria, general stimulation and feeling “high,” and for some, this was described as an adverse effect. However, these undesirable side effects were manageable and mitigated by recommendations from the pharmacist or prescriber to either switch to an alternative cannabis product or to reduce the dose. In addition, while patients were cautioned regarding smoking, some patients found this route of administration particularly helpful for sleep. The rapid onset and quick effect of smoking cannabis was cited by patients as helping reduce sleep onset latency.

This study highlights the importance of health care practitioner medication management, including proper dosing, product selection and adverse event mitigation. Most patients, 34%, used CBD-dominant ingestible products.

Study limitations

There were limitations to the current study. This was a retrospective chart review, and as a result, it was not possible to determine causation, only association. Although an initial 159 patients were identified as seeking cannabis for insomnia, there was a limited sample size of 38 patients due to a lack of follow-up data, which reduces the applicability of the current findings. Many of the patients included in this analysis were motivated to try cannabis or were already using medical or recreational cannabis with good effect, and this may have introduced bias, as the patients included in the analysis were likely more willing and motivated for medical cannabis to be effective. The ISI scores were collected at baseline; however, there were no follow-up scores for the vast majority of patients, so it was not possible to compare scores over time. This indicates a possible area of future study. By looking at objective measures of sleep, including the ISI, it would be possible to better quantify the beneficial impact of medical cannabis on sleep. In addition, other scores such as the Brief Pain Inventory and Generalized Anxiety Scale–7, for patients with chronic pain and anxiety, respectively, would provide more objective data on the impact that cannabis may have on these conditions. Since insomnia, chronic pain and anxiety are often comorbid conditions, it is important to evaluate the response of cannabis on these medical and mental health conditions as well. Given the limitations of this study, the results are only hypothesis generating and unfortunately cannot inform current practice. While there appears to be a benefit for cannabinoids for sleep, larger randomized controlled trials are needed to provide clear data to change practice.

Conclusion

Our review of cannabis use in patients with sleep disorders suggests some benefits, with a subjective patient-reported improvement in insomnia and a decrease in use of prescription hypnotics. While this study provides some important insights into medical cannabis and sleep disorders, it is a low level of evidence because of the nature of the study. Overall, ongoing clinical trials of cannabinoids in patients living with insomnia are integral to ensuring evidence-based decisions on the role of cannabinoid therapies in the treatment of sleep disorders. ■

Footnotes

Funding: There was no funding for this project.

Contributor Information

Régis Vaillancourt, Department of Pharmacy, Children’s Hospital of Eastern Ontario, Ottawa.

Shannon Gallagher, Hybrid Pharm, Ottawa, Ontario.

Jameason D. Cameron, Department of Pharmacy, Children’s Hospital of Eastern Ontario, Ottawa.

Rahim Dhalla, Hybrid Pharm, Ottawa, Ontario.

References

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How To Fall Asleep:
Finding The Right Insomnia Treatment

Can’t Sleep? Learn about insomnia solutions to help you fall asleep and stay asleep including sleep aids, OTC supplements, and sleep hygiene practices.

Highlights

An estimated 30% of American adults experience symptoms of insomnia each year.

Sleep deprivation can lead to serious health and safety consequences if left untreated. These include an increased risk of disease, poor mental health, and an increased likelihood of accidents.

If you’re suffering from insomnia, work with an expert to find the right treatment option for you. Remedies for insomnia include prescriptions, supplements, therapies, and more.

For the fourth night in a row, Johannah found herself suddenly awake in the middle of the night.

She was annoyed at how alert her body felt, knowing that when her alarm rang in a few short hours she would feel anything but alert.

Over the past few weeks, Johannah had been experiencing increasingly bad sleep but didn’t understand why. She was so tired during the day. She felt slow at work and could barely keep her eyes open, despite drinking enough coffee to wake up a rhinoceros.

It seemed like she should be able to crash as soon as her head hit the pillow.

Johannah suspected the cause behind her sudden insomnia was stress. Despite a new job that covered most of her expenses, she had a wedding coming up and wasn’t sure how she and her fiance would be able to pay all the vendors. Johannah suspected that solving her money problems would also solve her sleep issues.

But finding a solution to late-night tossing and turning was taking longer than she had expected. She needed some rest, but she didn’t know how to get it.

Sleep is a crucial element to our overall wellbeing and our ability to perform at our best each day.

We all experience particularly stressful periods in our lives when we lose some shuteye due to anxiety. In most cases, such sleep issues are short-lived and resolve themselves. But when it doesn’t, you may need to seek help.

Here, we’ll help you learn more about insomnia. We’ll also clarify the different solutions available to help you get rest when you need it the most.

Introduction

Insomnia Defined

The Mayo Clinic defines insomnia as:

  1. The inability to fall asleep; or
  2. The inability to stay asleep

And it’s one of the most commonly reported sleep disorders. One in seven adults reports experiencing long-term sleep troubles.

Long-term, or chronic insomnia, occurs when a person has trouble sleeping at least three nights a week for a period of at least three months.

But sleep deprivation isn’t always chronic. It can strike for shorter periods of time, what’s known as “acute insomnia.”

Psychiatrist and Sleep Specialist Dr. Alex Dimitriu has helped hundreds of patients overcome their insomnia. According to Dr. Dimitriu:

“Acute causes can certainly be due to sudden life stressors – job change, move, or interpersonal. More chronic cases of insomnia may be psychophysiological – a situation in which the very fear and anxiety of getting good sleep interfere with good sleep”.

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Insomnia has serious consequences in our lives. In fact, a lack of rest can:

  • Impair mood
  • Increase anxiety and impulsivity
  • Hurt learning and memory
  • Reduce creativity
  • Weaken the immune system
  • Cause weight gain
  • Reduce sex drive

Sleep deprivation can also shift us towards “survival” mode, an extremely unhealthy state in the long term.

Insomnia Symptoms

Insomnia is disruptive to our lives in many different ways.

Over the next two weeks, keep track of any symptoms you experience. Be sure to make note of how you’re feeling at night as well as during the daytime.

If you suffer from sleep deprivation, you’ll often feel groggy throughout the day. It also commonly impacts your mood.

The most common symptoms include:

  • Inability to fall asleep
  • Waking up throughout the night
  • Feeling tired, even after a night of rest
  • Irritability
  • Depression
  • Anxiety
  • Inability to focus
  • Forgetfulness
  • Increased mistakes or even accidents
  • Obsession with sleep

Insomnia is often self-perpetuating, obstructing the actions that would help us rest better.

“In some cases, [insomnia] sets up a vicious cycle, of getting stuck in activities at night, sleeping less and poorly, and having diminished impulse control to not do so the following night.”

That tendency for the symptoms to exacerbate the problem is probably the most infuriating aspect of lack of sleep. Once you have it, it feels like you can’t escape.

Insomnia Causes

Most of us will experience insomnia at some point in our lives. The most common type is acute, short-term insomnia lasting from a few days to a few weeks.

Causes can include:

  • Stress or anxiety
  • A significant life change (new child, divorce, new job, etc.)
  • Trauma
  • Travel (jet lag)
  • Change in work shift or schedule
  • Sleep disorders like sleep apnea, restless leg syndrome, or sleep terrors
  • An inappropriate rest schedule (staying up too late or waking up too early)
  • Poor sleep hygiene
  • Seasonal Affective Disorder
  • Change in health
  • Pain
  • Bathroom breaks
  • Phone or laptop use

When To Get Help For Insomnia

It’s not unusual to experience a poor night of shuteye every once in a while. But if you notice that your sleep debt is beginning to detract from your life, you may want to see a specialist.

Need help finding the right sleep solution for you? Start a consult with a board-certified doctor today.

According to Dr. Dimitriu, you should speak with your doctor, and maybe an expert if you notice certain symptoms. They include:

  • Periods of loud snoring, gasping for air, or sleep apnea
  • Waking up numerous times per night
  • Sleep disorders
  • No benefit from non-medical treatments
  • You regularly have trouble sleeping (more than a week or so)
  • Serious daytime grogginess (not just fatigue), particularly while driving
  • A significant change in daytime symptoms like increased agitation, anxiety, depression, or suicidal thoughts.

Additionally, if you find that you have nasal congestion when lying down or find that you tend to breathe through your mouth at night, be sure to see an allergist or ENT (Ear, Nose, & Throat) doctor.

Clear nasal breathing and airflow are important to getting rest.

More Than Tired has a search tool that can help you find a specialist in your local area.

Although insomnia feels invincible, you have several options at your disposal. Solutions range from lifestyle treatments to prescription medications. The right solution for you will depend on the type of insomnia you’re experiencing, its cause, and your medical history. For most patients, applying several different treatments is the most effective.

Prescription sleep medication may be helpful when stress is keeping you up at night. But not all Z drugs are created equal.

It’s important to work with your doctor to find the correct medication and dosage level for you.

Here we’ll walk through some common prescriptions used to help alleviate insomnia.

Sleep Prescriptions

Prescription sleep medication may be helpful when stress is keeping you up at night. But not all Z drugs (sleeping pills) are created equal.

It’s important to work with your doctor to find the correct medication and dosage level for you.

Here we’ll walk through some common prescriptions used to help alleviate insomnia.

Doxepin

Doxepin is in a class of medications known as tricyclic antidepressants and is commonly used to treat insomnia, especially for patients who can’t stay asleep. It’s a non-controlled substance and does not carry a risk of addiction or dependence.

Rather than acting as a sedative, Doxepin has been shown to help control your circadian cycle. Studies have also shown that Doxepin can:

Help you fall asleep more quickly

  • Increase your sleep quality, and
  • Help you stay asleep longer

There is ongoing research to determine exactly how Doxepin influences rest, but experts believe that it may slow activity in the brain, helping you fall asleep.

Most people, having taken the right dose, wake up after a full night’s rest, feeling refreshed and without drowsiness.

The recommended dosage for Doxepin for insomnia depends on the individual. You should discuss this with your doctor to make sure you’re taking the right dosage for your needs.

Low-dose Doxepin does carry some side effects including nausea and dizziness. Reach out to your doctor if you experience these or any other unusual side effects after taking Doxepin.

Doxepin may lead to morning sedation. It’s recommended that you test this medication out during the weekends so you can gauge your response to it. Always be careful about driving when taking Doxepin.

Trazodone

Trazodone is an antidepressant that doctors often prescribe to treat insomnia. Many doctors also prescribe it to minimize anxiety symptoms, or to treat depression.

Researchers believe that Trazodone helps you sleep by influencing certain neurotransmitters and restoring the balance of serotonin (a natural chemical) in the brain.

Trazodone is considered effective for acute insomnia and can be useful for patients with sleep issues resulting from trauma or negative life experience.

For insomnia, doctors prescribe low doses of Trazodone, usually from 25-50 mg, taken at bedtime. While Trazodone is available in tablets up to 300 mg, a high dose can actually have an adverse effect, keeping you awake rather than helping you get some shuteye.

Again, it’s important to work with your doctor to find a dosage that’s suitable for you.

At low doses, Trazodone causes few side effects. Still, as with any medication, side effects are possible.

Drowsiness is one common side effect of Trazodone, making it an effective sleep aid. And with the correct dosage, drowsiness shouldn’t carry over to the morning.

Tell your doctor if you experience any of the following:

  • Confusion
  • Dry mouth
  • Nervousness
  • Blurred vision
  • Weakness
  • Sexual dysfunction
  • Cardiac arrhythmia

In some cases, Trazodone has been shown to cause nasal congestion.

Nasal breathing and airflow are important when it comes to sleep. If you have allergies or nasal congestion when lying down, or if you tend to breathe through your mouth at night, you should be sure to see an allergist or ENT (Ear, Nose, & Throat) doctor.

Very rarely, Trazodone has been shown to cause priapism for men, which may require an ER visit if it persists for more than four hours.

Trazodone may lead to morning sedation. It’s recommended that you test this medication out during the weekends so you can gauge your response to it. Always be careful about driving when taking Trazodone.

Hydroxyzine

Hydroxyzine is an antihistamine that primarily treats itching caused by allergies. Because of its sedative properties, it’s also considered an effective treatment for insomnia.

Like other antihistamines including Benadryl, Zyrtec, or Claritin, Hydroxyzine works by blocking your body’s production of histamine. Histamine is a chemical that your body produces in response to an allergen.

At a low dose commonly used for insomnia, most side effects are rare and certain side effects (like drowsiness) make it helpful.

Though it’s considered a mostly safe medication, Hydroxyzine does carry some side effects:

  • Drowsiness
  • Dizziness
  • Constipation
  • Dry mouth
  • Blurred vision

As with any medication, tell your doctor if you experience these or any other side effects after taking medication.

Hydroxyzine may lead to morning sedation. It’s recommended that you test this medication out during the weekends so you can gauge your response to it. Always be careful about driving when taking Hydroxyzine.

Gabapentin

The FDA has approved Gabapentin to treat seizures and nerve pain. However, studies have shown that Gabapentin is also an effective treatment for insomnia and can even enhance deep sleep.

That makes it particularly helpful for patients who frequently wake up in the middle of the night.

Doctors, therefore, commonly prescribe Gabapentin off-label for restless leg syndrome and insomnia.

Gabapentin is an anticonvulsant drug, meaning it affects nerves in the body that can cause seizures and pain. Some research indicates that Gabapentin improves sleep by reducing agitation and stress before bed, helping you fall asleep faster.

The average Gabapentin dose for insomnia falls between 300-600 mg per day, taken one hour before bed. Your doctor can help you determine a safe and effective dosage.

Gabapentin is generally safe, but like most prescription medications, it carries some risk of side effects. Some of the most common include:

  • Dizziness
  • Drowsiness
  • Blurred vision
  • Cold-like symptoms
  • Trembling

Tell your doctor if you experience these or any other side effects.

Gabapentin may lead to morning sedation. It’s recommended that you test this medication out during the weekends so you can gauge your response to it. Always be careful about driving when taking Gabapentin.

Ambien

Unlike the medications listed above, Ambien (or Zolpidem in generic form) was developed specifically to treat insomnia. It belongs to a class of drugs known as sedative-hypnotics.

It works by increasing the effects of GABA in the brain, creating a calming effect.

There are two types of Ambien: immediate-release and extended-release. Immediate-release Ambien, as its name suggests, releases quickly in your system to help you fall asleep quickly. Extended-release Ambien helps you fall asleep quickly and has a slower releasing part that helps you stay asleep throughout the night.

Finding out which type of Ambien is right for you requires speaking with your doctor.

Ambien has been shown to have some side effects. Some of the most common include:

  • Drowsiness
  • Feeling tired
  • Loss of coordination
  • Stuffy nose
  • Dry mouth
  • Throat irritation
  • Nausea
  • Upset stomach
  • Headache
  • Muscle pain

Other side effects such as depression, anxiety, aggression, confusion, memory problems, hallucinations, changes in behavior, and thoughts of suicide are rare but have been reported.

Also, beware that people taking Ambien have reported sleepwalking or doing unusual activities in their sleep.

Tell your doctor if you experience these or any other side effects.

Ambien can be habit-forming, so it must be taken under the close supervision of a doctor. It’s intended only for short-term use and should never be used as a long-term option.

The FDA has issued safety warnings about Ambien and its use.

Ambien is not intended for anyone under the age of 18. It should only be taken if you’re intending to stay asleep in your bed for a full night (7-8 hours), and should never be taken with alcohol.

Ambien may lead to morning sedation. It’s recommended that you test this medication out during the weekends so you can gauge your response to it. Never drive after taking Ambien.

Lunesta

Lunesta, similar to Ambien, belongs in the sedative-hypnotics drug class. It also works by creating a calming effect on the brain.

Lunesta is intended for short-term use and should only be taken under the close supervision of a doctor.

You should only take Lunesta if you’re planning on resting in your bed for a full night of rest (7-8 hours).

Lunesta has been shown to be habit-forming. The risk of addiction may be higher if you have a history of substance abuse. Taking this medication exactly as your doctor has prescribed can help lower the chances of dependence.

Though not an exhaustive list, some of the most common side effects of Lunesta include:

  • Dizziness
  • Grogginess
  • Dry mouth
  • Loss of coordination

Though rarer, other reported side effects include memory loss, changes in behavior, depression, confusion, hallucinations, and thoughts of suicide.

Also, beware that people taking Lunesta have reported sleepwalking or doing unusual activities in their sleep.

Reach out to your doctor if you’ve experienced these or any other side effects.

Lunesta may lead to morning sedation. It’s recommended that you test this medication out during the weekends so you can gauge your response to it. Never drive after taking Lunesta.

Sonata

Sonata is a medication used to treat insomnia and is known as a hypnotic. Like Ambien and Lunesta, Sonata works to create a calming effect and help you fall asleep.

Sonata has been shown to be habit-forming. The risk of addiction may be higher if you have a history of substance abuse. Taking this medication exactly as your doctor has prescribed can help lower the chances of dependence.

You should only take Sonata if you’re planning on going to sleep in your bed for a full night of rest (7-8 hours).

Sonata is intended as a short-term solution and should only be taken under the close supervision of a doctor.

Some of the most common side effects of Sonata include, but aren’t limited to:

  • Dizziness
  • Feeling tired
  • Memory loss (generally short-term)
  • Loss of coordination

Other reported side effects include anxiety, depression, aggression, memory loss, unusual behavior, confusion, hallucinations, and thoughts of suicide.

Also, beware that people taking Sonata have reported sleepwalking or doing unusual activities in their sleep.

Reach out to your doctor if you’ve experienced these or any other side effects.

Sonata may lead to morning sedation. It’s recommended that you test this medication out during the weekends so you can gauge your response to it. Never drive after taking Sonata.

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Sleep Supplements

If prescriptions aren’t the right fit for you, there are quite a few over-the-counter sleep aids available. Below, we overview some of the most common supplements to help promote better sleep.

Cannabidiol (CBD) is a compound found in cannabis. It’s non-psychoactive, meaning that it won’t get you high, and studies have shown it helpful in treating conditions from inflammation to anxiety and insomnia.

CBD isn’t technically a supplement, but you can buy CBD products in many forms without a prescription. Although most patients take it as an oil, one hour before sleep, CBD also comes in capsules, chocolate, gummies, and sprays.

Researchers are currently trying to determine how CBD influences rest (and its effectiveness). Still, there is evidence that it calms the central nervous system, helping you relax and fall asleep.

Though it isn’t a prescription, it’s wise to talk with your doctor about CBD before giving it a try.

Not everyone reacts to CBD identically. Some patients feel energized and alert, rather than calm and relaxed. Additionally, the potency of each CBD product may vary, so check the label to confirm your dose.

CBD has no universal dose; each person is different. The dosage you need depends on your personal tolerance to CBD and the product’s CBD concentration. Most people will need to start with a smaller dose (11mg is considered low) and experiment to find the right level for them.

CBD’s side effects aren’t particularly common or serious, but some people do experience nausea, vomiting, and even mood swings or irritability. If you experience any negative effects after using CBD, you should consult with a doctor.

Melatonin

Melatonin is one of the most well-known supplements.

Most people aren’t aware, however, that melatonin is actually a hormone that your body naturally releases. The pineal gland in the brain produces melatonin and releases it at varying levels throughout the day to sync with your circadian rhythm. At night, your body naturally produces more melatonin to tell your whole system that it’s bedtime.

Dark rooms can signal that your body should produce more melatonin, while light rooms can stop the release. That’s why blue light has such a bad reputation among scientists. Backlit screens can tell your brain to stop producing melatonin and to wake up instead.

For people with naturally low levels of melatonin, a melatonin supplement might be helpful. In some studies, taking melatonin an hour before bed helped people fall asleep faster.

While generally considered safe, melatonin should be a short-term solution. Taking melatonin for more than two years has been associated with side effects like:

  • Headaches
  • Dizziness
  • Cramps
  • Depression

It’s always smart to speak to your doctor before taking any supplement. They can advise you on its effects and help you find the right dosage.

If you’ve never taken melatonin before, start with the lowest dose available and adjust as needed. Too large a dose can increase the risk of side effects.

Magnesium

Magnesium is another supplement that’s gained a reputation for helping people sleep. While supplementation is possible, you get most of your magnesium through the foods you eat. Magnesium is one of the most common natural minerals on Earth.

Low magnesium levels have been associated with sleep trouble.

Studies have found that magnesium improves rest in three ways:

  1. Help activate your parasympathetic system, making you feel more calm and relaxed.
  2. Help regulate the natural melatonin levels in your body, so your system knows when it’s time to sleep.
  3. Attaches to your gamma-aminobutyric acid (GABA) receptors, helping quiet your nervous system.

You can have too much of a good thing. Too much magnesium can lead to nausea, diarrhea, and vomiting. Your first step should be to ensure you’re getting enough magnesium through your diet.

Magnesium-rich foods include:

  • Avocados
  • Spinach and leafy greens
  • Nuts
  • Fatty fish like salmon or mackerel
  • Bananas

If you’re still not getting enough magnesium, talk to your doctor to find out if a supplement is right for you. They can also help you determine the right dosage. Contact your doctor if you experience any negative side effects after trying magnesium.

Ashwagandha

Ashwagandha is a supplement that comes from a small plant prevalent in India and North Africa.

Like CBD, studies have found it effective to help reduce symptoms of stress and anxiety. More research is ongoing to determine its effectiveness.

While the medical community considers it mostly safe, women who are pregnant or breastfeeding and people with some autoimmune diseases shouldn’t take ashwagandha. It also interacts with some blood pressure and thyroid medications.

To be safe, speak with your doctor before adding ashwagandha to your daily regimen.

Other popular supplements used for shuteye include GABA, Valerian Root, and L-theanine.

Warnings for these are much the same as for ashwagandha.

  1. Ask a doctor
  2. Be careful with your doses
  3. Don’t take it for too long

Building up a dependency on any sleep aid, no matter how natural, is unhealthy. Consult with your doctor on the best way to reduce your intake when your rest has returned to normal.

Whether you and your doctor decide that a prescription or supplement is the right choice or not, you can begin certain practices tonight that will improve your sleep in the long run.

Non-Medication Solutions

Whether you and your doctor decide that a prescription or supplement is the right choice or not, you can begin certain practices tonight that will improve your sleep in the long run.

Sleep Hygiene

Sleep hygiene is useful for everyone, insomniac or not. Think of it as building better habits. Sleep hygiene is just a series of actions, personalized to your specific needs to achieve better sleep.

According to Dr. Dimitriu, poor sleep hygiene is one of the most common reasons people can’t sleep:

“People just need time to unwind after a very busy day, and unfortunately, it’s easy to stay up late to get that much needed alone time…This is exactly the reason so many of us have insomnia – there is no time, or desire, to just leave the mind alone – to do its thing.”

The good news is that you don’t need to follow a specific set of rules. Sleep hygiene is about creating nighttime and morning routines that you tailor precisely to your needs.

Some of the most effective practices include:

  • Practice consistency. Go to bed and wake up at the same time every day. Even weekends!
  • Limit caffeine and alcohol consumption, especially later in the day. Some people use alcohol to fall asleep, but it lowers sleep quality and makes your shuteye less restful.
  • Expose yourself to the appropriate light at the right times of the day. Sunlight during the day and darkness at night will help your body maintain a natural sleep-wake cycle.
  • Limit blue light at night (you probably already know you should be avoiding screens 30 minutes before bed. Actually do it!)
  • Exercise regularly.
  • Limit naps to no more than 30 minutes each day.

“I advise people to focus on wake as much as sleep…I tell patients to think one day at a time, and not to problem-solve for the future, or question the past…Using relaxing activities to help facilitate sleep at night – reading, audiobooks, or music, can always be helpful.”

Before bed, you might consider:

  • Reading a book
  • Taking a bath or hot shower
  • Lighting a candle
  • Practicing relaxation exercises like meditation or breathing exercises
  • Gentle foam rolling
  • Making a to-do list for the next day
  • Writing in a journal
  • Spending time with your loved ones

The length of your routine depends on your needs. It can be 15 minutes or an hour. Once you’ve determined what works best for you and your schedule, stick to it.

So, what if you find yourself lying awake even after you’ve followed your routine?

Resist the urge to turn on the TV or start scrolling through your phone. That won’t help you sleep, but it will help you lie there awake for the next few hours.

Instead, get up and try opening a book, journaling, or just sitting beside your bed until you start to feel tired. Only return to your bed when you actually feel tired again.

Dr. Dimitriu also strongly recommends making your bedroom a space that’s specifically designed for sleep. The ideal space is a cool, dark room with a comfortable bed. He also advises keeping “daytime” activities (like eating and working) out of the room.

Your local home goods store can help you create that space with things like:

  • Weighted blankets
  • Blackout curtains
  • Eye masks
  • Cooling pillows
  • Earplugs

Meditation

Mindfulness practices like meditation can help fight off insomnia, particularly during times of high stress when your agitated mind won’t let you rest.

Meditation is an ancient practice that has recently gained wide popularity through apps like Calm and Headspace.

The idea is to quiet the mind by bringing your focus to the current moment and your breath.

Meditation can activate your body’s relaxation response, which counteracts your body’s stress response. Practicing meditation regularly – 20 minutes daily or so – teaches your body to activate its relaxation response more quickly.

The relaxation response causes the same physiological reaction your body should experience before sleep: the calming of your muscles, your heart rate slowing, and your stress levels dropping.

If regular, breath-focused meditation isn’t for you, you can experiment with other styles. Most meditation apps include things like body scans, visualization, and effortless presence. These can feel less daunting than using only your breath to silence your racing mind.

A short, gentle yoga session can accompany your meditation if it helps you relax.

Sleep Sounds

Though your room should be quiet when it’s time to sleep, that doesn’t necessarily mean complete silence. In fact, a little noise can actually help you fall asleep.

The trick lies in finding the right noise.

Try creating a playlist of soothing music. Natural sounds like crickets, rustling trees, or forest animals are also popular.

If all else fails, there’s always white noise.

White noise machines have been around for decades and produce noise at multiple frequencies to block out background sounds. Certain apps will also play white noise.

Alternatively, you can try pink noise. It’s like white noise but derived from natural ingredients. The sounds of water, like pouring rain or a rushing river, tend to produce similar effects to white noise, obscuring background sounds that can ruin your rest.

A newer trend is ASMR, autonomous sensory meridian response. The theory is to create a calming relaxation response via pleasant sounds or sights. ASMR videos often include people talking in a soothing voice, whispers, rain, tapping noise, and more.

ASMR is somewhat polarizing. People either love it or hate it. But technology has created so many options for sleepers in the last few years, it’s worth trying these non-medical treatments if you struggle with insomnia. You may find something that makes sleeping feel as easy as falling off a log.

Sleep Tracking

Another tech-age treatment for insomnia is sleep tracking.

Create a journal for yourself to track your sleeping patterns. After a couple of weeks, share your journal with your doctor and see if you can identify any patterns in your sleep habits.

Sleep tracking is intended to capture a clearer picture of your current habits and to better understand the tactics that help you sleep.

Oura Ring is one of the most popular sleep trackers available. It tracks how long you took to fall asleep, your sleep duration, sleep cycles, heart rate, body temperature, and more.

Several fitness trackers like the Apple Watch and Fitbit can also track your patterns.

While these devices can be useful, you don’t necessarily need a device to track your sleep. Analog sleep journals are still a perfectly valid way to record your habits. Over time, they can provide insight into your personal habits and progress.

Things to incorporate into a journal include:

  • The time you went to bed
  • The time you woke up
  • Number of times you woke up in the middle of the night
  • How you felt when you went to started to drift off (stressed, worried, calm, tired)
  • How you felt in the morning (rested, alert, groggy)

If you’re experimenting with different supplements or nighttime routines, include those too so you learn which ones are most helpful over time. Also, include any prescriptions from your doctor.

Additionally, consider sharing your journal with your doctor so they can help you fine-tune your treatment plan.

Other relevant items to consider tracking include:

  • Amount of time exercised
  • Time of last caffeinated drink
  • Time of last alcoholic drink
  • Time of last major meal

“Tracking sleep quality is complicated. Some people are just not morning types, and will never wake to feel completely refreshed…More important, is how you feel during the day, and specifically in the afternoon. While everyone gets tired in the afternoons, feeling irresistibly sleepy, is not a good sign…I encourage tracking energy later in the day, not just mornings, as a true marker of sleep quality.”

Conclusion

Sleep is a critical piece to your overall well-being, and there’s nothing odd about experiencing occasional difficulty.

But when insomnia starts bleeding into your life, affecting your performance or safety, it’s imperative that you seek help.

Talking with a doctor can help you find the right solution for you.

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