There are a number of treatment options for patients with insomnia and chronic pain. Consult with your doctor to pick the one that is right for you.
Once your doctor has diagnosed insomnia, he or she can develop a treatment plan for you. Both the severity and cause of insomnia will help your doctor determine which treatments will work for you. The first steps to treating insomnia are simple and easy, and do not require medications. Lifestyle changes, like employing relaxation methods, is one behavioral intervention that is recommended as an initial approach.
For the best results, you may require a combination of treatments:
There are many ways to treat insomnia without relying on pharmaceutical interventions. One of the most important first steps to treating your insomnia is to assess your sleep hygiene. “What is ‘sleep hygiene?’” The term relates to a number of simple practices (or habits) that can help you have a restful night’s sleep.
Examples of Good Sleep Hygiene Dos:
- Set a bedtime and wake-up time—the same time every day.
- Exercise (light exercise) for 30 minutes five days a week—but don’t exercise 2 to 3 hours before you go to bed. It can be difficult to fall asleep right after exercise because your heart rate is elevated.
- Increase your exposure to bright lights during the day.
- Take a hot shower or bath before bedtime. This helps your body relax and makes falling asleep that much easier.
- Avoid naps, especially after 3 pm.
You also want your sleep environment to be conducive to rest. Try to keep your room quiet, the lights off, and the temperature cool so you don’t feel hot and uncomfortable in bed. Don’t use the bedroom except for sleeping and sexual activity. This makes your bedroom the designated area for rest.
Examples of Good Sleep Hygiene Don’ts:
- Avoid stimulants 4-6 hours before bedtime (caffeine, nicotine)
- Avoid alcohol before bedtime
- Avoid medications that may disrupt sleep (diuretics, decongestants, beta-blockers, asthma medication, etc) (link here)
- Avoid heavy meals and liquids 2-3 hours before bedtime
- Avoid late-afternoon naps
Try to avoid sitting in bed for a long period of time. Many people like to work on their laptop or watch TV while lying in bed. Try to avoid these activities which can cause overstimulation of the brain right before bedtime. The LED lighting of tablets and iPads also have been shown to delay sleep onset, so it is best to avoid these, especially among teenagers and other night owls. The more exclusive you make your bed for sleeping, the easier it is to fall asleep.
And if you can’t sleep, don’t lay in bed awake. Get out of bed and do something relaxing like reading a book. Do this until you feel tired and ready to try to go to sleep. Don’t let yourself be frustrated by not being able to fall asleep; this will only make your situation worse. Just focus on relaxing—worrying over sleep won’t lead to better sleep.
There are four types of drugs that have been approved by the Food and Drug Administration (FDA) to help treat insomnia: benzodiazepines, nonbenzodiazepines, melatonin receptor agonist, and antidepressants.
Benzodiazepines are a common class of drugs used to treat insomnia. However,it is generally discouraged to prescribe a benzodiazepine if the patient is taking an opioid(s). Benzodiazepines are not generally used to treat insomnia in patients with chronic pain, especially when safer alternatives are available.
Benzodiazepines work on the central nervous system (CNS, brain) to induce feelings of relaxation, sedation, euphoria, and muscle relaxation. These medications are used with caution since they can be habit-forming, and should not be combined with alcohol, opioids, or other CNS depressants as this increases the risk for toxicity and overdose. Examples of benzodiazepines include estazolam, flurazepam, and quazepam. These medications are indicated for people who have difficulty failing asleep, frequent awakenings, and early morning awakening.
Other benzodiazepines, like temazepam (Restoril, generics) and triazolam (Halcion, generics), are designed for the short-term treatment of insomnia. Triazolam is believed to cause rebound anxiety, and may not be an appropriate choice for certain patients.
All benzodiazepines should be used in caution in elderly patients due to increased risk of falls. Tolerance to the effect may develop after 1 month of therapy.
Generally considered a first choice for medical treatment of insomnia, nonbenzodiazepines are closely related to benzodiazepines, but have only the sedative effects (and not the hypnotic, anti-anxiety, or muscle relaxant effects).
The best known product in this category is zolpidem (Ambien). Other formulations of zolpidem include Edluar and Intermezzo (long-acting tablet), and Zolpimist (oral spray).
- Zolpidem is designed to treat insomnia in the short term by aiding patients to fall asleep.
- Zolpidem CR, also known as Ambien CR, helps with inducing sleep onset and maintenance (staying asleep and getting a full rest).
- Intermezzo is used to treat patients who are able to fall asleep, yet awake in the middle of the night and can’t fall back asleep. Patients must have at least 4 hours of sleep before awakening if they are going to use Intermezzo.
Ambien CR is a useful medication for treating insomnia because it is a controlled-release form. This will help prevent you from waking up after you have fallen asleep.
Zolpidem is associated with certain side effects such as drowsiness, amnesia, dizziness, headache, wakefulness after sleep onset, and gastrointestinal effects. Well publicized, but rare side effects of these medicines, include sleep eating, sleep walking, or driving while asleep. This led the FDA to ask manufacturers provide a warning to inform patients of these risks before taking it and to adjust the dosing of zolpidem differently for men and women.
Eszopiclone, better known as Lunesta, is commonly prescribed to treat insomnia. Due to a recent labeling change, all patients should start at a lower dose lower (at 1 mg) to reduce the onset of next-day memory impairment and impaired driving skills. Eszopiclone is prescribed to prevent you from awakening in the early morning hours. Eszopiclone, like most drugs for insomnia, is not recommended for long-term use.
Eszopiclone is known to cause daytime sleepiness, which can be very dangerous when patients are operating machinery or a motor vehicle. Eszopiclone also causes unpleasant or metallic taste as well as other side effects such as headaches, chest pain, cold-like symptoms, drowsiness, pain, dry mouth, lightheadedness, dizziness, gastrointestinal effects, decreased sexual appetite, heartburn, and painful menstruations in women.
Another nonbenzodiazepine that is similar to eszopiclone is zaleplon (Sonata). Zalepon starts working a little faster than eszopiclone; at 30 minutes instead of an hour, so it is very useful for helping you fall alseep. Zaleplon isn’t effective for reducing nighttime awakenings or increasing total sleep time because it has a very short half-life. Unlike other medications, zaleplon doesn’t have significant residual effects, which makes it a lot safer for people who need to commute frequently or operate dangerous machinery. Side effects of zaleplon include headaches, dizziness, and somnolence.
Melatonin Receptor Agonist
This type of drug class works by activating the melatonin receptor in the brain. The receptor is responsible for binding melatonin, a hormone known to help regulate the circadian rhythm, or sleep cycle. Ramelteon (Rozerem) is an example of a melatonin receptor agonist that your doctor may prescribe to you to help you fall asleep, especially if you are suffering from chronic or transient insomnia. Like zaleplon, this drug is not as helpful for reducing nighttime awakenings. Side effects commonly associated with the drug are headache, dizziness, and somnolence.
It was discovered that one side effect of tricyclic antidepressants was sedation. Thus, antidepressants have become an option for patients who suffer from depression and insomnia. Your doctor may prescribe a low-dose form of a medication like trazodone, mirtazapine, doxepin, and/or amitriptyline. If you have chronic pain, you may want to consider using a sedating antidepressant, as this will help with your depression and provide a useful analgesic effect. There are certain advantages and disadvantages to what type of antidepressant to use—and only doxepin is FDA-approved for insomnia—so you should discuss your options with your doctor.
When treating your insomnia, be honest about all the conditions you have. Is it just insomnia? Or do also have chronic pain and/or depression? These are important factors that your doctor needs to know so they can properly prescribe the right medications to give you the relief you need.
There are many products at your local pharmacy that are designed to put you to sleep. Not all these products are used as intended. And not all these products are as safe as they may seem. Read more to find out about these products and which one may suit your needs.
Besides the prescription drugs previously listed, there are over-the-counter (OTC) products that you may want to consider when trying to treat your insomnia—under your doctor’s care. You never want to combine a prescription medication with an OTC drug without first consulting your doctor.
OTC drugs are not intended to be used for long periods of time. Relying on these drugs to treat chronic insomnia is not advisable. Chronic insomnia is a condition that your doctor needs to know about. Your doctor can offer effective means of managing your sleeping problems.
Diphenhydramine, also known as Sominex and Nytol, and doxylamine, commonly marketed as Unisom, are OTC sleep aids you’ll likely see at your local pharmacy. The FDA has approved diphenhydramine to be safe and effective, and the drug is known to help with other problems including coughing, motion sickness, and certain allergies. Many people quickly become tolerant to the sleep effects of antihistamines.
There are also many OTC products designed for both pain and sleep problems. They commonly contain a pain reliever with an antihistamine. If you are not in pain, don’t take these combination products (eg,Tylenol PM).
Diphenhydramine and doxylamine are considered safe for mothers to use during pregnancy and breastfeeding. Because of lack of safety studies, however, children under the age of 12 should not take antihistamines. Also, antihistamines should be used with caution in the elderly, as they can cause daytime drowsiness and can interact with other medications. Paradoxically, in some people, antihistamines actually cause insomnia, especially in young children and the elderly.
Because these OTC medications can have a sedating effect, don’t take these drugs while operating a motor vehicle, heavy machinery or other task that requires alertness. You should be wary of adverse side effects like dry mouth, constipation, and difficulty urinating. Antihistamines are also known to worsen certain medical conditions like heart issues, glaucoma, asthma, and prostate gland enlargement. If you have any of these medical conditions, talk to your doctor before you use an antihistamine.