NON-MEDICATION METHODS SO IMPROVE SLEEP:

  • Take a hot bath (or shower) prior to going to bed. A warm bath may work as well as a sleeping medication.  [The brain literally cools down when we fall asleep and stays cooled down for the first part of the night.   The reason the warm bath works is apparently because it provides the occasion for a significant pre-sleep drop in brain temperature–from the hot bath to the bed.  Reference: Manic Depression by Goodwin and Jamison.]   I have also heard it alleged that after a warm bath or shower, do not dry off, but get into pajamas wet, and immediately get under the covers in a cold room.
  • Worrying is bad for sleep. Try to think of something boring and mundane.  g.,  count backwards from 100;  or try to remember the plot of a recent movie or book; imagine playing 9 holes of golf on a course you know well.
  • The Iphone or Ipad solution: download a book on tape [e.g., from audible.com, which is part of Amazon].  You can use a blue tooth headphone (e.g., LG  device that wraps around the neck). There are free audible books online, but if one is going to spend 30 hours listening to a novel, one might as well have a professional actor doing the reading.  [E.g.,:  Middlemarch, by George Eliot, read by Maureen O’Brien.  Some people claim that Ms Eliot’s masterpiece is the world’s best novel.]  On Amazon Audible one can set the reading to end in 15 minutes, 30 minutes, or at end of chapter, etc—so it will stop after you are asleep but not go far into the book.
    • Note: studies that show that people feel quite miserable if they are awake more than 20 minutes—it feels like forever.   If you are listening to an interesting book, however, it is not torture.   Tell yourself that you are doing something positive:  g., educating yourself reading great literature.
  • tryptophan (protein or meat is made from amino acids; this is one of them): 500mg: usually 2-3  pills  ½ hr before bedtime. Non-addictive, no dependence.
  • exercise hard during the day
  • take melatonin 3 to 5mg ½ hr prior to sleep [or chew about a ½ mg—it works faster and more is absorbed this way]
    • and/or chew 1/2mg at 2:30PM to allow yourself to sleep at 10 or 11 instead of 12 or 1AM. [if a tablet is 3mg, chew about ¼ of it]—see below for a longer explanation.

 

MEDICATIONS FOR SLEEP

ANTIDEPRESSANTS:

  • trazodone 50mg, a generic:  1-2 pills at bedtime is usual dose for sleep; this was approved as an antidepressant {Desyrel}, but a dose of 300mg or so is necessary for antidepressant effect and that is too sedating.  It gives a good, normal sleep, so it is mostly used as a sleeping pill.  Men have to be cautious as 1/5000 men get priapism (an erection that won’t leave) and need to go to an E.R. as an emergency.
  • mirtazepine/ Remeron  15mg: 1-2 at bedtime.   It is an antidepressant that helps anxiety very well, is fairly sedating, and causes and á in appetite.   Maximum is 45mg. It is available 15,30, 45.
  • doxepin 10 to 50mg 
  • Silenor (doxepin) 3 to 6mg at bedtime. It comes in 3mg pills and 6mg pills and probably most people need 6mg.   If it is too expensive, then get generic doxepin 10mg and take 10 to 20mg at night, possibly even 30mg.  

NEW SLEEPING MEDICATION in 2015:   

Belsomra (suvorexant) 5, 10, 15, 20mg       Go to the Belsomra website and you can down load a coupon to save money on this, depending on your insurance.   We are starting with 10mg pills.  It comes as: 5, 10, 15, 20mg.  Plan: Take 10mg at bedtime; if you are still awake in an hour, take another 10mg; if it turns out you need 15mg or 20mg at night, call us for a bigger script.  The maximum dose is 20mg every night.

F.Y.I.: Sleeping medications generally activate receptors that induce sedation. Belsomra (suvorexant) has a novel method of promoting sleep.  It blocks receptors—orexin receptors.  Orexin is a neuropeptide that promotes wakefulness (in the mammillary bodies on the underside of the brain, in the diencephalon).           Rx 10mg   #30 1-2 HS Refill x5.

STANDARD BENZODIAZEPINES:

  • Halcion (triazolam) Short acting.  Available generically.  It is on “triplicate” Rx in NY—i.e., controlled like a narcotic.  The main medication we used prior to Ambien.     125mg & 0.25mg tablets  (the brand comes in white and blue tablets, respectively).  It is very inexpensive generically.   The maximum is 0.5mg HS (2 of the 0.25mg pills).
  • Xanax / alprazolam –short acting; not officially a sleeping pill, but short acting.
  • Ativan / lorazepam —- it is longer acting than Xanax, so may cause a little sedation the next day, or take the edge off of anxiety the whole next day.
  • Klonopin/ clonazepam – long acting and usually used for panic attacks or daytime anxiety, but some people can take it at night for sleep—and sometimes there is enough left the next day to reduce anxiety.

BENZODIAZEPINE-RELATED SLEEPING MEDICATIONS:

  • Ambien (zolpidem)the most widely used sleeping medication. 5mg and 10mg: first try 1/2  of a 10mg–(e.g., on the weekend, you could try 1/2 tablet every 1/2 hr  til asleep).  Some people need more than 10mg, but insurance will usually only pay for 30 pills per month. [available in tablets of 5mg coral or 10mg white] .  It lasts about 8 hours.
  • Sonata (zaleplon)—the very shortest acting; closely related to Ambien—very good if you wake in the middle of the night.    —comes in 5mg and 10mg capsules (each capsule is two shades of green; the 10mg capsules are a little darker). Try 5 to 10mg at bedtime.  (The maximum dose can be 20mg in some people, but the usual is 5 to 10mg. If you are using 5mg capsules you can take up to 4 capsules per night. Another reasonable maximum would be 2 at bedtime and 2 if you wake up at 2-4AM.)  The ½ life is only 1 hour, which means ½ of the medication is gone in 1 hour.  In 4 hours the sedation and memory problems are usually gone.  In fact, in testing for FDA approval, even after a 20mg dose, the dexterity and memory of the people being studied was back to normal in 4 hours!  Therefore, it is the ideal medication to take if you wake up in the middle of the night (at 3-4AM, but obviously not at 7AM).  Though the sedation only  lasts about 3-4 hours, once you are asleep from it you usually  get a full night.  It may work better after you have been taking it for a few nights, even a week.
  • Lunesta (eszopiclone) is the newest [2005] sleeping pill–a cousin of Ambien and Sonata. It is available in 1mg, 2mg [white], and 3mg [blue] scored tablets.  It has a long ½ life so people often feel sedated by it the next day.    It is the only sleeping medication approved for long  term use.  The maximum is 3mg per night.
  • Zopiclone is sold as Imovane, Zimovane and Zopinox in Europe and Canada, and as the eszopiclone analogue Lunesta in the United States. Zopiclone is known colloquially as a “Z-drug“. Other Z-drugs include zaleplon (Sonata) and zolpidem (Ambien and AmbienCR) and were initially thought to be less addictive and/or habit-forming than benzodiazepines. However, this appraisal has shifted somewhat

A SLEEP MEDICATION THAT MIMICS “SLEEP HORMONE” MELATONIN: 

  • Rozerem 8mg, 1-2 at bedtime. Not abusable at all.  It is not powerfully sedating, and it is not long lasting.

A BLOOD PRESSURE MEDICATION: 

  • clonidine 1mg –1 to 4 pills at bedtime. Available generically [the brand name was Catapres].  It comes in 0.1, 0.2, and 0.3 tablets.     This medication is used for high blood pressure, performance anxiety, for ADD and for methadone withdrawal. It is totally non-addictive.  The only side effect is sedation—which is why it is a good sleeping medication.  Also, you don’t want orthostatic hypotension—getting dizzy from low blood pressure.    Maximum for blood pressure is 2.4mg in divided dose (2 of the 0.3mg, pills 4x/day).   It often works well as a sleeping pill—e.g., 0.2mg at bedtime. It should not be taken with beta-blockers which are used for blood pressure, and heart attack prevention (propranolol, atenelol/ Tenormin, et al are beta-blockers).
  • Prazosin

ANTISEIZURE MEDICATION: Neurontin / gabapentin

MEDICATION FOR SLEEP APNEA: Xyrem [sodium oxybate]   500mg/ml—180 ml bottle.   1 866 997 3688

  • Start with 6 grams in the evening: ½ at bedtime and ½ about 3 hours later when you wake up in the night.   e., start with 3 grams [6 ml] at bedtime;
  • when you wake up 2½ to 4 hours later, take another 3 grams.

A week or two later we will probably ­ to 7.5 grams.  The maximum dose is 9 grams per evening.  Each bottle has 180 ml.   XyremThe usual directions:    Quantity:   360 mL         The directions are take total night time does:  6 grams        Sig: take 3 grams (6 mL) p.o. diluted in 60mL water at HS and then again 2½ to 4 hours later.

MEDICATION FOR PARKINSONISM OR RLS (RESTLESS LEG SYNDROME):

ropinirole (Requip) (anti‑Parkinsonian drug, a non‑ergoline dopamine agonist; 0.25 mg, 0.5 mg, 1 mg, 2 mg or 5mg; full intrinsic activity at the D2 and D3 dopamine receptor subtypes, binding with higher affinity to D3 than to D2 or D4 receptor subtypes. Moderate in vitro affinity for opioid receptors. The relevance of D3 receptor binding in Parkinson’s disease is unknown. The mechanism of ropinirole hydrochloride‑induced postural hypotension is presumed to be due to a D2‑mediated blunting of the noradrenergic response to standing and subsequent decrease in peripheral vascular resistance. Nausea is a common concomitant of orthostatic signs and symptoms. Bradycardia. At oral doses as low as 0.2 mg, ropinirole suppressed serum prolactin in males.

Mirapex: another anti‑Parkinsonian drug—both of these make you sleepy and may have an antidepressant effect.

 

THINGS TO TRY FIRST FOR SLEEP:

MEDICATION and NUTRIENTS:  to use instead of a benzodiazepine [also try to gradually decrease and even stop benzodiazepine if you are on one];  these medications are not controlled:

NUTRIENTS—OTC (over the counter) — no side effects and not drowsy the next day

  • tryptophan 500mg: 2 to 3 pills—usually 3 pills;   an amino acid, found in meat, etc;  OTC (over the counter) in health food store or pharmacy.
  • Melatonin Swallow melatonin every night 2-3mg, or even more—mostly it is sold as 5mg or 10mg tablets now. It is even better to bite off a chip, approximately  ½ to 1mg (about ¼ of a 3mg tablet) and let it melt in your mouth (i.e.,, take it “sublingual”) at bedtime.  This will advance the sleep cycle to a more appropriate time, but it may take weeks.
  • Al Lewy told me a long time ago that taking about ½ mg of melatonin at 2:30 PM will more effectively advance your internal sleep cycle, so that you can go to sleep earlier.   But you should at 5-6PM.   Every couple of days take it an hour earlier until you reach 2:30PM to 3PM.  Use an alarm on a watch or smart phone to remind you.  If you forget to take it, you can take it later that evening or skip it altogether.  [Al Lewy is a prominent researcher who published  in 1982 the first paper on the successful treatment of seasonal depression using light therapy.]
  • I have had many women become quite sleepy on ½ mg sublingual [which means it may help a lot at bedtime as well]. So women should try it out first in the evening after work.  I have never had a man become sleepy at that dose.
  • Note that melatonin is our “sleep hormone”. It is a major regulator of the day-night cycle in virtually all living things, including insects.

MEDICATIONS THAT ARE NOT CONTROLLED SUBSTANCES:

  • trazodone 50mg: 2 pills at bedtime, occasionally 3
  • Neurontin/ gabapentin 100mg:  1 to 3 pills at night; actually maximum is 1200mg at bedtime.  You might need 300mg:  1-3 pills.  If you need 300mg pills, call for them.
  • clonidine 0.1mg : 1 to 3 pills at bedtime, possibly more.  Watch out for dizziness.  For the first few nightsk, only take one pill per night.   This officially a medication to lower blood pressure, but it also #1: makes a person sleepy, but does not carry over the next day, #2: decreases anxiety, and #3: helps concentration and thus is quite effective for attention deficit disorder, even if you take most of the dose at bedtime.  The half life is 6 to 20 hours.

My usual directions:

  • The first week take 1 pill
  • The 2nd week take 2 pills
  • The 4th week you can try 3 pills at bedtime, but be careful; it may cause orthostatic hypotension—dizziness upon standing; then stand slowly and hold on to something, and lower the dose.