Dear physicians who prescribe medications:
Stop prescribing antipsychotic medications as sleepers! Other than the obvious fact that they are not indicated for such, they are also extraordinarily expensive, have side effects that are not benign (particularly when you are prescribing them in doses for people with diagnoses of schizophrenia!), and are often totally unnecessary—try addressing sleep hygiene first!
Thank you,
Maria
30 Nov 2007 |
I prefer to diagnose the sleep disorder before treating it. Depression? Sleep apnea? Drug related? (Alcohol may help younger patients sleep but it’s a significant interfering factor in older ones.) Caffeine? Poor sleep hygiene? Amazing what can be accomplished with a history, physical and appropriate investigations. CPAP works a helluva lot better than Ambien for someone with obstructive sleep apnea. Sleep hygiene first and always, though.
I have never understood writing out prescriptions for “sleepers” on request. Do we do the same with pain? (”My chest hurts.” “Here, have some Vicodin.”)
That said, I have been known to use the occasional atypical antipsychotic (Seroquel, eg) at bedtime after making the diagnosis of Bipolar Disorder. Is that ok?
Comment by #1 Dinosaur | 30 Nov 2007 @ 3:09pm
No kidding; the metabolic consequences of long-term atypical therapy are grim.
Is it because prescribers don’t want the scrutiny that would come with controlled substance rxs? Tricyclics, Remeron, Seroquel. . . no pesky DEA issues.
E
Comment by Eric | 30 Nov 2007 @ 3:19pm
When I take Predisone for hives, I get the worse nightmares (in addition to developing a ginormous appetite). I also got into a minor car accident because I was so tired from not being able to sleep. About 15 doctors ago, before they put me on Prednisone for hives, I was using a combination of Zyrtec and Doxapin. This meant I actually had an excuse for sleeping throught my first summer of grad school. About four doctors ago, I finally started on Prednisone for the really bad hives and my current doctor has recently prescribed Doxapin for the sleep problem. Apparently, it also helps control the hives. In sum, my appetite is still uncontrollable when I’m on steroids, but at least I can sleep at night.
Comment by Maria H. | 30 Nov 2007 @ 9:57pm
In the past, I have been prescribed Seroquel for sleep… only at a dosage of 25mg, though (or sometimes 12.5 mg), because 25mg was usually sufficient to knock me flat out. It was only prescribed after one had stopped working (Imovane) and I complained about how bad another one tasted (Trazodone). I ended up alternately taking Trazodone and Seroquel for a good while, until I finally stopped taking sleeping pills altogether. I haven’t taken any for months, but I no longer seem to need them, which is good. :)
Comment by Niika | 2 Dec 2007 @ 8:16am
Thank you. I hate seeing doctors prescribe seroquel for sleep when they haven’t addressed why the individual can’t sleep.
Comment by donnalee | 3 Dec 2007 @ 5:13am
I agree. The setting in which this occurs most frequently for me is the coverage call for a nursing home patient. I find in those cases, sometimes, I am treating the person making the call(LPN/RN/CNA) and not the patient….
Things take time.
http://poemd.blogspot.com/2007/04/nature-of-things.html
Comment by Dan J Schmidt | 3 Dec 2007 @ 9:30am
As a nurse, I can tell you that it is normal for a doc rx’s a sleeper without addressing sleep hygiene/underlying cause. Working in both inpatient & outpatient settings I have seen this. It’s a rarity that the doc has (or takes?) the time to investigate. Perhaps b/c I’ve mostly worked in oncology, there’s an obvious reason for poor sleep…but still, many times patients aren’t even trying the basics, like cutting down on caffeine intake. OF course, it doesn’t help that there are tons of ads for sleep aides, too. Pretty soon they’ll invent a a wake-up pill…
Comment by Rae | 3 Dec 2007 @ 7:24pm
Rae:
Too late. Provigil is the magic wake-up pill; there’s anecdotal evidence that the lingering drug in the bloodstream after a dose 24 hours earlier promotes vigilance/wakefulness in the morning. Though approved for narcolepsy, sleep apnea refractory to CPAP and “shift work sleep disorder”, it’s insanely commonly used off-label in Parkinson’s disease, jetlag, ADHD, cancer-related fatigue, and a stack of other uses. The manufacturer is in deep dung over off-label promotion; something like 70% of Provigil is used for something other than approved indications.
Mmmmn, magic wake-up pills…
E
Comment by Eric | 4 Dec 2007 @ 8:01am
This seemed like as good as spot as any to thank you for recommending thecarlatreport.com. Coincidentally, just finished reading the issue on sleepers. Signed up for my own subscription!
Comment by Denver Doc | 8 Dec 2007 @ 2:40pm