Pharmacist management of sleep disorders

In the United States, approximately 70 million people suffer from persistent sleep disorders, and nearly 15% of all American adults suffer from insomnia.1 These are worrying numbers, especially since insomnia can impact how an individual functions throughout the day, impairing their ability to work, drive, and perform almost all daily activities. For patients suffering from insomnia, turning to their pharmacist can be a good first step to combating sleep problems and getting the rest they need.

Farah Khorassani, PharmD, associate clinical professor at the University of California, Irvine School of Pharmacy and Pharmaceutical Sciences, noted that pharmacists play a crucial role in educating patients about good sleep habits, also known as sleep hygiene, as well as in the identification of medications. or substances that could contribute to insomnia; recommend medications and doses for insomnia; provide training to clinicians on the risks, benefits, and evidence for the use of different agents; and advise patients on the use of these medications.

There are 5 FDA-approved benzodiazepines for insomnia: estazolam (Prosom), flurazepam (Dalmane), quazpam (Doral), temazepam (Restoril), and triazolam (Halicon). Pharmacists can advise patients on the use of these prescribed medications, but for many patients, insomnia can be alleviated through lifestyle modifications and proper sleep hygiene. “According to the CDC, some examples of good sleep hygiene include going to sleep and waking up at a consistent time each day, removing electronic devices from the bedroom, maintaining a comfortable temperature, exercising during the day, but not too late as this can keep you up later and avoid large meals, caffeine and alcohol too close to bedtime,” Khorassani explained.

Kathy M. Campbell, PharmD, has been an independent pharmacist for over 30 years in Owasso, Oklahoma, and has served 4 generations of patients, many of whom suffer from sleep problems and insomnia. Campbell noted that, traditionally, when it comes to medications, pharmacists help customers manage their prescriptions or triage issues before someone even sees their primary care provider.

“They may tell me they’re having sleep problems and ask me what they should take, but I tend to be more interested in why they’re having sleep problems,” Campbell said. “When a patient comes to me about this, (I always do) a more thorough triage to determine what the source of the insomnia might be.” The two biggest culprits she sees are lack of oxygen or sleep apnea that prevents the patient from sleeping or blood sugar irregularities. “There are certain tools that patients can use, such as sleep apps like a Fitbit, (so) they can see changes in their sleep and monitor if blood pressure or heart rate is increasing, which is a symptom of poor oxygenation. ” said Campbell. “Nothing freaks out the brain more than lack of oxygen. If you don’t have enough oxygen, your body will wake you up.

In these cases, Campbell will refer the patient to a sleep study or to their primary care provider to further discuss other options.

Josh Rimany, RPh, FACA, founder and wellness director of Dilworth Wellness Center in Charlotte, North Carolina, likes to be known as the “beyond the pill pharmacist” because he takes a patient-focused approach. wellness in his practice, focusing on moving away from medication dependence. When working with a patient who has a sleep problem, his first course of action is to talk about the importance of sleep and ask questions about the “why” and lifestyle choices that may contribute to the issue.

“Seventy million people don’t get enough sleep, and the CDC considers it a public health issue, but only 43 percent of providers talk to their patients about sleep,” Rimany said. “Sleep is considered one of the #1 tools for longevity. If we want to give a vibrant life to people, it is very important to get 7-8 hours of quality sleep.

Over-the-counter options

The pharmacist may also advise patients and clients about over-the-counter options to aid sleep, such as melatonin or antihistamines, including the benefits and potential side effects of each medication. It’s in counseling where a pharmacist’s expertise truly shines.

The over-the-counter options available to a patient depend on various factors, including their comorbidities and the duration of insomnia, Khorassani explained. “In my opinion, melatonin is a good place to start because of its tolerability profile,” she said. “This is an over-the-counter supplement that is safe to use in most patients with insomnia. It is also not addictive and therefore can be taken long term and has few adverse effects. The evidence for its effectiveness is not very strong, but anecdotally, many patients have told me that it relieves their insomnia.

Other agents such as diphenhydramine HCI (Benadryl) and doxylamine (Unisom) are also options, but they cause more side effects than melatonin, such as dry mouth and drowsiness the next day. For this reason, these agents are best used only for short-term insomnia.2

It is important for pharmacists to assess the patient’s individual needs and take into account any comorbidities or medications that may impact sleep. They can also refer patients to a sleep specialist if necessary.

“I’ve had a few patients who complained of insomnia because they were taking (the antidepressant bupropion (Wellbutrin)), which can cause insomnia,” Khorassani said. “Several of them took it twice a day and took the second dose at bedtime. If this medicine is taken twice daily, the second dose is ideally administered before 4 p.m. due to its stimulating properties.

“Talking to patients about when to take their medications helped me discover a way to improve their insomnia. By suggesting they take the medication earlier in the day, their sleep improved and they did not need any additional medication.

Implement lifestyle changes

Poor sleep is linked to several chronic diseases and can also increase the risk of developing Alzheimer’s disease, depression, dementia, obesity, anxiety, etc., including premature death.3

“It really gets patients’ attention,” Rimany said. “You can give them tips and advice on their lifestyle habits all day long, but they generally won’t adopt them unless it’s really important to them. When I talk to patients about sleep at the pharmaceutical level – and this is a topic I’ve done quite a bit of research on – there is an increased mortality rate in people who take sleeping pills regularly.4

Sleep should be a priority for a long life, and pharmacists can also help patients manage their sleep problems by recommending non-pharmacological interventions such as cognitive behavioral therapy for insomnia. Other lifestyle modifications include reducing caffeine intake, avoiding electronic device use before bed, and establishing a consistent sleep routine, all before turning to prescription medications.

Campbell will occasionally recommend melatonin, but says she’s more concerned about the patient’s sleep hygiene. Before melatonin, she will remind patients to make sure their room is optimized for sleep and that they don’t eat too close to bedtime or drink too much alcohol.

“If they’re at the age where they’re not producing as much melatonin as they need, I’ll give them a very low dose of melatonin,” she said. “I incorporate a lot of nutrition science and a lot of stress science into the way I approach and coach patients.”

One of the factors that has contributed to poor sleep over the past decade is our use of social media. Campbell stressed the importance of reminding patients to disconnect from their devices well before bedtime.

Another sleep disruptor? Our pets. Individuals who sleeping with their pets or who are regularly awakened by their pets during the night have poor sleep. “Sleep is the time when the brain and body recover and rebuild, and sleep is essential for long-term health,” Campbell said. “Tolerating interruptions will harm your long-term health and longevity.”

Rimany offers her clients many options for help and always seeks to educate them more about the benefits of sleep and ways to combat their sleep problems. “A ‘Pharmacy 2.0’ that wants to go beyond distribution will look at lifestyle (diet, supplements and labs) to find the best plan,” he said. “Consistency matters (and) quality matters…Removing stimulants during the evening and keeping the room at 68 degrees or colder (this can help. Some people even use weighted blankets.”

Rimany advises patients to set a time limit of 2 hours before bedtime to eat or drink anything other than water, explaining that while the body is digesting, it is not working to rest. “Working out is also not a good thing to do before bed,” he said. “Screen time is obviously huge, because the blue light and LED lights emitted by these devices tell your eyeballs that it’s noon, so your brain doesn’t let your body calm down. Blue light blocking glasses are very important in these cases. Total darkness – with blackout curtains, if necessary – is also crucial for managing insomnia, as any burst of light can wake up the body clock.

For patients who wake up and can’t get back to sleep within 5 minutes, “it’s actually healthier (for them) to get out of bed and read, or do something quiet to tire themselves out,” said Rimnay. “I’m a big fan of meditation and relaxation. (Putting thoughts into) a journal can also help (the patient) rest their brain better.

The references
1. Suni E, Truong K. Sleep statistics. Sleep Foundation. Updated May 18, 2023. Accessed June 29, 2023. https://www.sleepfoundation.org/how-sleep-works/sleep-facts-statistics
2. Olson EJ. Adult health. December 9, 2021. Accessed July 11, 2023. https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/sleep-aids/faq-20058393
3. What are sleep deprivation and lack of sleep? National Heart, Lung, and Blood Institute. Updated March 24, 2022. Accessed July 11, 2023. https://www.nhlbi.nih.gov/health/sleep-deprivation
4. Sun Y, Tsai MK, Wen CP. Association of sleep duration and sleeping pill use with mortality and life expectancy: a cohort study of 484,916 adults. Sleep health. 2023;9(3):354-362. doi:10.1016/j.sleh.2023.01.017


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