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How could you treat insomnia in a patient who is on methadone?


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Atarax?  Makes you dopey, has some GABA activity so decreases a bit of anxiety...trazadone another with a bit of mood stuff, though is a tricyclic and has a fairly rapid tolerance development.  Was given it once - they should have told me to take it IN BED not while in the living room - made me legless in about 20 minutes and had to crawl to the bedroom...there is a hangover in the morning that needs a lot of coffee.

Edit to add - should also use the usual CBT stuff, makes sure they get some exercise, watch diet, stimulant intake, sleep diary, etc, as an of course as well.

 

SK

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2 hours ago, sk732 said:

Edit to add - should also use the usual CBT stuff, makes sure they get some exercise, watch diet, stimulant intake, sleep diary, etc, as an of course as well.

A sleep medicine referral is a good idea, too.  We'll do the workup, detailed sleep-specific H&P, and rule out other sleep disorders prompting the insomnia.  "Insomnia" is like "anemia"  It includes many different issues, all lumped together when there's a variety of etiologies and hence treatments,

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Have to play devil's advocate.

Is the drug screen clear of stimulants/amphetamines? 

What psych diagnoses does this person carry? Bipolar not well managed?

Is the patient on Wellbutrin? First side effect is insomnia.

Does the patient have any schedule during the day and any physical activity?

I really don't like adding more drugs to drugs if at all possible.

Could this person be switched to buprenorphine from methadone? Safer profile overall.

I would strongly suggest a sleep study and then behavioral cognitive therapy or even hypnosis to work on a sleep pattern.

Drugs would be my last choice.

Polypharmacy is not always better living through chemistry.

My crusty old 2 cents.

And, I am a buprenorphine waivered provider, for what it's worth.

 

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13 hours ago, Reality Check 2 said:

And, I am a buprenorphine waivered provider, for what it's worth.

 

Not to threadjack, but if you're using buprenorphine for pain, not opioid abuse treatment, you don't even need a waiver, do you?  Never really looked into it myself, but like the idea of an opiate that prevents further abuse.  Now, if it were actually affordable for anyone...

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CBT-I would be my first step. If you don't have any providers in the area who provide this there are some good online programs that studies have shown to be as effective as in person CBT-I. I work in sleep medicine and pulmonary and recommend to my patients: cbtforinsomnia.com, myshuti.com, and sleepio.com but there are other ones out there too. 

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What's wrong with good old diphenhydramine 50mg QHS?

With trazadone there is the risk of possibly dangerous priapism requiring intrapenile epinephrine, and rare risk of penile necrosis (seriously, look it up) which you have to warn patients about...

Not sure if quetiapine is contraindicated, but in low doses 25-50mg QHS it works well for sleep and has no tolerance I know of...

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#1 education on sleep hygeine

#2 Melatonin up to 6mg

#3 NEVER use Benzo's  EVER!!

 

Rest in no particular order

#4 try remeron, elavil, vistaril (atarax), trazodone

#5 can also try benadryl

#6 screen from poly sub abuse, active psych dx ie depresion

#7 Avoid ETOH - bad bad

#8 no caffeine after noon, out of bed same time every day and so on.... (see #1)

#9 rule out metabolic and sleep issues is OSA, OAB, BPH

#10 See #1 and make them do a sleep journal

#11 warm milk and a cookie... (it works!)

 

 

This is the dirty little secret - we don't have a good sleep med - by trying to provide a medication sure to the patients sleep complaints you are lessening the likelihood they will realize that he real problem for their sleep is themselves......

 

 

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On 9/7/2018 at 9:56 AM, quietmedic said:

What's wrong with good old diphenhydramine 50mg QHS?

With trazadone there is the risk of possibly dangerous priapism requiring intrapenile epinephrine, and rare risk of penile necrosis (seriously, look it up) which you have to warn patients about...

Not sure if quetiapine is contraindicated, but in low doses 25-50mg QHS it works well for sleep and has no tolerance I know of...

Absolutely true. I had to perform a detumescence on guy couple months ago. Awesome case. Not so much for him.

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1 hour ago, ventana said:

#1 education on sleep hygeine

#2 Melatonin up to 6mg

#3 NEVER use Benzo's  EVER!!

 

Rest in no particular order

#4 try remeron, elavil, vistaril (atarax), trazodone

#5 can also try benadryl

#6 screen from poly sub abuse, active psych dx ie depresion

#7 Avoid ETOH - bad bad

#8 no caffeine after noon, out of bed same time every day and so on.... (see #1)

#9 rule out metabolic and sleep issues is OSA, OAB, BPH

#10 See #1 and make them do a sleep journal

#11 warm milk and a cookie... (it works!)

 

 

This is the dirty little secret - we don't have a good sleep med - by trying to provide a medication sure to the patients sleep complaints you are lessening the likelihood they will realize that he real problem for their sleep is themselves......

 

 

Up to 6 mg?! I pop like 20-30mg of that stuff at a time. Gotta do what you must to sleep on that 10 hour c-130 flight ? 

I usually tell people no more than 10mg.

 

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I may have missed this but what is dose of methadone? And for what it’s worth, I am a waivered buprenorphine provider as well. I see insomnia as a frequent side effect of opioid users, and I agree with the sleep hygiene education, and melatonin. I also try to encourage exercise as well. One other thought was about using subutex for pain management? Methadone has so many interactions with other drugs, and buprenorphine may be better choice to help with pain and management of other co-occurring or side effect issues.


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On 9/10/2018 at 2:23 PM, LT_Oneal_PAC said:

I usually tell people no more than 10mg.

There's really not that much of a dose-response curve with melatonin.  Six seems to be barely any better than three, and any more than that is just wasted...  Do also educate your patients that melatonin is for sleep onset, not sleep maintenance.

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1 hour ago, rev ronin said:

There's really not that much of a dose-response curve with melatonin.  Six seems to be barely any better than three, and any more than that is just wasted...  Do also educate your patients that melatonin is for sleep onset, not sleep maintenance.

Anecdotally, I agree there isn’t a dose response curve but find that there is diminishing response with prolonged use, thus why I personally was using high doses when I was using it often on deployment and advise patients no more than 10mg. I also agree it doesn’t help with preventing night time awakenings, but I did tell patients that it can help to go back to sleep after you wake up without the groggy feeling in the morning.

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