Insomnia: Restoring Your Relationship with Sleep

If you have trouble sleeping, you are part of 3.3 million Canadians (15 years of age and older) who report suffering from insomnia. Not being able to have a restful sleep can have a huge impact on one’s daily activities, ability to perform at work, relationships and overall functionality. 

What is Insomnia?

Insomnia can be defined in two ways: sleep-onset insomnia and sleep-maintenance insomnia.

Sleep onset insomnia: this occurs when people have difficulty falling asleep, usually as a result of an actively thinking mind. Sometimes the body is physically not ready for sleep, even though the individual is trying to fall asleep at a “usual time for sleep”. This is often the result of circadian rhythm sleep disorders (i.e. shift workers, jet lag), where the body’s internal clock is out of sync with usual daytime and nighttime activities.

Sleep maintenance insomnia: this occurs when people do not have trouble falling asleep, but rather have trouble staying asleep or waking up earlier than required. This type of insomnia is more prevalent in older people, people who use certain substances (i.e. caffeine, alcohol, tobacco), and in people who have certain sleep disorders (i.e. sleep apnea).

What Causes Insomnia?

Insomnia can be caused by a variety of external and internal factors. Most often it is caused by:

  • Poor sleep habits (i.e. intaking caffeine before bed, irregular sleep-wake cycle)
  • Health disorders (i.e. anxiety, heart or lung disorders, chronic pain)
  • Life stressors (i.e. loss of a loved one, change in career paths)

Insomnia can also be caused by a number of prescription medication, not only when they are initiated but also when they are discontinued.

Given the multitude of causes, it is very important for the individual to reflect and take a good health history to determine the factors that are most likely causing the insomnia.

When does an individual need to seek medical care?

It is common for an individual to have a couple of restless sleeps throughout the week, especially if experiencing life stressors. Insomnia becomes a medical concern when warning signs begin to appear or when sleepless nights outweigh restful nights on an ongoing basis (i.e. not being able to sleep 4/7 nights per week). At this point, it would be beneficial for the individual to see their physician for evaluation. Warning signs may include:

  • Falling asleep while driving
  • Unexpectedly falling asleep during waking hours on frequent occasions
  • Waking up from sleep choking or gasping for air
  • Moving violently during sleep
  • Sleepwalking
  • Unstable health disorders (i.e. heart/lung)

Can insomnia be treated?

Insomnia can be treated by adopting new sleep habits (i.e. behavioural techniques), using prescription medication, or non-prescription medication.

Prescription Drug Therapy

Benzodiazapines are the most commonly prescribed sleep aids. There are only a few medications within this class that have been approved by Health Canada for insomnia, however many others are still prescribed off label as they share common mechanisms of action and side effect profiles. As with all medication but especially with benzodiazepines, therapy should be tailored to the individuals’ tolerability and be closely monitored and re-evaluated at frequent intervals. An important consideration should be given to the elderly population, as they are frequently prescribed sleep aids to assist with their insomnia. Long acting benzodiazpeines (i.e. diazepam, flurazepam) should be avoided, as they carry an increased risk of accumulating in the body because they are not eliminated as efficiently compared to younger adults. This can significantly increase injury-related hospitalizations and later consequences such as reduced quality of life, chronic pain, sustained injuries (i.e. hip fracture) and death.

Other types of medication such as hypnotics or sedatives (i.e. zopiclone) can also be prescribed to treat insomnia. These medications are typically shorter acting. However, it is still recommended that 12 hours elapse between medication intake and activity that requires mental alertness (i.e. driving).

Non-Prescription Over-The-Counter (OTC) Therapy

It is a common misconception that OTC products which can be purchased without a prescription are safer than prescription products. In fact, these products can cause similar adverse reactions to prescription products, and they carry the added risk of being misused as they are not prescribed under the supervision of a physician. OTC sleep aids usually have diphenhydramine (an antihistamine) as the main ingredient listed. Adverse reactions include drowsiness, dizziness, dry mouth, nausea, difficulty urinating, falls, and nervousness or agitation.

Other non-prescription products are marketed as “natural health products”. Some examples include melatonin and valerian. These products are less studied than their prescription drug counterparts, so their safety and efficacy must be carefully considered when deciding to use of these products.

It is very important to keep in mind that both prescription and non-prescription drug therapy is not a long-term solution to treating insomnia. Most products carry a maximum duration of use to reduce the risk of long term dependency (i.e. do not use more than 7 days). The long-term treatment lies in identifying the underlying cause of insomnia.

Behavioural Techniques

Some examples of behavioural techniques used to combat insomnia may include:

  • Following a regular sleep-wake cycle (i.e. going to bed and waking up at the same time each day, even on weekends)
  • Following a regular pre-sleep routine (i.e. washing the face, setting an alarm clock)
  • Exercising helps adopt a healthy sleep-wake cycle. However, it is important to avoid exercise within 5 hours of bedtime because it can stimulate the brain and prevent a restful sleep
  • Avoiding consumption of substances before bed than can interfere with sleep (i.e. caffeine, alcohol, chocolate, nicotine)
  • Getting out of bed if you are unable to fall asleep within 20 minutes and returning to bed when you feel tired again.

References:

  1. Insomnia and Excessive Daytime Sleepiness (EDS). (2016 February). Merck Manual. Retrieved from: https://www.merckmanuals.com/en-ca/home/brain,-spinal-cord,-and-nerve-disorders/sleep-disorders/insomnia-and-excessive-daytime-sleepiness-eds.
  2. Study: Insomnia. (2005 November). The Daily Statistics Canada. Retrieved from: https://www150.statcan.gc.ca/n1/daily-quotidien/051116/dq051116a-eng.htm
  3. Understanding senior’s risk of falling and their perception of risk. (2014 October). Article: Health at a Glance Statistics Canada. Retrieved from: https://www150.statcan.gc.ca/n1/pub/82-624-x/2014001/article/14010-eng.htm

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This article was provided by Daniella Santaera, Clinical Pharmacist for RXI Specialty Pharmacy in association with Rx Infinity. Rx Infinity provides optimal and sustainable patient management solutions through customized programs, innovative technology and added value services that improve the overall patient experience; while helping payers and plan sponsors achieve sustainability in the management of drug plans expenditures.

This information is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions about your medical condition. Do not disregard professional medical advice or delay seeking advice or treatment because of something you have read here.