Systematic Approach to Sleep

Get some sleep – NOW

Sleep is number one and I ask all my patients with insomnia to work with their primary care doctors to find a solution – and quickly. There are many ways to get a good night’s sleep and most physicians are comfortable with their own combination of strategies and medications to induce sleep. Regardless of the approach, not sleeping is not an option. This is especially true if you are considering any invasive procedure. Video: Get it Right the First Time

Approaches to Insomnia

  1. Sleep hygiene – set of well-known basic principles to optimize sleep.
  2. Stress management at bedtime – i.e. don’t read business emails while you are trying to fall asleep.
  3. Exercise – It is not helpful to exercise late in the evening but overall physical conditioning improves sleep.
  4. Expressive writing – has been shown to help decrease the time it takes to fall asleep.
  5. CBT-I – stands for Cognitive Behavioral Therapy Insomnia. There are online resources that may be helpful in addressing some of the anxiety around trying to get a good night’s sleep.
  6. Over the counter sleep aids – I do not have specific recommendations and they should not be used long-term. You also should make your physicians aware that you are using them.

Under the guidance of a physician

  1. Prescription Medications – There are many medications that are effective in dealing with insomnia. I have observed that if you are suffering from chronic pain that you often need a kick-start with fairly strong sleep meds. Once your nervous system quiets down you can and should come off of them relatively soon. I would also add that using narcotics for sleep is not recommended and creates many additional problems.
  2. Diagnosing a sleep disorder – there are over 100 sleep disorders with the most common one being sleep apnea. In sleep apnea your airway intermittently becomes occluded while sleeping and you are gasping for air. Sleep quality is poor and you are tired the next day. More importantly it has an adverse effect on your heart. If simple measures are not working it is important to diagnose and treat this. Restless Leg Syndrome is another common sleep disorder that is treatable with the correct medications.

I have used the metaphor of fighting a forest fire to become pain free. All aspects of chronic pain must be addressed simultaneously with you taking control of your own situation. Sleep is one of the more defined and solvable issues and is a great starting point.




My Ambien adventure

I missed my plane last night. I take an Ambien for red-eye flights so I can sleep well enough to enjoy the following day. My wife has repeatedly told me not to take Ambien before the flight takes off. I had a challenging week and had not slept well. I was finishing it off with a Friday night red-eye, so I decided to take the Ambien just as I was boarding the flight. I sat down and fell asleep – until the crew announced that the plane was broken and we had to get off of the plane, go to the next gate and catch a flight about 45 minutes later. I seemed to feel fine and sat down to read. The next thing I knew was that the boarding area was empty. The plane was just leaving the gate. The attendants had tried to track me down but I was unresponsive. I slept on the floor of the airport last night (Ambien was still working) until I caught the first flight out this morning.




Sleep was a major issue during my struggle with chronic pain. Ambien was a significant factor in getting me through it, although it was a relief to be able to come off of it. I also had some other close calls while on Ambien. I was not aware of the role of sleep in chronic pain at the time. I was just desperate. Knowing what I now know I would have taken a much different approach to my sleep problems.

I read a book, The Promise of Sleepwhich was an autobiography of Willam Dement, the founder of the Stanford sleep lab. He pointed out that at the time (60’s) that only about 5% of doctors addressed sleep. I felt that it was a definable problem that could and should be aggressively treated. I was surprised how many people would improve their mood and pain with just getting a better night’s sleep. It was the beginning of the DOC project, as I had always thought chronic pain was not solvable.

I will still use Ambien with my patients who still cannot sleep using simpler measures. If they are still struggling, I will add a sedating anti-depressant called Remeron. However, I am clear regarding the risks in that you cannot think clearly while the Ambien is on board. I never did give it to mothers with young children if there was not another adult in the house. It is also intended only for short-term use. With careful use I have not seen major problems with this approach, but it is no longer my first-line treatment.