How to counsel patients with sleep issues

Getting quality sleep is the foundation of a person’s overall health and well-being. The American Academy of Sleep Medicine recommends at least seven hours of sleep each night for adults. Not getting enough sleep has been linked to the development of several chronic conditions including Type 2 diabetes, hypertension, high cholesterol, and obesity. Sleep issues can also affect mental health: Lack of sleep is associated with new and worsening depression.

Roughly 1 in 3 people in the U.S. experience insomnia at one point or another. The Centers for Disease Control and Prevention (CDC) defines insomnia as the inability to initiate or maintain sleep—in other words, difficulty falling asleep or staying asleep. Chronic insomnia occurs three nights or more per week, lasts longer than three months, and is not caused by a concurrent health problem.

Many people rely on over-the-counter (OTC) sleep aids, but these medications may not always be the best solution. Pharmacists, with their expertise in medications and counseling, can play a vital role in helping patients manage sleep issues. As a pharmacist, you have a unique opportunity to help patients who are living with sleep problems and provide them with the guidance they need.

Counseling patients with sleep issues requires a comprehensive understanding of the root causes as well as knowledge of effective lifestyle modifications and treatment options. This guide aims to help pharmacists refresh their knowledge to effectively counsel patients on how to improve their sleep quality. 

How to help patients manage sleep disorders

Considering how common sleep issues are, many patients seek out solutions on the drugstore shelves. Pharmacists can help by recognizing the impact of sleep quality on overall health and guiding patients in managing sleep issues, whether that means recommending lifestyle changes, suggesting an OTC sleep aid, or identifying drugs on patients’ medication lists that could be causing insomnia or making it worse. It’s also important for pharmacists to recognize when a patient has a more severe or complex sleep disorder and know when to refer them to a provider or specialist for evaluation.

Lifestyle modifications for better sleep

Before suggesting an over-the-counter sleep aid, pharmacists can help patients by first recommending lifestyle modifications for better sleep. By pointing out the habits that contribute to sleep issues, patients may be able to adjust their routines to get better sleep. The following lifestyle changes may do the trick for mild or occasional insomnia, potentially bypassing the need for any pharmacologic intervention:

• Follow a set schedule. Sticking to a consistent bedtime and setting a wake-up alarm for the same time each morning helps to prevent sleep issues. Encourage patients to maintain this schedule, even on weekends, to help them adapt to a consistent pattern.
• Create a dark bedroom. Most people sleep best in a dark, cool environment. Encourage patients to make adjustments to their bedroom if necessary, such as investing in some blackout curtains or even a sleep mask to block out light. 
• Resist scrolling in bed. Stop using devices 1.5 hours before bedtime. Screens emit blue light, which can suppress the sleep-promoting natural melatonin in your body and make it harder to settle into sleep. Recommend removing TVs, cell phones, computers, gaming consoles, and other electronic devices from the bedroom to limit temptation. 
• Time food and exercise intake. Exercising during the day—but not right before bedtime—can help make it easier to fall asleep at night. Similarly, consuming caffeine, alcohol, or large meals late in the day can negatively influence sleep quality. Talk with your patients to identify these factors and be more mindful of their timing.

Over-the-counter sleep aids

If lifestyle modifications aren’t helping, pharmacists can recommend an over-the-counter (OTC) sleep aid for mild or occasional insomnia. Popular OTC options include antihistamines as well as dietary supplements like melatonin.

However, OTC sleep aids should not be recommended for severe or chronic cases. If a patient’s insomnia occurs three days a week or more and persists for over three months, it’s best to refer the patient to their primary care provider for further evaluation. Explain that over-the-counter medications and supplements have limited evidence supporting their long-term safety and effectiveness.

Antihistamines for sleep

OTC antihistamines are commonly used to treat mild or occasional insomnia. Antihistamines work by blocking histamine from binding to histamine receptors, resulting in drowsiness, among other effects. Patients may already be familiar with antihistamines for relieving allergy symptoms, but antihistamines have several other uses as well, including sleep issues, hives, and motion sickness. 

First-generation antihistamines, such as diphenhydramine, readily cross the blood-brain barrier and block muscarinic receptors in addition to histamine receptors, and accordingly tend to be sedating. Second-generation antihistamines, such as loratadine, block histamine receptors but do not cross the blood-brain barrier. As such, they are relatively less sedating. Because of this difference, first-generation antihistamines are generally better for helping people fall asleep.

Examples of OTC first-generation antihistamines:

• Dimenhydrinate (Dramamine)
• Diphenhydramine (Benadryl, Simply Sleep, others)
• Doxylamine (Unisom)

Diphenhydramine and doxylamine are popular OTC sleep aids. For adults, the recommended dosage is 25-50 mg of either medication at bedtime. Note that these antihistamines should be used short-term, usually for less than two weeks.

Antihistamines are useful, but only to a limited extent. A 2014 review found that while antihistamines increased sleep quality, they also increased daytime sleepiness. So, while antihistamines may help patients sleep better, they can also lead to next-day tiredness. 

Another downside is that people may develop a tolerance to first-generation antihistamines. A study in 2012, which included 16 trials, observed that over-the-counter antihistamines can be effective for short-term insomnia in younger adults, but a diminished response called tachyphylaxis develops quickly.

Side effects of first-generation antihistamines include dry mouth, dry eyes, dizziness, headache, blurred vision, constipation, urinary retention, and increased heart rate. These antihistamines should be used with caution in older adults, as this drug class can increase the risk of falling. Likewise, patients with kidney problems, liver disease, hypertension, urinary retention, or prolonged QT syndrome should also use antihistamines with caution. Pregnant women should consult their healthcare provider before taking an antihistamine.

While antihistamines may be useful occasionally for sleep, these medications should not be used long-term, especially in older adults. Chronic use may even be linked to the development of Alzheimer’s disease or dementia.

Antihistamines can be used cautiously in children as a short-term solution. However, the effectiveness of diphenhydramine for treating insomnia in children has not been proven in clinical trials. In pediatrics, diphenhydramine is the most commonly used antihistamine, with a recommended dosage of 0.5 mg/kg or up to 25 mg per day for children ages 6 and older. Younger children should not be given diphenhydramine unless instructed by a pediatrician. Also, warn parents that Benadryl could lead to increased arousal or hyperactivity in children.

Melatonin for sleep

The Food and Drug Administration (FDA) has not approved melatonin (nor any dietary supplement) for treating or managing sleep disorders. Still, pharmacists should be familiar with the options because patients seeking natural remedies for better sleep will seek advice. 

Melatonin is a natural hormone that your body produces to help regulate your sleep cycle. It is available as a dietary supplement and has become a popular OTC choice for helping people fall asleep. 

The evidence supporting melatonin supplements for sleep is mixed. One meta-analysis published in 2013 found that taking melatonin reduces the time to fall asleep by about seven minutes on average, compared to falling asleep naturally. While melatonin may give your patients a few extra minutes of sleep, it doesn’t seem to be clinically significant. The American Academy of Sleep Medicine therefore does not recommend melatonin as a treatment for chronic insomnia.

Melatonin doses range from 0.1 mg to 5 mg in most studies, though higher doses of 10 mg have been safely used in smaller studies. There is limited evidence regarding melatonin use in pediatric patients, but studies have typically used doses of 0.5 mg to 1 mg in children, given one hour before bedtime. 

If patients choose to take a higher dose of melatonin, it may be more effective if they take it closer to bedtime. With lower doses, patients can take it two to four hours before going to sleep.

Regarding risks, melatonin supplements seem to be generally safe and non-addictive. Side effects of melatonin may include headache, nausea, and dizziness. Pharmacists should avoid recommending melatonin for patients who are pregnant, breastfeeding, or have renal or hepatic disease. Parents should be encouraged to check with their child’s pediatrician before giving their child any medication or supplements for sleep.

A variety of other supplements are available over the counter that contain herbs thought to have sedative properties, such as chamomile or valerian. While some patients may experience better sleep with such supplements, there’s little evidence behind them. A 2007 review consisting of 29 clinical studies found valerian to be generally safe, but the supplement made no difference in insomnia management compared to a placebo. 

Insomnia-inducing medications

It is quite possible that a patient’s insomnia could be drug-induced. Sometimes, this can be resolved by simply taking the medication at a different time of day. In other cases, pharmacotherapy discontinuation may be necessary. 

As a pharmacist, you can play an important role in managing and preventing drug-induced insomnia. It is important to obtain an accurate medication history to determine if any of the patient’s medications could be causing or worsening sleep issues. Be sure to ask your patients when they take their medications and assess if they have tried changing the administration time. 

Examples of medications that commonly cause insomnia include:

• Steroids: Steroids increase alertness, making it difficult to fall asleep.
• Anticonvulsants: These medications may increase arousal, making it hard to fall asleep.
• Antidepressants: Certain antidepressants can have activating effects. Examples include Wellbutrin (bupropion), Prozac (fluoxetine), and Effexor (venlafaxine). 
• Thyroid drugs: Insomnia can occur if the dosage of Synthroid (levothyroxine) is too high. 
• Nicotine: Nicotine can increase alertness. Advise patients who smoke to quit, or at least avoid smoking before bedtime.
• Diuretics: Diuretics may worsen insomnia by making patients get up in the middle of the night to urinate.
• Asthma medications: Theophylline, albuterol, and ipratropium have been associated with nighttime awakenings and increased alertness.
• Birth control: Hormonal contraceptives may alter body temperature, which results in difficulty falling asleep for some women.
• Stimulants: Stimulants increase arousal and alertness, often disrupting sleep. Examples are nasal decongestants and ADHD medications like Ritalin (methylphenidate). Some stimulant medications for ADHD have extended-release formulations that are known to cause insomnia. 

When assessing patients’ medication lists, ask about any recent changes in medication, including dosage and timing. Consider if the symptoms could be related to a specific medication or dose timing. Suggest early morning dosing first if appropriate, but if this doesn’t work, recommend discussing shorter-acting formulations or other alternatives with the prescriber.

Know when to refer

Mild, short-term insomnia can be managed with lifestyle interventions and over-the-counter medication if needed. However, if a patient is experiencing insomnia at least three nights per week and lasts for longer than three months, they should be referred to a specialist for management.

Pharmacists can help by checking for medications that may be contributing to insomnia. They can also recommend appropriate adjustments to patients’ dosing schedules. It is crucial for pharmacists to understand the complications of inadequate sleep in order to provide the best care for their patients.