Insomnia? Referral, Drugs Not Usually Needed

Marcia Frellick

May 05, 2021

Chronic insomnia is often underrecognized and misunderstood in primary care, sleep expert Christopher Lettieri, MD, told attendees at the American College of Physicians (ACP) Internal Medicine Meeting 2021.

Too often, medications are the treatment of choice, and when used long term they can perpetuate a problematic cycle, said Lettieri, professor in pulmonary, critical care, and sleep medicine at Johns Hopkins School of Medicine in Baltimore, Maryland.

However, medications alone won't work without other behavior modifications and they come with potential side effects, he said in his talk. Prescription medications typically don't treat the cause of the insomnia, just the symptoms.

"In the 15 years I've been practicing sleep medicine, I can honestly say I only have a handful of patients that I treat with long-term pharmacotherapy," Lettieri said.

He said he typically uses pharmacotherapy only when conservative measures have failed or to help jump-start patients to behavior modifications.

Restricted sleep is a good place to start for chronic insomnia, he continued.

Physicians should ask patients the latest time they can wake up to make it to school, work, etc. If that time is 6 AM, the goal is to move bedtime back to 10-11 pm. If the patient, however, is unable to sleep until 12:30 AM, move bedtime there, he says.

Though the 5.5-hour window is not ideal, it's better to get into bed when ready for sleep. From there, try to get the patient to move bedtime back 15 minutes each week as they train themselves to fall asleep earlier, he says.

"I promise you this works in the majority of patients and doesn't require any medication. You can also accomplish this with one or two office visits, so it is not a huge drain on resources," he said.

Sleep Specialists in Short Supply

Cognitive behavioral therapy (CBT) is "without question the best way to treat chronic insomnia and it's recommended as first-line therapy by all published guidelines," Lettieri said.

He defined chronic insomnia as happening most nights over at least 3 months. It affects twice as many women as men.

CBT offers a formalized way of changing sleep patterns with the help of an expert in sleep behavior disorders. It combines cognitive therapies with education about sleep and stimulus control and uses techniques such as mindfulness and relaxation.

However, most programs take 4-8 sessions with a sleep medicine provider and are usually not covered by insurance. In addition, the number of insomnia specialists is not nearly adequate to meet demand, he added.

Online and mobile-platform CBT programs are widely effective, Lettieri said. Many are free and all are convenient for patients to use. He said many of his patients use Sleepio, but many other online programs are effective.

"You can provide sufficient therapy for many of your patients and reserve CBT for patients who can't be fixed with more conservative measures," he said.

Insomnia Among Older Patients

Interest in helping older patients with insomnia dominated the chat session associated with the talk.

Insomnia increases with age and older patients have often been using prescription or over-the-counter sleep aids for decades.

Additionally, "insomnia is the second-most common reason why people get admitted to long-term care facilities, second only to urinary incontinence," Lettieri said.

If physicians use medications with older patients, he said, extra caution is needed. Older people have more neurocognitive impairments than younger adults and may already be taking several other medications. Sleep medications may come with longer elimination half-lives. Polypharmacy may increase risk for falls and have other consequences.

"If you have to go to a medication, try something simple like melatonin," he said, adding that it should be pharmaceutical grade and extended release.

Also, bright lights during the day, movement throughout the day, and dim lights closer to bedtime are especially important for the elderly, Lettieri said.

Andrew Corr, MD, a geriatric specialist in primary care with the Riverside Medical Clinic in Riverside, California, told Medscape Medical News the main message he will take back to his physician group is more CBT and less medication.

He said that although he has long known CBT is the top first-line treatment, it is difficult to find experts in his area who are trained to do CBT for insomnia, so he was glad to hear online programs and self-directed reading are typically effective.

He also said there's a common misperception that there's no harm in prescribing medications such as trazodone (Desyrel), an antidepressant commonly used off-label as a sleep aid.

Lettieri's talk highlighted his recommendation against using trazodone for sleep. "Despite several recommendations against its use for insomnia, it is still commonly prescribed. You just shouldn't use it for insomnia," Lettieri said.

"It has no measurable effect in a third of patients and at least unacceptable side effects in another third.  Right off the bat, it's not efficacious in two thirds of patients."

Additionally, priapism, a prolonged erection, has been associated with trazodone, Lettieri said, "and I have literally never met a patient on trazodone who was counseled about this."

Trazodone also has a black box warning from the US Food and Drug Administration warning about increased risk for suicidal thoughts.

Lettieri and Corr have disclosed no relevant financial relationships.

American College of Physicians (ACP) Internal Medicine Meeting 2021: "Pearls for the Management of Insomnia Not to Miss." Presented April 30, 2021.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News and and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick

For more news, follow Medscape on Facebook, Twitter, Instagram, YouTube, and LinkedIn


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.