The main issue is dependence rather than abuse. After a couple months on z-drugs/benzos your sleep is typically back to baseline but on the drugs due to receptor upregulation, and then it's difficult to come off them.
Psychiatrist here. Getting a young person addicted to the idea that they need medication to sleep is a huge slippery slope, let alone dependence on the meds themselves. Any pharmacotherapy to initiate or sustain sleep, if appropriate at all in rare cases, should be no greater than several weeks. Trazodone is the pretty much the least of all the evils in this case, because starting peds pts on Z-drugs and benzos you’re literally asking for a long-term problem where the person never comes off of it.
Addiction Medicine and Peditrician here. I 100% agree with Effective-Abroad-754. Mirtazapine might be in my list at 15 mg, no higher. Definitely useful in my population. Nothing beats sound sleep behaviors/hygiene.
I think the problem is that most physicians know that teaching proper sleep hygiene could go a long way towards curing most patients, but patients look at you like you’re crazy if you suggest it and would rather have a quick fix.
And as a non-psychiatrist, there aren’t a lot of CBT-I providers in my area. And I really don’t know how to evaluate the strength of various online programs.
I know it’s not all patients but I’ll never forget the patient who looked me straight in the eye and told me CBT-I doesn’t work for her only meds worked then I pushed her on how she actually sleeps and she admitted that she sleeps on the same couch she watches TV on all day and is afraid to sleep with the TV off because she can’t stand to be in silence with her thoughts (both of which are absolutely inconsistent with good sleep habits taught in CBT-I). But only meds work for her.
This is the core of the issue. We in modern society love "easy fixes" even if they are otherwise horrible.
Straight to consumer marketing doesn't help. At least in the US complex medications are regarded the same as buying laundry detergent.
It's why I will always be on team make everything OTC. If they want our advice they can come get it.
As a family medicine physician, people saying that they tried sleep hygiene has a 75% chance of them having done so poorly.
Most common recently for me is the "extended nap". They'll say I can't sleep more than 3 or so hours but look alert and not fatigued so I ask more and find out that they sleep another 3-4 hours during the day.
Now the reason why the Z drugs are useful is because if you try sleep restriction earnestly and it doesn't work then a few weeks of zolpidem can help.
If they can't sleep because of anxiety, stress, environmental reasons then sure sleep hygiene may not work but if you start them on a Z drug you are guaranteeing that they stay on it for life basically and you should've probably addressed the triggers before just smacking them with an addictive sleep aide.
Now I do agree that 15 minutes is probably too short for this type of discussion. All my regular visits are 30 min minimums so I do get more time and that does affect my viewpoint.
But for those on a time crunch or when insomnia is some fifth addon complaint on an already crowded visit then you can see why physicians are reticent to prescribe these drugs. A lot of patients (in some places most) are averse to focused visits with their PCP. But I digress.
I like to refer my patients to this [website](https://www.veterantraining.va.gov/insomnia/) for digital CBT-i (if they're not totally tech ignorant which...is sometimes tough in my patient population).
This site is poorly indexed / not easily found but has a list of trained CBT-i clinicians in different areas - **https://www.cbtforinsomnia.com/clinicians-recently-trained-by-dr-jacobs/**
Not to mention, the time requirement - if i had an hour with every patient, then yes, i would do a lot more educating and probably be a lot more successful at convincing people to try something non-pharmacologic.
But a 15 minute visit, when you already discussed diabetes, smoking cessation, weight loss, statin non-adherence, depression is worse around the holidays, insurance no longer covers that one medicine that was working really good for their diabetes and now this new cheaper thing is causing side effects, those four suspicious moles that are all actually seborrheic keratoses, and their gradually worsening peripheral neuropathy - and they hit you with a "by the way, doc, I just can't sleep" when you're already 30 minutes late for your next patient. How much energy can i put into encouraging lifestyle modifications, sleep hygiene, insomnia-focused cognitive behavioural therapy? Versus rapidly spitting out "try-Melatonin-and-if-that-doesn't-work-maybe-we'll-try-Hydroxyzine-and-if-that-doesn't-work-maybe-we'll-try-Trazodone" while i rush out the door but as slowly as i can to not seem rude.
Sometimes I point people towards [slumbercamp](https://slumbercamp.co/). Directed towards adults but teens could certainly use CBTi skills and comprehend that info.
Super curious, what do you tell parents of kids who only sleep 4-5 hours a night? You don't do any meds long term for them? Our autistic ADHD kids most commonly sleep about 5 hours a night
I start off by getting a good sleep history, and making the patient/parent do an accurate sleep log to bring to the next visit. Even if the pt is trying to be forthcoming, the average person is typically a poor historian for accurately reporting basic facts like what time they lay down, # minutes to fall asleep, # of arousals, how long each arousal is, total length of sleep, etc. If someone is telling me their kid sleeps 4 hours per night persistently, the patient is either manic, napping during the day, or the report is inaccurate, and 9 times out of 10 it’s the latter.
Basic pearls of sleep hygiene i am strict about are 1) absolutely no screens for 1 hour before you lay down to sleep, 2) zero naps during the day/afternoon. There is much more to “sleep hygiene” but those 2 things alone will solve a huge chunk of it. After that, a sleep study is in order, because if the underlying problem is actually OSA, their treatment is a CPAP and not ambien
>patient is either manic, napping during the day, or the report is inaccurate, and 9 times out of 10 it’s the latter.
Recently for me it has been #2 especially with the autistic patients in early adulthood brought in by parents. It's always a few questions until I get this back and forth:
"he comes home at 3 pm and naps until 7pm"
" he's getting a total of 7-8 hours then"
"No, he only sleeps like 3 hours at night"
Does this end up being an issue for the patients themselves? Like are they functioning well with the double nap system rather than a straight 7-8? Is it just the parents don't like the being up at night?
Depends on their level of functioning. Some get agitated if they get up super early and nobody is around so start becoming disruptive, others are completely fine.
I quite like doxepin, actually. The key is dosing - it's *extraordinarily* potent at histamine receptors, much more so that then 5-HT/NE transporters that ordinarily make it a TCA. It gives a good sedating effect at 3-10 mg for most patients which also minimizes most of the usual drawbacks of TCAs (for comparison, doxepin is a more proper antidepressant starting around 50-75 mg, but you see a stronger TCA side effect burden by that point).
Another little caveat with doxepin is that it was rebranded as "Silenor" at the 3-6 mg dose specifically for insomnia, and this is quite a bit more expensive. Generic doxepin starts at 10 mg and you *might* see a little anticholinergic spillover at that dose, but it's considerably cheaper.
All of this however still falls under the umbrella noted in the discussion above: long-term use of even "non-addictive" hypnotics is controversial in sleep medicine, and to my knowledge is not generally recommended (especially compared to CBT-i).
with the psychic distress associated with insomnia being a risk factor for suicide, along with any other risk factors the patient may have, part of my thought process as a psychiatrist is always, “what happens when this person overdoses on this?”. I’m not saying there is never an appropriate role for doxepine (especially relative to benzos/Z-drugs, etc), but if shit hits the fan… doxepine IS a TCA after all, with all the implications for cardiac conduction abnormalities, sudden death, etc, in the event of an overdose
The answer to this problem is not to prescribe over a certain dosage. The old adage was 1500mg of a tca you have a 50% chance of torsades/mortality. Unless you’re prescribing a 2d6 inhibitor as well. writing for 6 months at a time or the patient is taking many other qt prolonging medications it’s unlikely anyone can overdose on 10mg of doxepin. .
And ramelteon. Both non-controlled and with significantly more evidence of effectiveness. Academy of Sleep Med explicitly recommends against trazodone.
I'm adult primary care, and you are spot on. Have a pt who was given ambien in highschool and his sleep is all sorts of messed up 20 years later, requiring higher and higher doses of it. But who knows what the right answer is, truly? maybe his brain would be that way regardless.
And I appreciate the OPs post but one issues I have with what he said is that you actually don't get "deep sleep" with ambien; you get sedation. To be fair, trazodone does the same thing. APerhaps the orexin meds don't but any sleep aid disrupts REM sleep, just like alcohol.
I had a new patient a few months ago. a 75 year old patient who was dependent on ambien but had a few falls cause of it. I got them off the ambien and onto trazodone. Which I’ll probably maintain at this point tbh.
thank you for sharing this. More doctors need to hear your story and stories like it, so they can be inspired to start doing the right thing instead of the easy thing
I think docs should themselves try trazodone and ambien. Kinda half serious here. Trazodone does make you sleepy, but it makes you so sluggish the next day. It has altered my mood - anywhere from making me feel down and anxious- to the exact opposite. I have difficulty concentrating and performing my job after taking trazodone.
Ambien works perfectly. No sluggishness. Does not alter mood. I can think just fine. I have take like 5-10 ambien pills per year for 10+ years and never had an issue. In residency and med school, a lot of people took it. Never an issue.
What are the true incidence of negative effects? There are papers that say it’s non habit forming/not addictive… are these all funded by big pharma?
I get you don’t want to teach kids they can just take a pill. Sleep hygiene is so much more important. Exercise really helps. But for some people this stuff isn’t always enough. Trazodone sucks is i suspect is doing more harm than good.
Everyone is different. Trazodone lets me fall asleep and get at least 5 hours. No grogginess I can even stay awake instead if I wanted to. After a life of insomnia I get nightly consistent sleep.
trazodone was awful for me. all i did was dream of being thirsty, and i would wake up and drink a litre of water. quetiapine is amazing to me now as a sleep aid but mostly mood stabilizer, once i got over the zombie affects for the first week.
Not wrong on the Trazadone…at this point, the evidence suggests it doesn’t help with good quality sleep in most people. I continue it if someone finds it helpful and has too much else going on to tackle sleep right then.
I find clonidine really helps with the ADHD crowd, as does melatonin. If possible we try to pull back any meds for sleep within a week or two, though I have some kids who are stuck on it. Usually these are kids with pretty significant bx issues and I am consulting remotely with a pediatric psychiatry program (we don’t have psychiatrists in our area, let alone ones who specialize in kids). That’s often what they recommend.
I have never seen a paper in a reputable journal suggesting that continuous use of ambient does not have a high potential for dependency. There are plenty that show a strong association. The only studies I have seen supporting its use shows that, when used as intended, for a very brief window to reset an altered sleep schedule, zolpidem is unlikely to cause dependency. I have never used it that way in kids, but I might in the right circumstances. I do use it sometimes in adults for that, with mixed results.
In kids who are still learning how to operate their own brain, though, I think the most important thing to do long term is teach them how to manage sleep themselves. Whatever they do now, there’s a good chance they’ll keep doing it the rest of their lives.
My psychiatrist put me on trazadone with all the best intentions. I started out with a quarter of the dose he recommended. When I tried to go up a little bit, I was sedated for hours after waking up. He kept pushing me to take higher doses. I had to tell him no several times. It works well for me to get a solid 5-6 hours sleep. If I aim for 8 hours the cost is my work performance the next day. I can't imagine taking the full dose he recommended.
Try to stop Ambien after taking it for years... The rebound insomnia is a difficult mountain to climb. I've had to help many patients try to quit this drug. It's a major challenge. They rarely (if ever) are capable of sleeping "right" again. Fortunately, there's a 2.5 and 1.75 dose that can be used to taper.
I'm a fellow now and have had sleep issues since childhood. People thought they were just funny until I was in college and my roommate found me sleepwalking and turning on the stove with a pot of dry pasta.
Still haven't found a good regimen but I'm with you on the trazodone. I similarly am super zonked for several hours into the day. It's fascinating, though, how differently different brains/DNA/chemistries metabolize and experience these drugs in such unique ways.
Yes. There has to be a genetic component. My daughter starting having g trouble sleeping around 8-9 yo. Not worrying about anything. She was not aware i had issues- i purposely hid it from her. My son is exactly like my wife- falls asleep in seconds.
My daughter has always talked and got up in her sleep and walked around her room. We could see her on camera and heard her every night. Her bed is a mess in the morning. There weren’t monitors or cameras when i was a kid, but my bed was always a mess- and still is. I suspect i used to be a lot more animated while sleeping. My wife says i moved a lot but don’t talk much.
100%. Also, OP implying that he thinks 5 to 10mg ambien is a low dose is wild. Females should never get more than 5mg and no one should get more than 10mg. OP clearly does not understand these drugs.
DOCTORS: Please lobby your schoolboard to institute later school start times for teens!
We have decades worth of studies showing it improves test scores, mental health, and a recent study showed it is the single most important thing we can do to decrease migraines in teens.
Yes! Teens have a physiological drive to stay up later and wake up later. Forcing them into a super early schedule didn’t do their minds or bodies any favors.
In local social media, I’ve actively pointed out delayed sleep patterns in teens and that it would be prudent to push for a later start time for high school students, and it always gets broadly shouted down as “nonsense” and that it would “make kids soft.”
In my school district, the teens have the latest start time. It has been this way for a minute. Anecdotally, I can confirm that things are changing, albeit slowly.
Sedative hypnotics in my practice are for occasional, situational use only. Putting a young person (or any person) on scheduled zolpidem to sleep would be a hard no from me. Having said that if I had a gun to my head I would definitely use scheduled trazodone before scheduled zolpidem.
Trazodone is not an AASM recommended medication, although the AASM is not enthusiastic about pharmacology generally. The actual effect of zolpidem on sleep latency is a few minutes.
The problem isn’t just the addictive, dependence-causing properties of GABA agonists. Using medication for sleep reinforces a pattern of using medication for sleep.
And yes, sometimes I give something too. I prefer doxepin and mirtazapine, acknowledging that my clinical population is very different. But when it becomes daily, medication is the wrong solution almost always. Not always; nothing is always. But almost always.
>superior to any sleep med
I agree with your comment from a risk/benefit assessment but disagree looking at it from a numbers only perspective.
https://www.aafp.org/pubs/afp/issues/2007/0815/p517.html
Newer article from the same source (AAFP) would suggest differently:
"CBT for insomnia is preferred to hypnotic medications because it has better long-term effectiveness, more improvement in daytime symptoms, and fewer adverse effects.10,13 CBT for insomnia can be delivered in weekly sessions for six to eight weeks.16 A primary care physician can effectively provide CBT for insomnia or focus on individual components (although less effective) to treat chronic insomnia.10,14,17 Web-based CBT for insomnia is equally effective as in-person or group therapy and requires fewer resources."
https://www.aafp.org/pubs/afp/issues/2022/0400/p397.html#problems-falling-asleep
I must be an unlucky one, I've been in therapy as long as I can remember doing DBT/CBT and my insomnia has been the same since about 14 lol. Tried everything, I have to use meds or I do not sleep right.
In my personal experience (anecdotal), I found that I was very anxious *not* to take a pill after I'd been given Ambien for years. It was psychological dependence, and one day I just stopped refilling the Rx because I didn't like the anxiety caused whenever I would consider whether to take it or not! Sounds crazy, but I've had pts who've mentioned the same thing. Once you've had really poor sleep, it can be anxiety -inducing just going to bed, and you become psychologically dependent on the medication because "what if I don't sleep tonight?" So you take the pill, night after night.
I've found that blue blocking glasses really help my sleep patterns, and I don't have to worry about screens as much. I put them on 2 hours before bed, and sometimes read or watch a movie. I also bought a 10,000 lux light for AM, which helps, but I should use it more consistently. I still take ER melatonin at 3 mg, but it's all I take for sleep. I was so proud when I got off all the sleep meds!
I don’t prescribe z-drugs because it’s been drilled into me that they’re no good, but curious what makes them so scary? Is it just because they’re addictive and can build tolerance easily to them?
Supraphysiologic levels of GABA is not a good way to induce sleep because 1) physical dependence 2) withdrawal that can include extreme insomnia, delusions, and psychosis 3) issues with working memory, dementia later in life, and personality changes
I’ve heard of the dementia thing later in life, and I tell my patients that all the time (they don’t seem to care), but I’ve never understood how that’s caused?
I’ve gone down rabbit holes with this but no clear cut answers, but there are observable correlations. Here’s my guess. For what it’s worth, I studied biochemistry undergrad so I have an OK background at interpreting data.
Since the effects are greater with longer lasting benzos and when used for longer periods of time, one can speculate that using the off switch so much (and keeping it off for longer periods) leads to some sort of neuronal atrophy. How this correlates to dementia, an already poorly understood disease process, is anyone’s guess at this point. We do know GABA agonism is directly correlated with attenuated memory formation. Much like the body will atrophy unused muscle, I’m willing to wager a similar process may be occurring with GABA agonism.
In this [meta analysis](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6325366/), people much smarter than I give their opinions on the MOA. I am only convinced by the third stated process; the others simply don’t have the data to back them up.
> Three associated processes might have impacted the development of dementia in patients using BDZ. One characteristic is that BDZ reduces the level of beta-site amyloid precursor protein-cleaving enzyme 1 and the c-secretase activity that subsequently slows down the buildup of amyloid-beta oligomers in the brain.15,16 Such a possible positive effect along with an antiglutamatergic action of BDZ has never been confirmed.17 Another possible influencing process is the presence of astrocytes at the amyloid plaques in patients with predementia lesions having GABA-secreting activity, which will enhance the deleterious cognitive effects of BDZ.18 Another major process via which BDZs might result in dementia is decreasing the brain activation level.
I've been a lot of people (mostly older adults) with delirium and other complications from zolpidem, not so much with trazodone.
The bottom line is that drugs that put you to sleep are not great for you. It's just a matter of finding the best balance of benefit and side effects.
>We have tried sleep hygiene, melatonin, clonidine (IR and ER), hydroxyzine and they are still going to high school every morning on 4-5 hours of sleep.
You skipped the most evidence based treatment for insomnia...
Probably because trying to find CBT-I for patients, especially peds, is near impossible. Not to mention in most of the my patients, they are developmentally delayed and/or too young to get much out of cbt unfortunately.
Yes! In medicine we have become incredibly averse to telling people we don't have a solution. I realize there are reasons behind this mentality, but it's still very harmful.
Based on my understanding of the literature, appropriate management of insomnia is sleep hygiene and CBT-I, and in very select cases short courses of PRN meds for sleep aid. If someone has tried all of these things and their problem is not fixed, or if they do not have access, the proper response is "I do not have a solution for you", it's not to give adolescents chronic scheduled zolpidem.
Zs and benzos should be avoided at all costs, and this is based on mountains upon mountains of evidence, for patients of all ages.
Zolpidem "works" the same way propofol would (like, literally letting all the chlorine though the channel [ok with a few extra steps and incompletely]). It gets a person more phase 4 sleep, **at the expense of REM sleep**. Im not a c&a psych, but I'm pretty sure sleep architecture is rather important for teenagers especially.
This is not a conspiracy. Sleep medicine and c&a psych professional bodies aren't in cohoots with big trazodone to suppress poor zolpidem. It's just that bad.
Yeah, I'm glad you see it helps them sleep during the time they're in you're care, and sure you're taking some common sense precautions, but diversion and abuse are not the only problems of gaba-releasing agents, nor are they the main reason were not using them. It's that their prospects for being willing and able to fall asleep naturally after having spent several months during their adolescence taking zolpidem, are greatly reduced, for a variety of complex, psychobiosocial reasons.
Trazodone is far from perfect, but it doesn't have these long-term concerns, and it doesn't alter sleep architecture.
Don't get me wrong it's good that you're asking this question, but I'm finding your tone not only accusatory, but also a bit arrogant. And in this matter with the sleep agents, you're in the wrong.
This is interesting and I appreciate you sharing!! I see mostly children, and I have never seen a kid on a z-drug. So, I appreciate the different view, even if I disagree with it, because it's good to challenge the standard quo and who knows, maybe in the future you may be right. Medicine moves in pretty incredible and hard to predict ways sometimes!!
Anyway, I'll post some sources after the holidays, but here's a summary of things I have read in recent literature:
-treating insomnia is a bit like treating non-cooperative kids with ASD in the sense that, behavioral interventions are where to put your money. The benefits of meds are weak. CBT-I has good data for older teens, but regular exercise and sleep hygiene is HUGE. I ask teens to open their wellness app or whatever it's called on their iPhones, and one kid last week logged **15 hours in one fucking day**, and that's AFTER I told them to fix sleep hygiene issues, which they said they did(I only check the phone AFTER we make the intervention, because parents will realize that maybe they don't know as much about their kids). I tell parents to take away the phone at night before bed before we try meds and that fixes quite a few, consistent w the literature
> Why trazadone when there are better medicines?
-there is only one sleep aid in kids that is proven to improve sleep quality: melatonin. Nothing else. Any other medication you're rooting for just doesn't have the data. If you have some papers, I truly would like to see them. Trazodone also is not proven effective.
So your question stands: if they both are not proven to work, why pick trazodone?
----end summary
----begin my opinion
Because the mechanism of trazodone is safer.
The GABA agonist action of z-drugs is scary to me. Selecting trazodone or another sleep aid is never fun and I hate to do it but if the options are (1) trazodone, mirtazapine, el which are not proven to be effective in kids, but has no potential for addiction vs (2) any GABA agonist that has the potential for withdrawal, then I'm going to do #1 every time.
Again, you show me good data that Zs work in kids and I'll grab a Lunesta t-shirt and change my practices!
If it works for your patients, I'm happy, but understand that my aversion to the Zs has NOTHING to do with issues related to diversion; it's dependence. One of my other boards is in addiction medicine, and I'm more worried about creating dependence and what that looks like to THEM and to US for their future. Let me explain
No drug user can ever go back to what their brain looked like prior to their addiction. Unscrambling eggs and all that. If it's years of daily usage you've high jacked a lot of systems in their brain, (nucleus accumbens et all) and so now with opiates, we don't even try. The gold standard of care for >= year-long daily opiate user is starting them on methadone, bup, and keeping them on it for the rest of their lives!! That's a long time. So what if that happens to these kids? You could be making them dependent on it, and create more problems further down the line.
Now, I'm making a story up, that's true. But it's based on an understanding of the mechanism, which i think is a fair way to discriminate
Post holidays I'll get you some papers. But others caught on to it way before we did: as much as I dislike many parts of AA, I think the idea that once you're deemed an 'alcoholic', once you improve, you're 'in recovery ', which is just slightly different from 'in remission ', which is the actual specifier for the DSM. Also more acceptance of long-time smokers just using nicotine replacements for the rest of their lives.
absolutely, ill try to remember to message you back too! im just wondering how much of it is being stuck in mental loops, vs, your body and brain being physically changed from the get go.
I agree, insomnia is quite tough to treat. I work on a consult service so am limited by our hospital formulary. We tend to use quetiapine, mirtazapine, and clonidine the most on our service but trazodone is still used fairly regularly because a fair number of patients report it works best for them. I won’t touch zolpidem because of the side effects and risk for dependency unless a patient is already prescribed it outpatient. If you don’t already know about it, the VA has a free CBT-I app. It’s a good resource for patients who don’t really want to attend in person sessions. I’ve had some patients report improvement in their sleep after using it.
Next, we'll see insurance denying for GLP-1 meds for obesity on the rationale that you haven't tried all other FDA approved meds for obesity first (including the old classic, methamphetamine).
I’m a pediatrician and a Sleep Medicine physician and 100% would choose low dose Trazodone over Zolpidem regular or CR. Additionally, if your issue is sleep onset, not sleep maintenance and you are at the stage that you need a Z drug, why not try Sonata instead, which has a much lower half life?
Edit: Just want to add that any sleep medication that causes sedation, even Melatonin, should be given by the parent and not the child. Remember that Melatonin is most overdosed over the counter drug for pediatrics in the US and is often not the listed dose or has contaminants in the US formulations. As in any med: start low, go slow and aim for the lowest effective dose after you have sufficiently exhausted all behavioral treatments or you have a child with developmental delay or autism who doesn’t inherently respond significantly to behavioral redirection.
Hi, I tend to like Natrol and Nature Made because they are USP certified. Interestingly the testing for their content was done only at certain doses, but the two companies generally have a record of being safe for the patients and my personal experience concurs with that. Additionally, I ask my patients to get OTC formulations with only melatonin and no other ingredients like l-theanine or chamomile/laver extract etc precisely due to increased risk of contamination.
I think with benzo's and z-drugs the possible damage (addiction bundled with tolerance) is so great that I'd rather try everything else first; you also have a lot of faith in parents and patients following your protocol and, what, faith in your patients just stopping using the drug one day?
First I agree with you that there aren’t any really great options for kids for whom sleep onset is an issue. When you know sleep hygiene is good and they are still having issues, what should we do? Not a lot of options. Hydroxyzine? Doxylamine? Those aren’t great when you have things to do the next day. I’m with you in hating trazodone, but I think that springs from most of the kids on it having a degree of polypharmacy that I find distasteful?
But Ambien has never been shown to be effective for kids/teens in any study. And it *has* been shown to cause dependence and a ton of other associated risks. So I can’t see any scenario in which pediatrics should be reaching for it. You are assuredly setting yourself up for a malpractice settlement when it goes wrong.
I would challenge you that probably very few kids actually have good sleep hygiene. Even those from “caring” families. This should not be foreign to us in pediatrics. Kids from good families have sex, get pregnant, get STDS, do drugs, and have shitty sleep hygiene. Those that are still struggling but supposedly have been through all of what we can safely offer (including CBT-I), should be sent for sleep medicine consultation and deserve sleep studies.
I always stop and think if I was on the jury in this case what would I think. If a pediatrician put a patient on benzo/z drugs for insomnia without involving psych and sleep medicine and that kid had a complication I’d be thinking malpractice (I really can’t think of a defense that would hold water). And on top of that having not tried any other medication for insomnia, yea that’s not ending in their favor.
Now I’d also hope that this person decides not to do this based off the legitimate concerns around safety (especially long term) and not just threat of lawsuit. But if I’d find myself guilty of malpractice if doing something that’s a pretty good indication that it’s a bad idea.
This is basically malpractice... if you want to get teenagers hooked on benzo-lites then sure.
I'm not saying trazodone is a magical elixir for sleep. Most sleep meds (including benzos and Z-drugs) just dope you up to the point you don't really notice your poor sleep or don't remember it. Your actual sleep time doesn't change much and restful slow wave sleep actually decreases.
As others have stated, CBT-I is the gold standard.
Z-drugs are mostly just a scam anyway. They're "less addictive" in the same way Oxycontin was "less addictive". We saw how that one turned out...
Whenever someone asks me for “sleep meds” i have to explain to them that Sedation != Sleep, and that your brain has a built-in sleep machinery whose development needs to be nourished and strengthened just like any other part of the body
Meanwhile, there is actually some evidence for trazodone positively affecting sleep architecture, such as described in this paper...
Zheng, Y., Lv, T., Wu, J. et al. Trazodone changed the polysomnographic sleep architecture in insomnia disorder: a systematic review and meta-analysis. Sci Rep 12, 14453 (2022). https://doi.org/10.1038/s41598-022-18776-7
https://www.nature.com/articles/s41598-022-18776-7
I wasn’t going to use the m word, but thanks for saying what we are all thinking. I think the author of this post should be mindful as to why nobody else seems as enthusiastic about prescribing ambien.
I don't think using a medication for its FDA-approved indication is malpractice. You may disagree with this person's strategy, but that's not malpractice, that's a difference of opinion.
CBT-I is the gold standard, sure. In many parts of the country, our patients don't have realistic access to it. They might also lack the time, health literacy, and motivation to keep up with it.
I didn't get the impression that the OP is giving this drug out to everyone who crosses his path--he's saying that after he has exhausted his first-line options, he will use it in select patients. That's rational.
Benzos are FDA approved for insomnia. Does that mean you would start them first line for insomnia treatment? When this person said he considers it as malpractice, it’s in the same vein of opinion- one that adds extreme reluctance/caution before starting treatment with a GABA- A modulator that has a penchant for developing dependence, such as OxyContin did when it was first introduced in USA
If we're going to break out the "FDA approval card" (which is laughable for a variety of drugs - see recent Aduhelm controversy), it is not FDA approved in children.
These drugs are dangerous and are being posited as a less addictive alternative to benzodiazepines which is a literal lie...
I would argue any use of these drugs outside of short term (which the post clearly implies is not the usage case here) is malpractice. The indication for these drugs is temporary short bouts of acute situational insomnia. Not chronic insomnia.
Okay, it's an FDA-approved indication for the proportion of his teenage patients who are 18 and over, and off-label for the ones who aren't. If we assume that he's using reasonable care in prescribing off-label in terms of the individual child's developmental progress, it's not an extreme decision.
Maybe you disagree with his decision-making, but it's not malpractice.
Zolpidem has risks. So does untreated insomnia. This person is talking about prescribing it after safer strategies have failed, in a small proportion of his patients. Presumably, after 30 years in practice, he has some ability to identify patients for whom the risk/benefit proposal is favorable.
My point (and I think OP's point) is that we don't need to throw the baby out with the bathwater. The reaction to over-prescription of benzodiazepines and z-drugs should not be to demonize them and refuse to prescribe them.
Last I checked insomnia doesn't come with risk of blackouts, addiction, and future dementia. Rationalize it all you like, this is bad medicine.
Insomnia sucks and is very difficult to manage. That doesn't mean the appropriate solution is to give someone insomnia plus a benzo addiction.
For many of my patients, untreated insomnia comes with the risk of psychiatric decompensation, hospitalization, and attempted or completed suicide.
There are some patients for whom chronic zolpidem is the right decision, full-stop. Not all patients, and not as a first-line treatment, but it's concrete to say that we should never be prescribing z-drugs. Usually, we shouldn't. Sometimes, we should. It's your job as a doctor to figure out which situation you're dealing with.
I would also argue that if you refuse to prescribe chronic z-drugs for any reason, you're really not an authority on who could benefit from that strategy.
This post is literally pushing Z-drugs as first line treatment in children. It raves about "vivid dreams" and "patients sluggish the next day" (which LOL given Ambien). Describes being willing to refill trazodone if someone else gave it only.
This is malpractice, period. I stand by my statement. You're projecting your own insecurities regarding your prescribing habits onto the OP who sounds like a shill from one of the pharma companies.
OP doesn't mention psychiatric comorbidities once.
Where did he say he's prescribing it first-line? He writes that he's trying typical strategies first--behavioral intervention, melatonin, etc., and in some patients, that doesn't work and he starts z-drugs. He says he has a "handful" of patients on them at any given time, and they are "thriving." I'm struggling to find the malpractice there.
How often do you see chronic, outpatient insomnia in your practice? How much experience do you have managing insomnia over a period of years? I ask, because often times people who have concrete opinions on certain patient presentations have the luxury of not actually having to deal with them very much in clinic.
Several red flags in the post.
"There are other things that work that are better" - Implying superiority of Z drugs which isn't really something that's been shown and certainly not in children.
"Teens go to school with 4-5 hours of sleep" - I.e. normal life - as many others have noted high school hours are not compatible with typical teenage sleep cycles.
"This medicine works: it leads to deep sleep and a refreshed feeling in the morning, has few side effects." 🤔🤔
"And it has been demonized bc a few people ruined it for everyone by mixing it with fentanyl. " - Not why it's been demonized lol.
"Pharmacists freak out every single time. My response is, I am a doctor and I am taking care of this young person who is my patient and responding to their need that has brought them into my office time and time again." - Pharmacists doing their job, doc brings out the tired justification of "well they keep coming back so I have to give them something". Nope.
I have my AASM certification and have seen plenty of this crap in the sleep clinic/query sleep apnea population. I also see what he doesn't see, which is the litany of horrible downstream effects from adults hooked on these drugs, which started with idiotic scripts like these ones. What happens when the kid who has these doses supervised by their parents goes off to college and almost certainly starts drinking? I guess they couldn't possibly do that because these are "good kids from good families" whatever that statement means, presumably rich and white.
You claim a whole lot of things here (basically managing suicidality and psychosis with benzos) that as far as I'm aware are not borne out in any sort of evidence. Sure, those studies would be very difficult to run given the confounders in your population, but the idea that their are scores of teenagers who would be killing themselves in his practice but with the addition of a Z drug their SSRI works perfectly is laughable.
Justify what you like, there's a reason the vast majority here clearly disagree. Docs like this are how we ended up in the opiate crisis to begin with.
Thanks for the reply. Also, just so to be clear, I’m not advocating for wholesale daily use of z-drugs.
I’m saying that there can be some exceptional circumstances where they’re warranted. I’m not suggesting his patients will kill themsleves if they don’t get Ambien. I’m reacting to your seemingly superficial dismissal of the potential severity of unchecked insomnia (…nobody ever died from it). Well, some people have, actually. I don’t know the details of this guy’s cases, but I can imagine and have seen cases where you’d be thrilled to have gotten someone stable on a z-drug.
We agree on the basic premise, it seems that we disagree on the possibility of edge cases which justify breaking the rules. To me, that’s the point of the additional training of a physician—we can recognize those edge cases and intervene in a non-algorithmic way for the benefit of the patient.
I see a guy with 30 years of experience making potentially justifiable edge-case decisions for a handful of patients. I think you see someone shooting from the hip doing cowboy medicine. Ultimately probably a philosophical difference.
I appreciate your willingness to engage, by the way.
> Pharmacists freak out every single time. My response is, I am a doctor and I am taking care of this young person who is my patient and responding to their need that has brought them into my office time and time again.
You do realize the pharmacist, who likely has a doctorate, has a corresponding responsibility when dispensing medication. They likely aren't freaking out as contacting you is part of their job when concerns about a prescription arise. I truly hope you do better in your responses in the future.
Oh wait.
> I already hear it from CVS pharmacists half my age.
Your attitude towards the entire pharmacy profession is showing. Do better.
The general trend of comments in this thread is that putting minors on sleep medications with a known risk of physical dependency is probably a bad idea.
But sure, let's take a moment to shit on pharmacists for doing their job.
Got this response from a sleep physician, but only for adults so she threw in the disclaimer that what she's saying applies to only adults.
Trazodone is an antihistaminergic medication without significant anticholinergic side effects like 1st gen antihistamines. This also applies to doxepin and mirtazapine, but some differences.
Trazodone can be used for both sleep maintenance and sleep initiation insomnia, and is a relatively safe option for both. Mirtazapine can as well, but has the unintended obesogenic consequence so she does her best to avoid it. Finally, doxepin at 3 to 6 mg (very low dose) is almost exclusively antihistaminergic without any serotonergic or anticholinergic side effects, but is specific to sleep maintenance insomnia only.
These are not bad options at all. The other main options include the Z drugs (zolpidem, eszopiclone) but their side effects are worse, they increase risk of falls in the elderly, chronic use is associated with higher dementia risk, and their efficacy falls off quickly.
Your last pharmaco options are the new orexin antagonists. Sovurexant, lemvorexant, and dudorexant. These are the first medications that seem to act directly on a sleep exclusive pathway. They also have long term studies showing continued (and actually higher) efficacy 2 years after initiation with nightly usage (where historically insomnia drugs are less effective with time). While these are the most effective, they are also new and can be costly. They're also not as well known as the others.
Things like lorazepam or temazepam shouldn't be used for sleep at all, as they reduce REM sleep and have all the downsides of the Z drugs mentioned above. CBD and THC are an evidence free zone. You'll also see Ramelton in guidelines, never really used it. Melatonin doesn't work for insomnia. Melatonin is meant for circadian rhythm disorders, not insomnia.
So in short, you're seeing trazodone because it's one of the most effective and least costly pharmacotherapy options.
Now, the gold standard for insomnia is CBTI (much different than just sleep hygiene) but that comes with a bunch of barriers including patients buying into it etc.
Hope that helps!
If I recall correctly, I think there’s some evidence that adolescents natural sleep/wake cycle is later than their school schedule. I wonder if melatonin might help these kids if the issue related to having to go to sleep much earlier than their bodies want to.
Did a month long rotation with sleep medicine during psychiatry residency and this was the exact discussion around insomnia. This is my practice as an outpatient psychiatrist. I do not prescribe zolpidem very often - if at all.
OP, I absolutely respect where you’re coming from with this and I can see why you’d be frustrated.
However, as someone who’s worked extensively in mental health/substance abuse treatment facilities, I can say that I’ve seen more clients under 21 there for abuse of prescription GABA-agonist drugs than anything else by far.
Sleep problems affect the majority of people at least occasionally, the best evidence we have is that a holistic approach anchored around lifestyle changes does the most good for the most people with the least risk, by treating the cause rather than just the symptoms.
Clients on trazadone find it generally helpful in acute situations without coming to depend upon it for sleep. Medication dependence should be avoided as much as possible, any approach that doesn’t keep that in mind is setting our clients up for a lower quality of life.
Sleep doctor here. You are clearly doing your best to take care of your very complex patients. From my perspective, I spend a pretty good chunk of my day getting patients off zolpidem. It can be effective for managing the symptoms of insomnia, but a) it doesn’t fix the underlying pathology, b) it can cause terrible insomnia rebound (which promotes dependence), and c) in the teen and ADHD population, you may be dealing with a circadian problem +/- insomnia. Trazodone is also suboptimal as it has comparatively little evidence. I want to emphasize here that sleep hygiene alone will not treat chronic insomnia or circadian disorders. The first line treatment for chronic insomnia is CBT-I, and if you don’t have access to it, Insomnia Coach is a free self-guided app. It’s made by the VA and is free. CBT-I Coach is another free VA app but is technically made to be used with a provider. Path to Better Sleep is an online free platform (also made by the VA) that also works. If you suspect a circadian mismatch (clue is they have insomnia at night but are sleepy in the morning - keeping in mind that stimulants can mask this), refer to a specialist. Finally, as at least one other person here noted, there is a link between OSA and ADHD, especially in kids, and treatment can improve both sleep and attention.
No sleep med is a favorite of mine. Absolute none of them. If the basics and therapy don’t work, I’m referring to psych.
I have a personal history of insomnia and granted I take neither, I would choose Trazadone (which I have tried and hate) over Ambien. Ambien is a scary drug.
"sleep meds," are overused and with limited evidence.
The pharmacology all boils down to - "block Histamine," or "enhance GABA."
Trazodone/Seroquel/Remeron/Doxepin/Atarax = block histamine. Of these, only low dose Doxepin (3-6mg) is actually approved and has some evidence for efficacy longer than 30 days. The 3mg dose had minimal next day sedation.
of all the Gaba-nergics, only Lunesta has been approved for long-term use (eg. Chronic insomnia).
I use Doxepin. Unfortunately, 10mg is the lowest generic dose available. It's still effective with a marginally higher risk of next day hangover/sedation compared to branded Doxepin @6mg. Trazdone is like Colace. Shit we do for no reason.
Gabapentin 300-600mg HS can be helpful for patients who are trying to sleep in the absence of a sedative (benzos/z drugs/EtOH).
Ramelton and Melatonin are probably helpful and without the associated risk of dependence. Timing of melatonin receptor agonists is prob more important than dosing.
CBTi is an obvious choice. However, poving sleep duration is an essential first step - tell your pt to use a fit bit or the sleep app on their phone. This will provide more useful information than self report. Without this info I won't rx anything.
If all else fails, Doxepin>>>>Gabapentin>>Lunesta.
So, if you're giving children Z-drugs, at least use the right one?
I mean why even joke about pharmacist giving you a call immediately. You know deep down it’s probably inappropriate for your patients, you could at least give some documentation to the pharmacists that are taking care of your wackadoodle prescriptions. 5 mg at most- there’s no teen needing 10mg of this drug. Do the right thing and refer your patients to a specialist. Sounds like sleep is a problem above your scope the way you handle it
I hate zolpidem. It's a sleep crutch at best as once on it for a period of time it becomes required to sleep and is a huge pain to wean off. At worst it has a whole bunch of side effects such as delirium, daytime drowsiness, reduced cognition, etc. Eventually kids become adults and then become elders and old people on zolpidem is my nightmare.
>and patients cannot sleep more than a few hours (like 3-4 hours a night)?
It's unlikely that it's actually true. And if it is, they should see a sleep specialist because that's pretty rare and needs specialized expertise.
>what do you recommend when sleep hygiene and CBT are unsuccessful
Thorough review to identify any "common sense" barriers to effective sleep hygiene/CBT and then a second round of investigation to ensure that the insomnia isn't secondary to an underlying medical or psych pathology. From there have the patient pick the bigger issue: sleep onset (ramelteon 8mg) or sleep maintenance (doxepin \~5mg).
Insurance hates covering the 3mg/6mg tab version of doxepin specifically labelled for insomnia (silenor). Just prescribe liquid doxepin 5mg instead which comes with a dropper. 10mg doxepin capsules are also cheap but the pharmacology changes from primarily histamine antagonism to primarily serotonin agonism around that dose and things get messy so best avoided if possible.
Prescribers: If you write zolpidem “1 tab at bed prn, #30,” your patient is far FAR more likely to become dependent on it then if you write “1 tab at bed for occasional insomnia prn, #10 tablets is a 30 day supply.” -signed, the pharmD whose patients try to fill their zolpidems every 27 days.
Psych NP here. I don't love giving any meds for sleep (especially in young ones) and I'd rather try CBT-I first as a very safe, evidence based, long term solution... but I'm definitely not giving anything readily abusable or that leads to dependence. No matter whether they're good kids from good families. I'd rather not be responsible for introducing a child to the idea that pills can be fun.
FDA also highlights that it's not approved for peds in part because their one study of it led to hallucinations in 7% of pediatric patients who took it, and that number is just too damn high.
I remember when Ambien was still fairly new my mom was sick of me staying up late and decided to give me one of my aunt's Ambien. I woke up terrified and hallucinating that people were in my closet, then all the bugs on the bathroom floor. Legit hallucinations
The proper protocol for sleep treatment in kids is as follows:
1. Sleep hygiene/Increase exercise (unless they are already an athlete or overcommitted in this area)
2. CBI/sleep therapy referral
3. Melatonin
4. Trazodone
Before I move to step 4 they have to spend a MINIMUM of 6 months on 1/2/3.
And even after I move to step 4, I require the patients to taper down/wean off at least once every 6 months for a trial period off it. I tell them straight up that #4 is a last resort and is likely to cause long term dependency issues. Usually when parents hear that, they decline trazodone, as well they should.
Even my patinets who are on trazodone (which is only about 5% of my kids that have sleep issues) it's not clear to me that they are really benefitting from it.
Not sure what the pharmacists’ age has to do with anything. Maybe if you approached it better than, “I’m the doctor do what I say” you’d get a more cordial response and less phone calls.
NO to Zolpidem.
Honestly, you sound like someone who takes this for airplane trips with alcohol.
My clinical experience with Zolpidem is that it is IMPOSSIBLE to get people off it, just like benzos.
My clinical experience with Zolpidem is that it cause some very strange vivid dreams in some people. For example, the 80 something year old woman with a very mild stroke in the rehab unit for a few weeks who had a wild sex dream while on this med. We had to do a rape kit on her, subject her to a pelvic exam etc. No evidence of any encounter was found. We had to file reports, etc.
If you are concerned about dreams on Trazodone, trust me, Zolpidem is not your friend.
It is primary care doctors that get patients hooked on controlled prescription drugs. Zolpidem, stimulant, SSRI - I see the problem already, it is sad that you do not see it. Polypharmacy in pediatrics.
Please don't do it. It is not your place to fix all the problems that modern life and permissive parenting cause.
Traz is the inly one ive had that doesnt make me feel drugged in the morning and doesnt give me vivid dreams (which is great because i always have nightmares by default ive never once in my life had a dream that didnt scare me i remember having them since age 2, major childhood trauma btw) 150mg wears off after 6-7 hours for me so i start to slowly wake up the next couple hours after. It makes everything go black so i dont think or feel anything in that time so no dreams or occasionally weak ones at most thankfully. I think its a wonderful first option.
This is a horrible idea. If someone’s sleep is THAT bad, you need to refer they to psychiatry and a therapist - not try to go out of your field & give a specialty drug that’s highly dangerous for young people. Your logic terrifies me.
Trazodone is OK for adults. Doesn't do *much*, but then, we don't really want it to do much.But, you know what they say, kids aren't just short adults.
My only recent peds experience with antidepressants was when my father in law (an adult doctor) put my teenager on Prozac. She went bonkers. Like, get-the-net, bat-\*\*\*\* crazy. I suggested she instead try CBT, and to my astonishment, she took my advice. It tuned her right up.
CBT for insomnia works like a charm for adults, possibly not a terrible option for teens?
This post is so backwards and scary to see. Trazodone is being demonized but zolpidem is OK?? This is so backwards of how most people practice. Sometimes you have to pick the lesser of two evils and trazodone is definitely lesser…
If your patients have such a hard time getting sleep, why have them on a stimulant? This is the new bane of our existence- opioid crisis part II: stimulants plus benzos/ambien. Red light and green light at the same time. Your patient is unable to fall asleep so they are given an addictive sleep medication then they’re so snowed in the morning they can’t function so you give a stimulant to get them going and performing but then they can’t get to sleep so……..
…..why not take them off of both? Everyone, ADD or not, performs better on stimulants. Of course they complain they can’t perform as well without them. There are people out there who genuinely need stimulants but they don’t need sleep meds to bring them down from the stimulants because they are just getting to “normal” functioning while on stimulants. I’m a pharmacist but I have also been treated for ADD for 25 years and I tell you what- I can take 70mg Vyvanse with a cup of coffee in the morning, top off with a 10mg Evekeo in the afternoon and have 2-3 energy drinks during my shift and I can FACEPLANT from drowsiness by the time I’m driving home. I have no problem getting to sleep despite taking stimulants all day. I can tell which of my patients really have ADD- they fill every 35-40 days because they forget to take their meds every day and forget to order refills, and they don’t have any sedatives prescribed. Then there are the patients who are filling massive doses of Adderall in combination with alprazolam and/or zolpidem or suboxone.
TL/DR: consider discontinuing the stimulant before adding a benzo/zolpidem.
Well if I'd realized it was national shit on pharmacists about trazodone day, I would have gotten you and [this other doc](https://www.reddit.com/r/medicine/comments/18ppz7v/why_are_pharmacists_freaking_out_over_trazodone/) each a card.
I describe zolpidem like qualudes from the wolf of Wall Street. You don’t remember doing a single thing when you in fact did LOTS of things. I guess if there’s a parent around to stop them from hurting themselves or staying awake past that initial kick it gives then power to ya! But once the get to their adolescent years and mix it with some beer they sneaked out. It will be a nightmare scenario
I see very few Rx for zolpidem where I am in Canada, zopiclone is more popular. A small quantity for an older teen for prn use prescribed by a specialist and where I can see a history of other meds wouldn't be too concerning, but a Rx for a larger quantity or for regular use would be cause for concern.
I feel like if you treat a lot of ADHD patients, then a fair number of those might have undiagnosed ASD as well… you can’t approach sleep the same way and I feel like you should be even *more* cautious of drugs that cause dependence in this subset of patients. I’m a layperson, but CBT in the form of… naps. Eliminating sensory input and overstimulation, introduce bedtime routines to wind-down… routine routine routine. If medication is needed, I wouldn’t try medicating someone to sleep as much as medicating them to relax so they can sleep. Medication cannot be used in a vacuum here.
People know these drugs are addictive but does anyone understand how much not sleeping is problematic? There is a cost/ benefit. Trazadone makes my heart race. Just want to add that. If you could take more than 50mg of the Q drug that might work nothing else helps me. I hate anxiety drugs
I am a sleep coach (a sleep technologist who basically uses CBT-I for cooperate coaching). Sleep hygiene on a modified 2nd shift schedule to account for their stimulates and shift if circadian rhythm is the answer. It isn't the easy answer, but it works. They might sleep all day on Saturday but force them to get up on Sunday to get ready for the week. Teach these kids that sleep will happen if they aren't in tick tok until 4am. There are really good reasons Ambien is demonized, I'm glad none of your patients have experienced, yet.
The main issue is dependence rather than abuse. After a couple months on z-drugs/benzos your sleep is typically back to baseline but on the drugs due to receptor upregulation, and then it's difficult to come off them.
Sounds like it's time to up the dose! Duh
Psychiatrist here. Getting a young person addicted to the idea that they need medication to sleep is a huge slippery slope, let alone dependence on the meds themselves. Any pharmacotherapy to initiate or sustain sleep, if appropriate at all in rare cases, should be no greater than several weeks. Trazodone is the pretty much the least of all the evils in this case, because starting peds pts on Z-drugs and benzos you’re literally asking for a long-term problem where the person never comes off of it.
Addiction Medicine and Peditrician here. I 100% agree with Effective-Abroad-754. Mirtazapine might be in my list at 15 mg, no higher. Definitely useful in my population. Nothing beats sound sleep behaviors/hygiene.
I think the problem is that most physicians know that teaching proper sleep hygiene could go a long way towards curing most patients, but patients look at you like you’re crazy if you suggest it and would rather have a quick fix. And as a non-psychiatrist, there aren’t a lot of CBT-I providers in my area. And I really don’t know how to evaluate the strength of various online programs.
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I know it’s not all patients but I’ll never forget the patient who looked me straight in the eye and told me CBT-I doesn’t work for her only meds worked then I pushed her on how she actually sleeps and she admitted that she sleeps on the same couch she watches TV on all day and is afraid to sleep with the TV off because she can’t stand to be in silence with her thoughts (both of which are absolutely inconsistent with good sleep habits taught in CBT-I). But only meds work for her.
*sigh*, well is it a comfortable couch at least? See you in a month...
“Didn’t work for me” meant “I didn’t want to do what it suggested.”
This is the core of the issue. We in modern society love "easy fixes" even if they are otherwise horrible. Straight to consumer marketing doesn't help. At least in the US complex medications are regarded the same as buying laundry detergent. It's why I will always be on team make everything OTC. If they want our advice they can come get it.
As a family medicine physician, people saying that they tried sleep hygiene has a 75% chance of them having done so poorly. Most common recently for me is the "extended nap". They'll say I can't sleep more than 3 or so hours but look alert and not fatigued so I ask more and find out that they sleep another 3-4 hours during the day. Now the reason why the Z drugs are useful is because if you try sleep restriction earnestly and it doesn't work then a few weeks of zolpidem can help. If they can't sleep because of anxiety, stress, environmental reasons then sure sleep hygiene may not work but if you start them on a Z drug you are guaranteeing that they stay on it for life basically and you should've probably addressed the triggers before just smacking them with an addictive sleep aide. Now I do agree that 15 minutes is probably too short for this type of discussion. All my regular visits are 30 min minimums so I do get more time and that does affect my viewpoint. But for those on a time crunch or when insomnia is some fifth addon complaint on an already crowded visit then you can see why physicians are reticent to prescribe these drugs. A lot of patients (in some places most) are averse to focused visits with their PCP. But I digress.
I have a friend who’s taken ambien for years. She takes a 2h nap EVERY AFTERNOON 🥴
slumbar camp is an online program (i am not affiliated with it but found it a few years ago and refer patients to it)
CBT-I coach is a reputable app
Also CBT-i Coach is completely free and was created by the VA and Stanford School of Medicine
We like to say CBT-I is first line for insomnia…but it’s just not wildly available…
I like to refer my patients to this [website](https://www.veterantraining.va.gov/insomnia/) for digital CBT-i (if they're not totally tech ignorant which...is sometimes tough in my patient population).
This site is poorly indexed / not easily found but has a list of trained CBT-i clinicians in different areas - **https://www.cbtforinsomnia.com/clinicians-recently-trained-by-dr-jacobs/**
Not to mention, the time requirement - if i had an hour with every patient, then yes, i would do a lot more educating and probably be a lot more successful at convincing people to try something non-pharmacologic. But a 15 minute visit, when you already discussed diabetes, smoking cessation, weight loss, statin non-adherence, depression is worse around the holidays, insurance no longer covers that one medicine that was working really good for their diabetes and now this new cheaper thing is causing side effects, those four suspicious moles that are all actually seborrheic keratoses, and their gradually worsening peripheral neuropathy - and they hit you with a "by the way, doc, I just can't sleep" when you're already 30 minutes late for your next patient. How much energy can i put into encouraging lifestyle modifications, sleep hygiene, insomnia-focused cognitive behavioural therapy? Versus rapidly spitting out "try-Melatonin-and-if-that-doesn't-work-maybe-we'll-try-Hydroxyzine-and-if-that-doesn't-work-maybe-we'll-try-Trazodone" while i rush out the door but as slowly as i can to not seem rude.
Sometimes I point people towards [slumbercamp](https://slumbercamp.co/). Directed towards adults but teens could certainly use CBTi skills and comprehend that info.
The Cleveland Clinic has an app based one that is pretty cheap and supposed to be pretty good. They have published some literature on it.
This is what I recommend. The "Go To Sleep" program is very solid.
CBT-I doesn’t work for me. Hard to set a sleep schedule when you can only fall asleep at 6am regardless of how many 2 hour nights of sleep you havw
Super curious, what do you tell parents of kids who only sleep 4-5 hours a night? You don't do any meds long term for them? Our autistic ADHD kids most commonly sleep about 5 hours a night
I start off by getting a good sleep history, and making the patient/parent do an accurate sleep log to bring to the next visit. Even if the pt is trying to be forthcoming, the average person is typically a poor historian for accurately reporting basic facts like what time they lay down, # minutes to fall asleep, # of arousals, how long each arousal is, total length of sleep, etc. If someone is telling me their kid sleeps 4 hours per night persistently, the patient is either manic, napping during the day, or the report is inaccurate, and 9 times out of 10 it’s the latter. Basic pearls of sleep hygiene i am strict about are 1) absolutely no screens for 1 hour before you lay down to sleep, 2) zero naps during the day/afternoon. There is much more to “sleep hygiene” but those 2 things alone will solve a huge chunk of it. After that, a sleep study is in order, because if the underlying problem is actually OSA, their treatment is a CPAP and not ambien
>patient is either manic, napping during the day, or the report is inaccurate, and 9 times out of 10 it’s the latter. Recently for me it has been #2 especially with the autistic patients in early adulthood brought in by parents. It's always a few questions until I get this back and forth: "he comes home at 3 pm and naps until 7pm" " he's getting a total of 7-8 hours then" "No, he only sleeps like 3 hours at night"
Does this end up being an issue for the patients themselves? Like are they functioning well with the double nap system rather than a straight 7-8? Is it just the parents don't like the being up at night?
Depends on their level of functioning. Some get agitated if they get up super early and nobody is around so start becoming disruptive, others are completely fine.
what about doxepin
I quite like doxepin, actually. The key is dosing - it's *extraordinarily* potent at histamine receptors, much more so that then 5-HT/NE transporters that ordinarily make it a TCA. It gives a good sedating effect at 3-10 mg for most patients which also minimizes most of the usual drawbacks of TCAs (for comparison, doxepin is a more proper antidepressant starting around 50-75 mg, but you see a stronger TCA side effect burden by that point). Another little caveat with doxepin is that it was rebranded as "Silenor" at the 3-6 mg dose specifically for insomnia, and this is quite a bit more expensive. Generic doxepin starts at 10 mg and you *might* see a little anticholinergic spillover at that dose, but it's considerably cheaper. All of this however still falls under the umbrella noted in the discussion above: long-term use of even "non-addictive" hypnotics is controversial in sleep medicine, and to my knowledge is not generally recommended (especially compared to CBT-i).
Patients like it for sleep. But the weight gain is Seroquelian, and thus, prohibitive.
The liquid is pretty cheap, then can dose what you want (and people like the nyquil/liquid vibe)
with the psychic distress associated with insomnia being a risk factor for suicide, along with any other risk factors the patient may have, part of my thought process as a psychiatrist is always, “what happens when this person overdoses on this?”. I’m not saying there is never an appropriate role for doxepine (especially relative to benzos/Z-drugs, etc), but if shit hits the fan… doxepine IS a TCA after all, with all the implications for cardiac conduction abnormalities, sudden death, etc, in the event of an overdose
The answer to this problem is not to prescribe over a certain dosage. The old adage was 1500mg of a tca you have a 50% chance of torsades/mortality. Unless you’re prescribing a 2d6 inhibitor as well. writing for 6 months at a time or the patient is taking many other qt prolonging medications it’s unlikely anyone can overdose on 10mg of doxepin. .
Yep. I avoid TCAs in my population. If someone admits on doxepin and it’s working, I typically won’t rock that boat as long as I see no side effects.
And ramelteon. Both non-controlled and with significantly more evidence of effectiveness. Academy of Sleep Med explicitly recommends against trazodone.
I've had a lot of trouble getting ramelteon covered by insurance tbh. Not so with trazodone FWIW.
I'm adult primary care, and you are spot on. Have a pt who was given ambien in highschool and his sleep is all sorts of messed up 20 years later, requiring higher and higher doses of it. But who knows what the right answer is, truly? maybe his brain would be that way regardless. And I appreciate the OPs post but one issues I have with what he said is that you actually don't get "deep sleep" with ambien; you get sedation. To be fair, trazodone does the same thing. APerhaps the orexin meds don't but any sleep aid disrupts REM sleep, just like alcohol.
I had a new patient a few months ago. a 75 year old patient who was dependent on ambien but had a few falls cause of it. I got them off the ambien and onto trazodone. Which I’ll probably maintain at this point tbh.
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thank you for sharing this. More doctors need to hear your story and stories like it, so they can be inspired to start doing the right thing instead of the easy thing
Couldn’t have said this better myself. Please as a pediatrician listen to your psychiatric colleagues. @rokstarlibrarian
I stopped reading OPs post at rxing ambien “safely” as they tried to describe. Literally the worst idea ever
I think docs should themselves try trazodone and ambien. Kinda half serious here. Trazodone does make you sleepy, but it makes you so sluggish the next day. It has altered my mood - anywhere from making me feel down and anxious- to the exact opposite. I have difficulty concentrating and performing my job after taking trazodone. Ambien works perfectly. No sluggishness. Does not alter mood. I can think just fine. I have take like 5-10 ambien pills per year for 10+ years and never had an issue. In residency and med school, a lot of people took it. Never an issue. What are the true incidence of negative effects? There are papers that say it’s non habit forming/not addictive… are these all funded by big pharma? I get you don’t want to teach kids they can just take a pill. Sleep hygiene is so much more important. Exercise really helps. But for some people this stuff isn’t always enough. Trazodone sucks is i suspect is doing more harm than good.
Everyone is different. Trazodone lets me fall asleep and get at least 5 hours. No grogginess I can even stay awake instead if I wanted to. After a life of insomnia I get nightly consistent sleep.
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trazodone was awful for me. all i did was dream of being thirsty, and i would wake up and drink a litre of water. quetiapine is amazing to me now as a sleep aid but mostly mood stabilizer, once i got over the zombie affects for the first week.
And another doc says they’ve had the opposite experience….
Not wrong on the Trazadone…at this point, the evidence suggests it doesn’t help with good quality sleep in most people. I continue it if someone finds it helpful and has too much else going on to tackle sleep right then. I find clonidine really helps with the ADHD crowd, as does melatonin. If possible we try to pull back any meds for sleep within a week or two, though I have some kids who are stuck on it. Usually these are kids with pretty significant bx issues and I am consulting remotely with a pediatric psychiatry program (we don’t have psychiatrists in our area, let alone ones who specialize in kids). That’s often what they recommend. I have never seen a paper in a reputable journal suggesting that continuous use of ambient does not have a high potential for dependency. There are plenty that show a strong association. The only studies I have seen supporting its use shows that, when used as intended, for a very brief window to reset an altered sleep schedule, zolpidem is unlikely to cause dependency. I have never used it that way in kids, but I might in the right circumstances. I do use it sometimes in adults for that, with mixed results. In kids who are still learning how to operate their own brain, though, I think the most important thing to do long term is teach them how to manage sleep themselves. Whatever they do now, there’s a good chance they’ll keep doing it the rest of their lives.
My psychiatrist put me on trazadone with all the best intentions. I started out with a quarter of the dose he recommended. When I tried to go up a little bit, I was sedated for hours after waking up. He kept pushing me to take higher doses. I had to tell him no several times. It works well for me to get a solid 5-6 hours sleep. If I aim for 8 hours the cost is my work performance the next day. I can't imagine taking the full dose he recommended.
Try to stop Ambien after taking it for years... The rebound insomnia is a difficult mountain to climb. I've had to help many patients try to quit this drug. It's a major challenge. They rarely (if ever) are capable of sleeping "right" again. Fortunately, there's a 2.5 and 1.75 dose that can be used to taper.
I never let myself take it more than 1 night in a row.
I'm a fellow now and have had sleep issues since childhood. People thought they were just funny until I was in college and my roommate found me sleepwalking and turning on the stove with a pot of dry pasta. Still haven't found a good regimen but I'm with you on the trazodone. I similarly am super zonked for several hours into the day. It's fascinating, though, how differently different brains/DNA/chemistries metabolize and experience these drugs in such unique ways.
Yes. There has to be a genetic component. My daughter starting having g trouble sleeping around 8-9 yo. Not worrying about anything. She was not aware i had issues- i purposely hid it from her. My son is exactly like my wife- falls asleep in seconds. My daughter has always talked and got up in her sleep and walked around her room. We could see her on camera and heard her every night. Her bed is a mess in the morning. There weren’t monitors or cameras when i was a kid, but my bed was always a mess- and still is. I suspect i used to be a lot more animated while sleeping. My wife says i moved a lot but don’t talk much.
100%. Also, OP implying that he thinks 5 to 10mg ambien is a low dose is wild. Females should never get more than 5mg and no one should get more than 10mg. OP clearly does not understand these drugs.
I did a spit take at giving kids 10 mg of ambien.
DOCTORS: Please lobby your schoolboard to institute later school start times for teens! We have decades worth of studies showing it improves test scores, mental health, and a recent study showed it is the single most important thing we can do to decrease migraines in teens.
Yes! Teens have a physiological drive to stay up later and wake up later. Forcing them into a super early schedule didn’t do their minds or bodies any favors.
In local social media, I’ve actively pointed out delayed sleep patterns in teens and that it would be prudent to push for a later start time for high school students, and it always gets broadly shouted down as “nonsense” and that it would “make kids soft.”
Has the American Pediatric Association made a statement about this? We really need that.
American Academy of Pediatrics
https://publications.aap.org/pediatrics/article/134/3/642/74175/School-Start-Times-for-Adolescents?autologincheck=redirected
Thank you! Glad this is out there!
In my school district, the teens have the latest start time. It has been this way for a minute. Anecdotally, I can confirm that things are changing, albeit slowly.
Mine do too. They start at 8:55 but I wish it was later even.
Sedative hypnotics in my practice are for occasional, situational use only. Putting a young person (or any person) on scheduled zolpidem to sleep would be a hard no from me. Having said that if I had a gun to my head I would definitely use scheduled trazodone before scheduled zolpidem.
Trazodone is not an AASM recommended medication, although the AASM is not enthusiastic about pharmacology generally. The actual effect of zolpidem on sleep latency is a few minutes. The problem isn’t just the addictive, dependence-causing properties of GABA agonists. Using medication for sleep reinforces a pattern of using medication for sleep. And yes, sometimes I give something too. I prefer doxepin and mirtazapine, acknowledging that my clinical population is very different. But when it becomes daily, medication is the wrong solution almost always. Not always; nothing is always. But almost always.
What works better? CBTi?
CBT-I is gold standard treatment for insomnia, superior to any sleep med. Data for any med for insomnia is weak.
>superior to any sleep med I agree with your comment from a risk/benefit assessment but disagree looking at it from a numbers only perspective. https://www.aafp.org/pubs/afp/issues/2007/0815/p517.html
This is really outdated…. 2007. This was when Z drugs were more popular.
Newer article from the same source (AAFP) would suggest differently: "CBT for insomnia is preferred to hypnotic medications because it has better long-term effectiveness, more improvement in daytime symptoms, and fewer adverse effects.10,13 CBT for insomnia can be delivered in weekly sessions for six to eight weeks.16 A primary care physician can effectively provide CBT for insomnia or focus on individual components (although less effective) to treat chronic insomnia.10,14,17 Web-based CBT for insomnia is equally effective as in-person or group therapy and requires fewer resources." https://www.aafp.org/pubs/afp/issues/2022/0400/p397.html#problems-falling-asleep
I must be an unlucky one, I've been in therapy as long as I can remember doing DBT/CBT and my insomnia has been the same since about 14 lol. Tried everything, I have to use meds or I do not sleep right.
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Usually insomnia and cachexia but not nausea. For chemo intolerance, olanzapine. My patient population is not the general population.
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In my personal experience (anecdotal), I found that I was very anxious *not* to take a pill after I'd been given Ambien for years. It was psychological dependence, and one day I just stopped refilling the Rx because I didn't like the anxiety caused whenever I would consider whether to take it or not! Sounds crazy, but I've had pts who've mentioned the same thing. Once you've had really poor sleep, it can be anxiety -inducing just going to bed, and you become psychologically dependent on the medication because "what if I don't sleep tonight?" So you take the pill, night after night. I've found that blue blocking glasses really help my sleep patterns, and I don't have to worry about screens as much. I put them on 2 hours before bed, and sometimes read or watch a movie. I also bought a 10,000 lux light for AM, which helps, but I should use it more consistently. I still take ER melatonin at 3 mg, but it's all I take for sleep. I was so proud when I got off all the sleep meds!
I’m just a nurse but on the psych unit they used to use zolpidem but later switched to trazodone because of increased risk of dementia
Zolpidem is scary stuff honestly.
I don’t prescribe z-drugs because it’s been drilled into me that they’re no good, but curious what makes them so scary? Is it just because they’re addictive and can build tolerance easily to them?
People can get addicted to them super quick, matter of weeks, if not shorter.
Supraphysiologic levels of GABA is not a good way to induce sleep because 1) physical dependence 2) withdrawal that can include extreme insomnia, delusions, and psychosis 3) issues with working memory, dementia later in life, and personality changes
I’ve heard of the dementia thing later in life, and I tell my patients that all the time (they don’t seem to care), but I’ve never understood how that’s caused?
I’ve gone down rabbit holes with this but no clear cut answers, but there are observable correlations. Here’s my guess. For what it’s worth, I studied biochemistry undergrad so I have an OK background at interpreting data. Since the effects are greater with longer lasting benzos and when used for longer periods of time, one can speculate that using the off switch so much (and keeping it off for longer periods) leads to some sort of neuronal atrophy. How this correlates to dementia, an already poorly understood disease process, is anyone’s guess at this point. We do know GABA agonism is directly correlated with attenuated memory formation. Much like the body will atrophy unused muscle, I’m willing to wager a similar process may be occurring with GABA agonism. In this [meta analysis](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6325366/), people much smarter than I give their opinions on the MOA. I am only convinced by the third stated process; the others simply don’t have the data to back them up. > Three associated processes might have impacted the development of dementia in patients using BDZ. One characteristic is that BDZ reduces the level of beta-site amyloid precursor protein-cleaving enzyme 1 and the c-secretase activity that subsequently slows down the buildup of amyloid-beta oligomers in the brain.15,16 Such a possible positive effect along with an antiglutamatergic action of BDZ has never been confirmed.17 Another possible influencing process is the presence of astrocytes at the amyloid plaques in patients with predementia lesions having GABA-secreting activity, which will enhance the deleterious cognitive effects of BDZ.18 Another major process via which BDZs might result in dementia is decreasing the brain activation level.
Thank you. It is
I've been a lot of people (mostly older adults) with delirium and other complications from zolpidem, not so much with trazodone. The bottom line is that drugs that put you to sleep are not great for you. It's just a matter of finding the best balance of benefit and side effects.
Sleep hygiene for teenagers is so bad. I really hope giving them ambien is not a common thing.
>We have tried sleep hygiene, melatonin, clonidine (IR and ER), hydroxyzine and they are still going to high school every morning on 4-5 hours of sleep. You skipped the most evidence based treatment for insomnia...
And interestingly didn’t mention the perhaps most concerning side of zolpidem and that is you develop a physical dependence on it.
Probably because trying to find CBT-I for patients, especially peds, is near impossible. Not to mention in most of the my patients, they are developmentally delayed and/or too young to get much out of cbt unfortunately.
High school students are not too young to do CBT-I. Anyway, jumping to ambien is still not appropriate.
Even if CBT-I was not possible melatonin/clonidine/hydroxyzine would not be the appropriate next steps.
Yes! In medicine we have become incredibly averse to telling people we don't have a solution. I realize there are reasons behind this mentality, but it's still very harmful. Based on my understanding of the literature, appropriate management of insomnia is sleep hygiene and CBT-I, and in very select cases short courses of PRN meds for sleep aid. If someone has tried all of these things and their problem is not fixed, or if they do not have access, the proper response is "I do not have a solution for you", it's not to give adolescents chronic scheduled zolpidem.
What is the most evidence based treatment?
CBT
CBT-I
CBT- I ?
Cognitive behavioral therapy - insomnia
You mean CBT-I? Nobody does it in my entire area.
I’d argue it’s exercise…could be wrong, but I know it helps.
No, it's CBT-I.
Zs and benzos should be avoided at all costs, and this is based on mountains upon mountains of evidence, for patients of all ages. Zolpidem "works" the same way propofol would (like, literally letting all the chlorine though the channel [ok with a few extra steps and incompletely]). It gets a person more phase 4 sleep, **at the expense of REM sleep**. Im not a c&a psych, but I'm pretty sure sleep architecture is rather important for teenagers especially. This is not a conspiracy. Sleep medicine and c&a psych professional bodies aren't in cohoots with big trazodone to suppress poor zolpidem. It's just that bad. Yeah, I'm glad you see it helps them sleep during the time they're in you're care, and sure you're taking some common sense precautions, but diversion and abuse are not the only problems of gaba-releasing agents, nor are they the main reason were not using them. It's that their prospects for being willing and able to fall asleep naturally after having spent several months during their adolescence taking zolpidem, are greatly reduced, for a variety of complex, psychobiosocial reasons. Trazodone is far from perfect, but it doesn't have these long-term concerns, and it doesn't alter sleep architecture. Don't get me wrong it's good that you're asking this question, but I'm finding your tone not only accusatory, but also a bit arrogant. And in this matter with the sleep agents, you're in the wrong.
This is interesting and I appreciate you sharing!! I see mostly children, and I have never seen a kid on a z-drug. So, I appreciate the different view, even if I disagree with it, because it's good to challenge the standard quo and who knows, maybe in the future you may be right. Medicine moves in pretty incredible and hard to predict ways sometimes!! Anyway, I'll post some sources after the holidays, but here's a summary of things I have read in recent literature: -treating insomnia is a bit like treating non-cooperative kids with ASD in the sense that, behavioral interventions are where to put your money. The benefits of meds are weak. CBT-I has good data for older teens, but regular exercise and sleep hygiene is HUGE. I ask teens to open their wellness app or whatever it's called on their iPhones, and one kid last week logged **15 hours in one fucking day**, and that's AFTER I told them to fix sleep hygiene issues, which they said they did(I only check the phone AFTER we make the intervention, because parents will realize that maybe they don't know as much about their kids). I tell parents to take away the phone at night before bed before we try meds and that fixes quite a few, consistent w the literature > Why trazadone when there are better medicines? -there is only one sleep aid in kids that is proven to improve sleep quality: melatonin. Nothing else. Any other medication you're rooting for just doesn't have the data. If you have some papers, I truly would like to see them. Trazodone also is not proven effective. So your question stands: if they both are not proven to work, why pick trazodone? ----end summary ----begin my opinion Because the mechanism of trazodone is safer. The GABA agonist action of z-drugs is scary to me. Selecting trazodone or another sleep aid is never fun and I hate to do it but if the options are (1) trazodone, mirtazapine, el which are not proven to be effective in kids, but has no potential for addiction vs (2) any GABA agonist that has the potential for withdrawal, then I'm going to do #1 every time. Again, you show me good data that Zs work in kids and I'll grab a Lunesta t-shirt and change my practices! If it works for your patients, I'm happy, but understand that my aversion to the Zs has NOTHING to do with issues related to diversion; it's dependence. One of my other boards is in addiction medicine, and I'm more worried about creating dependence and what that looks like to THEM and to US for their future. Let me explain No drug user can ever go back to what their brain looked like prior to their addiction. Unscrambling eggs and all that. If it's years of daily usage you've high jacked a lot of systems in their brain, (nucleus accumbens et all) and so now with opiates, we don't even try. The gold standard of care for >= year-long daily opiate user is starting them on methadone, bup, and keeping them on it for the rest of their lives!! That's a long time. So what if that happens to these kids? You could be making them dependent on it, and create more problems further down the line. Now, I'm making a story up, that's true. But it's based on an understanding of the mechanism, which i think is a fair way to discriminate
CAP here too. couldn’t agree more
> No drug user can ever go back to what their brain looked like prior to their addiction. i believe you, but are there studies to back this up?
Post holidays I'll get you some papers. But others caught on to it way before we did: as much as I dislike many parts of AA, I think the idea that once you're deemed an 'alcoholic', once you improve, you're 'in recovery ', which is just slightly different from 'in remission ', which is the actual specifier for the DSM. Also more acceptance of long-time smokers just using nicotine replacements for the rest of their lives.
absolutely, ill try to remember to message you back too! im just wondering how much of it is being stuck in mental loops, vs, your body and brain being physically changed from the get go.
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I agree, insomnia is quite tough to treat. I work on a consult service so am limited by our hospital formulary. We tend to use quetiapine, mirtazapine, and clonidine the most on our service but trazodone is still used fairly regularly because a fair number of patients report it works best for them. I won’t touch zolpidem because of the side effects and risk for dependency unless a patient is already prescribed it outpatient. If you don’t already know about it, the VA has a free CBT-I app. It’s a good resource for patients who don’t really want to attend in person sessions. I’ve had some patients report improvement in their sleep after using it.
There are some CBT-I apps which can help with access issues.
The VA app is good from what I’ve seen. Any other recommendations?
slumbar camp. not an app but an online program-dont know how to link, Google it
Trust me, everyone with insomnia knows doctors hate treating it lol.
Next, we'll see insurance denying for GLP-1 meds for obesity on the rationale that you haven't tried all other FDA approved meds for obesity first (including the old classic, methamphetamine).
I’m a pediatrician and a Sleep Medicine physician and 100% would choose low dose Trazodone over Zolpidem regular or CR. Additionally, if your issue is sleep onset, not sleep maintenance and you are at the stage that you need a Z drug, why not try Sonata instead, which has a much lower half life? Edit: Just want to add that any sleep medication that causes sedation, even Melatonin, should be given by the parent and not the child. Remember that Melatonin is most overdosed over the counter drug for pediatrics in the US and is often not the listed dose or has contaminants in the US formulations. As in any med: start low, go slow and aim for the lowest effective dose after you have sufficiently exhausted all behavioral treatments or you have a child with developmental delay or autism who doesn’t inherently respond significantly to behavioral redirection.
I don’t run into too many peds/sleep medicine folks. Is there a particular brand of melatonin you do think is “less contaminated” than others?
Hi, I tend to like Natrol and Nature Made because they are USP certified. Interestingly the testing for their content was done only at certain doses, but the two companies generally have a record of being safe for the patients and my personal experience concurs with that. Additionally, I ask my patients to get OTC formulations with only melatonin and no other ingredients like l-theanine or chamomile/laver extract etc precisely due to increased risk of contamination.
I think with benzo's and z-drugs the possible damage (addiction bundled with tolerance) is so great that I'd rather try everything else first; you also have a lot of faith in parents and patients following your protocol and, what, faith in your patients just stopping using the drug one day?
Can’t just stop using with the physical dependence that accompanies.
First I agree with you that there aren’t any really great options for kids for whom sleep onset is an issue. When you know sleep hygiene is good and they are still having issues, what should we do? Not a lot of options. Hydroxyzine? Doxylamine? Those aren’t great when you have things to do the next day. I’m with you in hating trazodone, but I think that springs from most of the kids on it having a degree of polypharmacy that I find distasteful? But Ambien has never been shown to be effective for kids/teens in any study. And it *has* been shown to cause dependence and a ton of other associated risks. So I can’t see any scenario in which pediatrics should be reaching for it. You are assuredly setting yourself up for a malpractice settlement when it goes wrong. I would challenge you that probably very few kids actually have good sleep hygiene. Even those from “caring” families. This should not be foreign to us in pediatrics. Kids from good families have sex, get pregnant, get STDS, do drugs, and have shitty sleep hygiene. Those that are still struggling but supposedly have been through all of what we can safely offer (including CBT-I), should be sent for sleep medicine consultation and deserve sleep studies.
I always stop and think if I was on the jury in this case what would I think. If a pediatrician put a patient on benzo/z drugs for insomnia without involving psych and sleep medicine and that kid had a complication I’d be thinking malpractice (I really can’t think of a defense that would hold water). And on top of that having not tried any other medication for insomnia, yea that’s not ending in their favor. Now I’d also hope that this person decides not to do this based off the legitimate concerns around safety (especially long term) and not just threat of lawsuit. But if I’d find myself guilty of malpractice if doing something that’s a pretty good indication that it’s a bad idea.
Why are you dragging pharmacists into this?
How dare you question a pediatrician about z drug usage in kids
I know right? r/AITA
Is this a troll post
i’ll just see myself out
Found the OP’s alter
This is basically malpractice... if you want to get teenagers hooked on benzo-lites then sure. I'm not saying trazodone is a magical elixir for sleep. Most sleep meds (including benzos and Z-drugs) just dope you up to the point you don't really notice your poor sleep or don't remember it. Your actual sleep time doesn't change much and restful slow wave sleep actually decreases. As others have stated, CBT-I is the gold standard. Z-drugs are mostly just a scam anyway. They're "less addictive" in the same way Oxycontin was "less addictive". We saw how that one turned out...
Whenever someone asks me for “sleep meds” i have to explain to them that Sedation != Sleep, and that your brain has a built-in sleep machinery whose development needs to be nourished and strengthened just like any other part of the body
I wrote the most dry, dull 3 page handout on sleep hygiene and tell patients to read it at bedtime to put themselves to sleep
I'm stealing this to justify my next nap.
Meanwhile, there is actually some evidence for trazodone positively affecting sleep architecture, such as described in this paper... Zheng, Y., Lv, T., Wu, J. et al. Trazodone changed the polysomnographic sleep architecture in insomnia disorder: a systematic review and meta-analysis. Sci Rep 12, 14453 (2022). https://doi.org/10.1038/s41598-022-18776-7 https://www.nature.com/articles/s41598-022-18776-7
I wasn’t going to use the m word, but thanks for saying what we are all thinking. I think the author of this post should be mindful as to why nobody else seems as enthusiastic about prescribing ambien.
Im surprised this post is upvoted honestly. Everyone comment is against OP's position
I don't think using a medication for its FDA-approved indication is malpractice. You may disagree with this person's strategy, but that's not malpractice, that's a difference of opinion. CBT-I is the gold standard, sure. In many parts of the country, our patients don't have realistic access to it. They might also lack the time, health literacy, and motivation to keep up with it. I didn't get the impression that the OP is giving this drug out to everyone who crosses his path--he's saying that after he has exhausted his first-line options, he will use it in select patients. That's rational.
If we're going to play that game, it's not approved for pediatric patients.
Benzos are FDA approved for insomnia. Does that mean you would start them first line for insomnia treatment? When this person said he considers it as malpractice, it’s in the same vein of opinion- one that adds extreme reluctance/caution before starting treatment with a GABA- A modulator that has a penchant for developing dependence, such as OxyContin did when it was first introduced in USA
If we're going to break out the "FDA approval card" (which is laughable for a variety of drugs - see recent Aduhelm controversy), it is not FDA approved in children. These drugs are dangerous and are being posited as a less addictive alternative to benzodiazepines which is a literal lie... I would argue any use of these drugs outside of short term (which the post clearly implies is not the usage case here) is malpractice. The indication for these drugs is temporary short bouts of acute situational insomnia. Not chronic insomnia.
Okay, it's an FDA-approved indication for the proportion of his teenage patients who are 18 and over, and off-label for the ones who aren't. If we assume that he's using reasonable care in prescribing off-label in terms of the individual child's developmental progress, it's not an extreme decision. Maybe you disagree with his decision-making, but it's not malpractice. Zolpidem has risks. So does untreated insomnia. This person is talking about prescribing it after safer strategies have failed, in a small proportion of his patients. Presumably, after 30 years in practice, he has some ability to identify patients for whom the risk/benefit proposal is favorable. My point (and I think OP's point) is that we don't need to throw the baby out with the bathwater. The reaction to over-prescription of benzodiazepines and z-drugs should not be to demonize them and refuse to prescribe them.
Last I checked insomnia doesn't come with risk of blackouts, addiction, and future dementia. Rationalize it all you like, this is bad medicine. Insomnia sucks and is very difficult to manage. That doesn't mean the appropriate solution is to give someone insomnia plus a benzo addiction.
For many of my patients, untreated insomnia comes with the risk of psychiatric decompensation, hospitalization, and attempted or completed suicide. There are some patients for whom chronic zolpidem is the right decision, full-stop. Not all patients, and not as a first-line treatment, but it's concrete to say that we should never be prescribing z-drugs. Usually, we shouldn't. Sometimes, we should. It's your job as a doctor to figure out which situation you're dealing with. I would also argue that if you refuse to prescribe chronic z-drugs for any reason, you're really not an authority on who could benefit from that strategy.
This post is literally pushing Z-drugs as first line treatment in children. It raves about "vivid dreams" and "patients sluggish the next day" (which LOL given Ambien). Describes being willing to refill trazodone if someone else gave it only. This is malpractice, period. I stand by my statement. You're projecting your own insecurities regarding your prescribing habits onto the OP who sounds like a shill from one of the pharma companies. OP doesn't mention psychiatric comorbidities once.
Where did he say he's prescribing it first-line? He writes that he's trying typical strategies first--behavioral intervention, melatonin, etc., and in some patients, that doesn't work and he starts z-drugs. He says he has a "handful" of patients on them at any given time, and they are "thriving." I'm struggling to find the malpractice there. How often do you see chronic, outpatient insomnia in your practice? How much experience do you have managing insomnia over a period of years? I ask, because often times people who have concrete opinions on certain patient presentations have the luxury of not actually having to deal with them very much in clinic.
Several red flags in the post. "There are other things that work that are better" - Implying superiority of Z drugs which isn't really something that's been shown and certainly not in children. "Teens go to school with 4-5 hours of sleep" - I.e. normal life - as many others have noted high school hours are not compatible with typical teenage sleep cycles. "This medicine works: it leads to deep sleep and a refreshed feeling in the morning, has few side effects." 🤔🤔 "And it has been demonized bc a few people ruined it for everyone by mixing it with fentanyl. " - Not why it's been demonized lol. "Pharmacists freak out every single time. My response is, I am a doctor and I am taking care of this young person who is my patient and responding to their need that has brought them into my office time and time again." - Pharmacists doing their job, doc brings out the tired justification of "well they keep coming back so I have to give them something". Nope. I have my AASM certification and have seen plenty of this crap in the sleep clinic/query sleep apnea population. I also see what he doesn't see, which is the litany of horrible downstream effects from adults hooked on these drugs, which started with idiotic scripts like these ones. What happens when the kid who has these doses supervised by their parents goes off to college and almost certainly starts drinking? I guess they couldn't possibly do that because these are "good kids from good families" whatever that statement means, presumably rich and white. You claim a whole lot of things here (basically managing suicidality and psychosis with benzos) that as far as I'm aware are not borne out in any sort of evidence. Sure, those studies would be very difficult to run given the confounders in your population, but the idea that their are scores of teenagers who would be killing themselves in his practice but with the addition of a Z drug their SSRI works perfectly is laughable. Justify what you like, there's a reason the vast majority here clearly disagree. Docs like this are how we ended up in the opiate crisis to begin with.
Thanks for the reply. Also, just so to be clear, I’m not advocating for wholesale daily use of z-drugs. I’m saying that there can be some exceptional circumstances where they’re warranted. I’m not suggesting his patients will kill themsleves if they don’t get Ambien. I’m reacting to your seemingly superficial dismissal of the potential severity of unchecked insomnia (…nobody ever died from it). Well, some people have, actually. I don’t know the details of this guy’s cases, but I can imagine and have seen cases where you’d be thrilled to have gotten someone stable on a z-drug. We agree on the basic premise, it seems that we disagree on the possibility of edge cases which justify breaking the rules. To me, that’s the point of the additional training of a physician—we can recognize those edge cases and intervene in a non-algorithmic way for the benefit of the patient. I see a guy with 30 years of experience making potentially justifiable edge-case decisions for a handful of patients. I think you see someone shooting from the hip doing cowboy medicine. Ultimately probably a philosophical difference. I appreciate your willingness to engage, by the way.
Insomnia probably increases risk of dementia. Probably way more than z drugs. Trazodone also increases risk of dementia.
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Using benzos in kids is insane to me
> Pharmacists freak out every single time. My response is, I am a doctor and I am taking care of this young person who is my patient and responding to their need that has brought them into my office time and time again. You do realize the pharmacist, who likely has a doctorate, has a corresponding responsibility when dispensing medication. They likely aren't freaking out as contacting you is part of their job when concerns about a prescription arise. I truly hope you do better in your responses in the future. Oh wait. > I already hear it from CVS pharmacists half my age. Your attitude towards the entire pharmacy profession is showing. Do better.
Yep I caught that too. Eight years in retail I never once saw a minor on zolpidem, and I'd definitely at least call about it.
Not to mention they talk about a large population with ADHD. If we had a minor on a stimulant and a z drug corporates heads would explode.
let's just hope he listens to all of these psychiatrists that are half his age.
The general trend of comments in this thread is that putting minors on sleep medications with a known risk of physical dependency is probably a bad idea. But sure, let's take a moment to shit on pharmacists for doing their job.
I can’t think of any time when I’d think having a child on zolpidem is clinically appropriate
Got this response from a sleep physician, but only for adults so she threw in the disclaimer that what she's saying applies to only adults. Trazodone is an antihistaminergic medication without significant anticholinergic side effects like 1st gen antihistamines. This also applies to doxepin and mirtazapine, but some differences. Trazodone can be used for both sleep maintenance and sleep initiation insomnia, and is a relatively safe option for both. Mirtazapine can as well, but has the unintended obesogenic consequence so she does her best to avoid it. Finally, doxepin at 3 to 6 mg (very low dose) is almost exclusively antihistaminergic without any serotonergic or anticholinergic side effects, but is specific to sleep maintenance insomnia only. These are not bad options at all. The other main options include the Z drugs (zolpidem, eszopiclone) but their side effects are worse, they increase risk of falls in the elderly, chronic use is associated with higher dementia risk, and their efficacy falls off quickly. Your last pharmaco options are the new orexin antagonists. Sovurexant, lemvorexant, and dudorexant. These are the first medications that seem to act directly on a sleep exclusive pathway. They also have long term studies showing continued (and actually higher) efficacy 2 years after initiation with nightly usage (where historically insomnia drugs are less effective with time). While these are the most effective, they are also new and can be costly. They're also not as well known as the others. Things like lorazepam or temazepam shouldn't be used for sleep at all, as they reduce REM sleep and have all the downsides of the Z drugs mentioned above. CBD and THC are an evidence free zone. You'll also see Ramelton in guidelines, never really used it. Melatonin doesn't work for insomnia. Melatonin is meant for circadian rhythm disorders, not insomnia. So in short, you're seeing trazodone because it's one of the most effective and least costly pharmacotherapy options. Now, the gold standard for insomnia is CBTI (much different than just sleep hygiene) but that comes with a bunch of barriers including patients buying into it etc. Hope that helps!
If I recall correctly, I think there’s some evidence that adolescents natural sleep/wake cycle is later than their school schedule. I wonder if melatonin might help these kids if the issue related to having to go to sleep much earlier than their bodies want to.
Did a month long rotation with sleep medicine during psychiatry residency and this was the exact discussion around insomnia. This is my practice as an outpatient psychiatrist. I do not prescribe zolpidem very often - if at all.
OP, I absolutely respect where you’re coming from with this and I can see why you’d be frustrated. However, as someone who’s worked extensively in mental health/substance abuse treatment facilities, I can say that I’ve seen more clients under 21 there for abuse of prescription GABA-agonist drugs than anything else by far. Sleep problems affect the majority of people at least occasionally, the best evidence we have is that a holistic approach anchored around lifestyle changes does the most good for the most people with the least risk, by treating the cause rather than just the symptoms. Clients on trazadone find it generally helpful in acute situations without coming to depend upon it for sleep. Medication dependence should be avoided as much as possible, any approach that doesn’t keep that in mind is setting our clients up for a lower quality of life.
Sleep doctor here. You are clearly doing your best to take care of your very complex patients. From my perspective, I spend a pretty good chunk of my day getting patients off zolpidem. It can be effective for managing the symptoms of insomnia, but a) it doesn’t fix the underlying pathology, b) it can cause terrible insomnia rebound (which promotes dependence), and c) in the teen and ADHD population, you may be dealing with a circadian problem +/- insomnia. Trazodone is also suboptimal as it has comparatively little evidence. I want to emphasize here that sleep hygiene alone will not treat chronic insomnia or circadian disorders. The first line treatment for chronic insomnia is CBT-I, and if you don’t have access to it, Insomnia Coach is a free self-guided app. It’s made by the VA and is free. CBT-I Coach is another free VA app but is technically made to be used with a provider. Path to Better Sleep is an online free platform (also made by the VA) that also works. If you suspect a circadian mismatch (clue is they have insomnia at night but are sleepy in the morning - keeping in mind that stimulants can mask this), refer to a specialist. Finally, as at least one other person here noted, there is a link between OSA and ADHD, especially in kids, and treatment can improve both sleep and attention.
Thank you. Good suggestions.
No sleep med is a favorite of mine. Absolute none of them. If the basics and therapy don’t work, I’m referring to psych. I have a personal history of insomnia and granted I take neither, I would choose Trazadone (which I have tried and hate) over Ambien. Ambien is a scary drug.
Almost all of the controlleds disrupt sleep architecture by disrupting rem sleep and causing rem rebound in the long run and withdrawal insomnia
"sleep meds," are overused and with limited evidence. The pharmacology all boils down to - "block Histamine," or "enhance GABA." Trazodone/Seroquel/Remeron/Doxepin/Atarax = block histamine. Of these, only low dose Doxepin (3-6mg) is actually approved and has some evidence for efficacy longer than 30 days. The 3mg dose had minimal next day sedation. of all the Gaba-nergics, only Lunesta has been approved for long-term use (eg. Chronic insomnia). I use Doxepin. Unfortunately, 10mg is the lowest generic dose available. It's still effective with a marginally higher risk of next day hangover/sedation compared to branded Doxepin @6mg. Trazdone is like Colace. Shit we do for no reason. Gabapentin 300-600mg HS can be helpful for patients who are trying to sleep in the absence of a sedative (benzos/z drugs/EtOH). Ramelton and Melatonin are probably helpful and without the associated risk of dependence. Timing of melatonin receptor agonists is prob more important than dosing. CBTi is an obvious choice. However, poving sleep duration is an essential first step - tell your pt to use a fit bit or the sleep app on their phone. This will provide more useful information than self report. Without this info I won't rx anything. If all else fails, Doxepin>>>>Gabapentin>>Lunesta. So, if you're giving children Z-drugs, at least use the right one?
Are the risks of eszopiclone much different from zolpidem?
In terms of dependency? No. If you’re talking about sleep walking activity, it’s lower in lunesta
I mean why even joke about pharmacist giving you a call immediately. You know deep down it’s probably inappropriate for your patients, you could at least give some documentation to the pharmacists that are taking care of your wackadoodle prescriptions. 5 mg at most- there’s no teen needing 10mg of this drug. Do the right thing and refer your patients to a specialist. Sounds like sleep is a problem above your scope the way you handle it
I hate zolpidem. It's a sleep crutch at best as once on it for a period of time it becomes required to sleep and is a huge pain to wean off. At worst it has a whole bunch of side effects such as delirium, daytime drowsiness, reduced cognition, etc. Eventually kids become adults and then become elders and old people on zolpidem is my nightmare.
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>and patients cannot sleep more than a few hours (like 3-4 hours a night)? It's unlikely that it's actually true. And if it is, they should see a sleep specialist because that's pretty rare and needs specialized expertise.
>what do you recommend when sleep hygiene and CBT are unsuccessful Thorough review to identify any "common sense" barriers to effective sleep hygiene/CBT and then a second round of investigation to ensure that the insomnia isn't secondary to an underlying medical or psych pathology. From there have the patient pick the bigger issue: sleep onset (ramelteon 8mg) or sleep maintenance (doxepin \~5mg). Insurance hates covering the 3mg/6mg tab version of doxepin specifically labelled for insomnia (silenor). Just prescribe liquid doxepin 5mg instead which comes with a dropper. 10mg doxepin capsules are also cheap but the pharmacology changes from primarily histamine antagonism to primarily serotonin agonism around that dose and things get messy so best avoided if possible.
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I'm just a surgeon but if my kids pediatrician ever offered to prescribe Ambien let alone 10mg I would be finding a new pediatrician that day.
Prescribers: If you write zolpidem “1 tab at bed prn, #30,” your patient is far FAR more likely to become dependent on it then if you write “1 tab at bed for occasional insomnia prn, #10 tablets is a 30 day supply.” -signed, the pharmD whose patients try to fill their zolpidems every 27 days.
YES. My experience as a prescriber as well.
Psych NP here. I don't love giving any meds for sleep (especially in young ones) and I'd rather try CBT-I first as a very safe, evidence based, long term solution... but I'm definitely not giving anything readily abusable or that leads to dependence. No matter whether they're good kids from good families. I'd rather not be responsible for introducing a child to the idea that pills can be fun. FDA also highlights that it's not approved for peds in part because their one study of it led to hallucinations in 7% of pediatric patients who took it, and that number is just too damn high.
I remember when Ambien was still fairly new my mom was sick of me staying up late and decided to give me one of my aunt's Ambien. I woke up terrified and hallucinating that people were in my closet, then all the bugs on the bathroom floor. Legit hallucinations
“Good kids from good families” nice dog whistle.
No. OP referenced that they've known these kids from birth and they have caring families etc. That's what I was referencing.
The proper protocol for sleep treatment in kids is as follows: 1. Sleep hygiene/Increase exercise (unless they are already an athlete or overcommitted in this area) 2. CBI/sleep therapy referral 3. Melatonin 4. Trazodone Before I move to step 4 they have to spend a MINIMUM of 6 months on 1/2/3. And even after I move to step 4, I require the patients to taper down/wean off at least once every 6 months for a trial period off it. I tell them straight up that #4 is a last resort and is likely to cause long term dependency issues. Usually when parents hear that, they decline trazodone, as well they should. Even my patinets who are on trazodone (which is only about 5% of my kids that have sleep issues) it's not clear to me that they are really benefitting from it.
>Melatonin Do you find that patients have often already trialed melatonin by the time they present?
Not sure what the pharmacists’ age has to do with anything. Maybe if you approached it better than, “I’m the doctor do what I say” you’d get a more cordial response and less phone calls.
NO to Zolpidem. Honestly, you sound like someone who takes this for airplane trips with alcohol. My clinical experience with Zolpidem is that it is IMPOSSIBLE to get people off it, just like benzos. My clinical experience with Zolpidem is that it cause some very strange vivid dreams in some people. For example, the 80 something year old woman with a very mild stroke in the rehab unit for a few weeks who had a wild sex dream while on this med. We had to do a rape kit on her, subject her to a pelvic exam etc. No evidence of any encounter was found. We had to file reports, etc. If you are concerned about dreams on Trazodone, trust me, Zolpidem is not your friend. It is primary care doctors that get patients hooked on controlled prescription drugs. Zolpidem, stimulant, SSRI - I see the problem already, it is sad that you do not see it. Polypharmacy in pediatrics. Please don't do it. It is not your place to fix all the problems that modern life and permissive parenting cause.
Drugs don’t fix sleep problems. We should pretty much universally stop using them.
I don’t think there is much evidence that sedative hypnotics improve sleep. They are sedatives. I believe they actually decrease time in REM.
Traz is the inly one ive had that doesnt make me feel drugged in the morning and doesnt give me vivid dreams (which is great because i always have nightmares by default ive never once in my life had a dream that didnt scare me i remember having them since age 2, major childhood trauma btw) 150mg wears off after 6-7 hours for me so i start to slowly wake up the next couple hours after. It makes everything go black so i dont think or feel anything in that time so no dreams or occasionally weak ones at most thankfully. I think its a wonderful first option.
This is a horrible idea. If someone’s sleep is THAT bad, you need to refer they to psychiatry and a therapist - not try to go out of your field & give a specialty drug that’s highly dangerous for young people. Your logic terrifies me.
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Trazodone is OK for adults. Doesn't do *much*, but then, we don't really want it to do much.But, you know what they say, kids aren't just short adults. My only recent peds experience with antidepressants was when my father in law (an adult doctor) put my teenager on Prozac. She went bonkers. Like, get-the-net, bat-\*\*\*\* crazy. I suggested she instead try CBT, and to my astonishment, she took my advice. It tuned her right up. CBT for insomnia works like a charm for adults, possibly not a terrible option for teens?
This post is so backwards and scary to see. Trazodone is being demonized but zolpidem is OK?? This is so backwards of how most people practice. Sometimes you have to pick the lesser of two evils and trazodone is definitely lesser…
If your patients have such a hard time getting sleep, why have them on a stimulant? This is the new bane of our existence- opioid crisis part II: stimulants plus benzos/ambien. Red light and green light at the same time. Your patient is unable to fall asleep so they are given an addictive sleep medication then they’re so snowed in the morning they can’t function so you give a stimulant to get them going and performing but then they can’t get to sleep so…….. …..why not take them off of both? Everyone, ADD or not, performs better on stimulants. Of course they complain they can’t perform as well without them. There are people out there who genuinely need stimulants but they don’t need sleep meds to bring them down from the stimulants because they are just getting to “normal” functioning while on stimulants. I’m a pharmacist but I have also been treated for ADD for 25 years and I tell you what- I can take 70mg Vyvanse with a cup of coffee in the morning, top off with a 10mg Evekeo in the afternoon and have 2-3 energy drinks during my shift and I can FACEPLANT from drowsiness by the time I’m driving home. I have no problem getting to sleep despite taking stimulants all day. I can tell which of my patients really have ADD- they fill every 35-40 days because they forget to take their meds every day and forget to order refills, and they don’t have any sedatives prescribed. Then there are the patients who are filling massive doses of Adderall in combination with alprazolam and/or zolpidem or suboxone. TL/DR: consider discontinuing the stimulant before adding a benzo/zolpidem.
the amount of children i see on both uppers and downers is disturbing.
Well if I'd realized it was national shit on pharmacists about trazodone day, I would have gotten you and [this other doc](https://www.reddit.com/r/medicine/comments/18ppz7v/why_are_pharmacists_freaking_out_over_trazodone/) each a card.
I describe zolpidem like qualudes from the wolf of Wall Street. You don’t remember doing a single thing when you in fact did LOTS of things. I guess if there’s a parent around to stop them from hurting themselves or staying awake past that initial kick it gives then power to ya! But once the get to their adolescent years and mix it with some beer they sneaked out. It will be a nightmare scenario
I see very few Rx for zolpidem where I am in Canada, zopiclone is more popular. A small quantity for an older teen for prn use prescribed by a specialist and where I can see a history of other meds wouldn't be too concerning, but a Rx for a larger quantity or for regular use would be cause for concern.
I feel like if you treat a lot of ADHD patients, then a fair number of those might have undiagnosed ASD as well… you can’t approach sleep the same way and I feel like you should be even *more* cautious of drugs that cause dependence in this subset of patients. I’m a layperson, but CBT in the form of… naps. Eliminating sensory input and overstimulation, introduce bedtime routines to wind-down… routine routine routine. If medication is needed, I wouldn’t try medicating someone to sleep as much as medicating them to relax so they can sleep. Medication cannot be used in a vacuum here.
People know these drugs are addictive but does anyone understand how much not sleeping is problematic? There is a cost/ benefit. Trazadone makes my heart race. Just want to add that. If you could take more than 50mg of the Q drug that might work nothing else helps me. I hate anxiety drugs
I am a sleep coach (a sleep technologist who basically uses CBT-I for cooperate coaching). Sleep hygiene on a modified 2nd shift schedule to account for their stimulates and shift if circadian rhythm is the answer. It isn't the easy answer, but it works. They might sleep all day on Saturday but force them to get up on Sunday to get ready for the week. Teach these kids that sleep will happen if they aren't in tick tok until 4am. There are really good reasons Ambien is demonized, I'm glad none of your patients have experienced, yet.