I saw a patient recently who was obviously very fatigued. The skin under his eyes sagged terribly. He was almost at the point of begging and said all he wanted was to be able to sleep. I noted that his chart said he was a substance abuser, so I was careful in considering what might be his best treatment options.
The patient said he had suffered from insomnia for most of his life. I went through the usual questioning and discovered that he had been a good sleep hygiene disciple. He had done sleep studies in the past with no evidence of sleep apnea or other sleep disorders that might be causing a problem.
He had tried melatonin and a few over-the-counter remedies but said that no one seemed to want to give him a sleep aid.
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Because the patient’s insurance company would only allow 15 pills per month, he said that whenever he was prescribed something he would cut his pills in half and that was only mildly helpful.
The patient reported his lack of sleep was affecting every aspect of his life. His work was suffering and he had been warned that his forgetfulness was jeopardizing his job. His wife was complaining that he never seemed to want to do anything and always seemed depressed. He realized he was short with his children but couldn’t seem to help it.
I gently asked him about his substance abuse and told him this may be a reason that providers might be reluctant to want to prescribe sleep aids. He was shocked. “What?! I’m not a substance abuser! I don’t even drink! I’ve never done drugs in my life,” he said.
I pointed out that his chart listed this as a problem. He was adamant that this did not accurately describe him. He offered blood and urine tests. He wanted to know why anyone would say this.
I asked the patient to wait while I made some calls. I found out quickly that his primary care doctor had noted substance abuse was a problem. I asked to speak with the physician. When he came to the phone, I told him what the patient had said. I asked what substance the patient had abused. “Sleep aids,” he responded.
I asked if the patient had been over using them. Had he asked for early refills? Had he used more than prescribed?
The doctor responded “no” to my questions, but replied that he was “sick of everyone wanting a sleeping pill.”
It did not seem fair to me that the doctor added substance abuse to the patient’s chart. It seemed as though the physician’s opinion was that anyone who used sleep aids everyday was abusing drugs, but what if someone really has insomnia?
The doctor stated that he was convinced that no one really needed sleep aids for more than a week or two. Period.
I don’t know what you think, but I do not agree with this sentiment. New studies using functional MRI have shown that the brains of those with insomnia are different from healthy controls. Nevertheless, if a patient is exhibiting symptoms of insomnia and has tried everything asked of them, should we not prescribe a sleep aid?
And don’t even get me started on the insurance company limit of 10 to 15 pills a month. How do we know which 15 days the patient is unable to sleep? If nothing else, we should be upset that insurance companies are practicing medicine without a license.
What if it medication to treat blood pressure? Would you get upset then? Would you tell your diabetic patients that they have used insulin long enough and needed to come off of it? Why is it that insomnia is any less an illness than any other condition we treat?
I realize that sleep aids are at the top of the list of prescribed drugs. I realize that hypnotics have been in the news for patients doing things that they don’t remember. But do we stop helping those who really need the medication because others have overused or abused it?
I am very careful in my interviewing process to try to find out why a patient may not be sleeping. Are they using computers too close to bed? Are they following a regular sleep schedule? More times than not, I do not prescribe a sleep aid as first line therapy. I wait until the patient has done everything else they can try to sleep on their own.
As providers, we often suggest patients make lifestyle change before medication. However, some patients have a true need, especially when their quality of life is suffering. Are we treating these patients fairly?
Interestingly, my patient noted that he would rather not take a pill, if there were a way for him to sleep without one.
What do you think? Do you have biases when practicing medicine? Also, what do you think about insurance companies dictating the number of pills plans cover each month? I’d love to hear your feedback. Please tell us in the comments section below.
Sharon M. O’Brien, MPAS, PA-C, is a practicing clinician with an interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.
