June 25, 2025 • 34 mins
Dr. Mitchell Rothstein joins Dr. Michael Koren to wake us up to the dangers of insomnia. Insomnia is a common sleep disorder affecting approximately 30% of adults and is characterized by poor sleep on at least three nights a week for three months or more. Dr. Rothstein reviews what insomnia is, what is happening in the brain, and what sufferers can do about it. He explains how lifestyle changes can make a big difference, especially in our digital world. Dr. Rothstein then reviews the effectiveness of cognitive behavior therapy, common over-the-counter treatments, prescription medicines, and when it's time to see a sleep specialist.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcement (00:00):
Welcome to MedEvidence, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts Hosted bycardiologist and top medical
researcher, Dr Michael Koren.
Dr. Michael Koren (00:11):
Hello, I'm Dr Michael Koren, the executive
editor of MedEvidence, and I'mhere with my colleague, Dr.
Mitchell Rothstein.
Mitch, thanks for joining usagain on MedEvidence! Always a
pleasure.
And, mitch, I'm going to pickyour brain today for our
audience.
In fact, I'm going to call thisour Medical Wisdom series.
Dr. Mitchell Rothstein (00:30):
Nice, okay, who you can have as a
guest?
Yeah.
Dr. Michael Koren (00:34):
And you are a master clinician.
You have a background inpulmonary medicine and sleep
medicine and critical caremedicine, and I want to talk
about a very common problem andI want to break it down for our
audience so that everybody canview this and have a really good
idea on how to approach it forthemselves or for a family
(00:56):
member.
And that problem is insomnia
Dr. Mitchell Rothstein (01:00):
Common problem.
Dr. Michael Koren (01:01):
You're familiar with that?
Dr. Mitchell Rothstein (01:02):
Very.
Dr. Michael Koren (01:03):
So it's something that a lot of people
talk about.
You go to cocktail parties andpeople talk about it, but I
rarely hear anybody approach itsystematically or approach it
from the way old schoolclinicians used to approach
problems.
So you and I are kind of oldschool clinicians I hate to
admit that, but I guess we areand so let's help people
(01:26):
understand that.
Break it down for people.
All right, All right.
So insomnia you said it's acommon problem.
How common is it?
Dr. Mitchell Rothstein (01:33):
The current estimate is that about
30% of the adult populationsuffers from insomnia Now,
that's not all chronic insomnia.
Of that, 30% about 10% sufferfrom chronic insomnia.
And we define chronic insomniaas having poor sleep on at least
three nights a week for atleast three months.
(01:53):
And when we talk about poorsleep, remember this is
primarily a perceptual issue.
So poor sleep is defined as theperception of inadequate,
insufficient or fragmented sleepassociated with a daytime
consequence, which is somethingthat initially, when we were
treating patients with insomnia,we didn't have included in the
(02:14):
definition.
And that's given an adequateopportunity to sleep Okay.
Dr. Michael Koren (02:19):
So when a person identifies the fact that
they're having sleep problems,should they assume that that's
insomnia in of itself, or arethere specific things that they
should know to understand thatthis is maybe a medical issue
that needs to be looked at?
So help break that down.
(02:40):
First of all, every night thatyou don't sleep well doesn't
mean that you have insomnia.
Dr. Mitchell Rothstein (02:44):
Correct.
So there are common cases oftransient insomnia and I think
every human experiences thoseover time.
For example, when there'strauma, death in a family,
(03:09):
people have difficulty sleepingfor a period of time that may go
on for a week or two, but onceit extends beyond, that is a
point where you have to startconsidering other alternatives,
especially when those daytimeconsequences start to appear.
So, for example, in the UnitedStates right now, we think that
there's probably about 100million adults that have chronic
insomnia.
And that costs, in terms ofproductivity, about $100 billion
in domestic product lossbecause of their presentism at
work, because they're drowsy,because they're making mistakes.
(03:30):
It has huge social impacts, ithas impacts on your health and
well-being and we know that it'sassociated with a number of
medical problems.
So my kind of rule for peoplein general when they were coming
to see me for insomnia aspatients was, if it got to the
point where it was interferingwith your life and it was going
(03:51):
on for more than a month, thatwas the time that you should
seek medical attention.
Dr. Michael Koren (03:56):
Okay, so let's just break that down a
little bit more for people.
So let's have you having a badweek.
You're not sleeping right,you're out of sink, maybe you
are traveling and you haven'tgotten back into your rhythm.
Is that when you call aphysician, or is there some
things you can do to sort ofaddress it before you get
medical advice?
Dr. Mitchell Rothstein (04:17):
There's plenty you can do to address it
before you get medical advice,and the most obvious issue in
our current society is sleepdeprivation.
More people suffer from sleepdeprivation than any other
medical condition out there andyou know that's thanks to
electricity, it's thanks tobeing on the computer and
watching TV and we're going tosee a bump in this as our COVID
(04:41):
generation kind of moves intoadulthood, because they've grown
up in a very poor sleep hygieneenvironment.
You know they were spending alot of time in their rooms, on
their beds, on their computers,and we like people sleep
specialists, like people toassociate seeing the bed with
sleep, not seeing the bed withbeing on the computer or
(05:02):
watching TV or being on yourphone talking to friends, and
that association is lost.
You know, as things go on andwe become more technically
associated.
Dr. Michael Koren (05:12):
When your bed becomes your office, you have a
problem.
Dr. Mitchell Rothstein (05:15):
You can have a problem.
Now there's people that don'thave any problem at all.
You know they can be doingwhatever they can be watching
you know fights on TV, shut offthe lights and go right to sleep
.
There's other people where, ifthey hear you know a drip from
the faucet in the house nextdoor, it keeps them awake all
night because they're worriedabout it.
So there's a number of issuesthat kind of complicate not
(05:40):
really complicate this, thatkind of determine what happens
to people and we kind of, inbroad phrases, we kind of
separate those into predisposingfactors, precipitating factors
and then perpetuating factors.
So, just like everything else,you know people that are that
have high blood pressure or arepredisposed to high blood
pressure.
If they stay away from salt,their blood pressure is fine.
If they eat salt, their bloodpressure goes up.
When people have the same issueswith insomnia, some are
(06:02):
predisposed to this hyperarousal state that they can't
shut their brain off.
And if a precipitating factorhappens, there's an accident,
they end up in the hospital,something changes in their
environment that triggers themover the line and they have
insomnia and then, depending onhow they cope with that,
determines whether the insomniais going to be transient and
(06:23):
goes away after that trauma isover or is going to continue if
they develop bad copingmechanisms.
So kind of to answer yourquestion.
The first thing somebody shoulddo is look at their own sleep
hygiene.
You know what are their sleeppatterns.
When did they get up, when didthey go to bed?
Do they have an adequate sleepperiod?
Is the sleep environment cooland quiet?
(06:43):
Is it conducive to good sleepor not?
And so, once you start lookingat that, if there's a
correctable easy issue there, ifyou know that the light's on in
the hallway and it bothers you,make sure the light's out.
If you stop using caffeine andalcohol six to 10 hours before
bedtime, if you shut off the TVyou know two hours before
(07:05):
bedtime.
If you avoid even dim lightillumination an hour before
bedtime, all those things canhelp you fall asleep.
And if those things aren'tworking, after about a month and
you're recognizing daytimeconsequences, you're not as
sharp as you used to, you havedaytime fatigue, you're
irritable.
That's the point where you needto see a physician.
Dr. Michael Koren (07:27):
Okay Now before we get to the physician
part, are there any homeremedies that you would
recommend?
People talk about melatonin orthings that are- antihistamines
that can help just help theaudience understand what is a
reasonable over-the-counterapproach to that.
Dr. Mitchell Rothstein (07:43):
Yeah, so there's no over-the-counter
approach that's actually beenshown to be effective in any
clinical FDA-approved trial.
That's why they'reover-the-counter.
So the issues with melatonininitially we thought melatonin
was going to be a great drugbecause melatonin drives the S
phase of sleep and our circadianrhythms, but as it turns out it
(08:08):
seems to have a very limitedapplication and it might be
helpful for people with jet lag,maybe in the elderly at low
dose to help sleep onset, butdoesn't really seem to have any
real clinical effectiveness.
Antihistamines work by ourmajor alerting neurotransmitter
(08:29):
in our brain is histamine.
So when you take anantihistamine you're dulling our
major alerting process and theproblem with antihistamines is
there's hangover and there'svery rapid habituation, so
people become tolerant to it andthen there are side effects.
I mean it's largely an elderlypopulation that has glaucoma or
(08:49):
large prostates and you get intoa lot of problems with that.
Magnesium has been touted as asleep aid and for people who are
magnesium deficient it mightwork, but in general large
trials it doesn't seem to reallyhave any proven effectiveness
with either sleep onset or sleepmaintenance.
Dr. Michael Koren (09:08):
Okay.
So just to get a littlegranular, if you're having a bad
week, you're not sleeping well.
Do you pop three milligrams ofmelatonin?
Do you pop 10 milligrams?
Do you pop 25 mg of Benadryl?
Just help people with thosedose ranges and what would be
reasonable before you getmedical attention.
Dr. Mitchell Rothstein (09:24):
Well, I would say that in general, if
you're going to use melatonin,most of the data suggests that
for somebody under the age of 50, they need a dose of at least 5
milligrams.
And if you're going to use anantihistamine, usually 25
milligrams is the recommendeddose.
But I don't really want torecommend either of those to
(09:46):
people.
There is a placebo effect thatmay help them fall asleep and
from that aspect, maybe they'llbe effective.
If you're going to use anantihistamine, I wouldn't use it
for more than a week.
Dr. Michael Koren (09:56):
Okay, and magnesium you mentioned, is
there a dose that you recommend?
Dr. Mitchell Rothstein (10:00):
Not really, so there's-
Dr. Michael Koren (10:02):
Magnesium oxide 400 before you go to sleep
can't hurt.
Dr. Mitchell Rothstein (10:06):
It can.
I think that's the right answer.
It CAN hurt so now and the samething.
There's also things that areavailable over the counter
without prescriptions that candefinitely help, and that's
cognitive behavioral therapy,and there's actually online
programs for free where, if youGoogle cognitive behavioral
therapy for insomnia, they'llhook you up with a program and
(10:28):
you can go through the steps ofthe program for behavioral
training, which has definitelyproven to help people with
insomnia.
Dr. Michael Koren (10:35):
Okay, and how about devices putting a pillow
over your head?
Yeah, tell me about those typeof approaches.
Dr. Mitchell Rothstein (10:43):
Well, I think most of these kind of
external issues really are formsof relaxation therapy and to
some degree some of themedications are a form of
relaxation therapy.
If you believe that anantihistamine, you know Tylenol
pm, is going to help you sleep,it has a better chance of
working than if you don'tbelieve that it's going to help
(11:04):
you.
And the same goes true withlike noise generating devices
and other sound generatingdevices.
Those can help peopletransition from an activated,
aroused state to a more relaxedstate that's conducive to sleep
onset.
Dr. Michael Koren (11:21):
What about a shot of Jack Daniels before you
go to sleep?
Does that work?
Dr. Mitchell Rothstein (11:24):
Well, it will help you fall asleep, but
as alcohol is metabolized, itsbyproducts will actually wake
you up.
So people don't sleep throughthe night and then they take
another shot of alcohol.
They'll sleep through the restof the night.
Dr. Michael Koren (11:35):
Okay.
So you're past that one weekmark and you're still struggling
.
It's been a month and you'rejust having trouble.
You're not sleeping well.
You either wake up earlyspontaneously or you have
difficulty getting to sleep inthe first place.
So what are your next steps?
Should you go to your primaryphysician, go to a sleep
specialist?
(11:57):
Google something?
What's the next step?
And help people understand thedifference between difficulty
falling asleep and people whowake up spontaneously?
Dr. Mitchell Rothstein (12:06):
So the next step is a good question.
I think it's largely insurancedependent right.
So if you have insurance thatrequires you to see your primary
care physician.
That would be your next stepand in the ideal world you would
see a sleep specialist.
And as a sleep specialist, thefirst job of the sleep
specialist is to figure out ifwhat you're dealing with is
insomnia or insufficient sleep.
(12:28):
So the first thing we do islook at a sleep log and we have
the patients fill out a sleeplog of when they go to bed, when
they get up, their awakeningsduring the night and their
estimate as to how much sleepthey're getting per night.
For about two weeks and whenthe patients come back, we know
that if the patient truly hasinsomnia, the most common
(12:48):
underlying issue is a mooddisorder.
We know that 50% of patientswith insomnia either suffer from
anxiety and or depression andwe'll usually do a depression
scale or an anxiety scale and ifthat's the case, we'll treat
that underlying mood disorder.
If that's not the case, then wewant to rule out other things
(13:09):
that can interfere with sleep.
So in an aging population, themost common, prevalent
underlying condition thatinterferes with sleep is pain.
So people have arthritic painsthat will wake them up.
We evaluate them for that.
We evaluate them for bladderissues that might wake them up,
for bowel issues that might wakethem up at night.
We want to make sure that theirenvironment is like we talked
(13:32):
about before, is adequate and inall those cases, regardless of
what the underlying etiology isfor insomnia, the first step is
always cognitive behavioraltherapy, which includes teaching
people how to relax, teachingpeople that the stimulus, that
their sleep environment can'tact as an arousal stimulus, and
(13:56):
teaching people what to do ifthey're waking up during the
night.
So, for example, if your issueis a sleep onset issue, if you
go to bed and you're doing theright things to help your brain
relax and you're not enteringsleep after minutes, we have you
get out of bed, go in anotherroom.
You can't do somethingstimulating, you know you can't
turn the tv on.
(14:16):
You can listen to music, youcan read in a dim light and then
we have you retry bed, but wedon't let you then extend your
morning awakening past its usualtime.
So the biggest problem thatpeople have with inadequate
sleep hygiene is they don't havea regular wake-up time and
that's important, not becausethat's when you wake up, but
(14:37):
it's important because that'sassociated with your first
exposure to bright natural light.
So one of the things people cando that suffer from insomnia is
pick a regular wake-up time ispick a regular wake-up time,
usually before 9 am.
Get outside in natural sunlight, because that natural sunlight
hits your retina.
The retina is connected to yourhypothalamus and in your
(15:00):
hypothalamus is this organcalled the suprachiasmatic
nucleus which is the pacemakerfor your entire body.
It tells your body that after myfirst bright light exposure,
which usually has to be about20, 000 lux, which transfers to
being outside in natural light,you don't have to sunbathe, you
can sit in the shade, just bearound natural light, no
(15:20):
sunglasses, and you can't be hot, be behind uv protective glass,
because that eliminates that400 wave blue green light that
you need.
And your brain knows that about12 hours after that first
bright light exposure is whenI'm going to start secreting
melatonin, because that meansthat my day is over and I'll be
(15:43):
going to sleep.
So if you sleep in, or if youget up at 8 in the morning but
you don't go outside till noon,your brain thinks noon is 7
o'clock in the morning and thenyou're up at 8 in the morning
but you don't go outside tillnoon, your brain thinks noon is
7 o'clock in the morning andthen you're up till 5 in the
morning.
Dr. Michael Koren (15:54):
So you have to reset those circadian rhythms
.
So interesting, so you dorecommend that you use natural
light to help you wake up in themorning.
Dr. Mitchell Rothstein (16:01):
Yeah, and actually we call it natural
light, and you'll like thisbecause I know you like language
is a zeitgeber.
So zeit- is time and -geber isgiver or gatekeeper, and so the
most powerful zeitgeber we haveis exposure to natural bright
light.
But there's other zeitgebersthat occur all during the day.
In fact, in the early 1970sthey did a study where they took
(16:24):
eight men and they put them ina cave and they had this cave
because the cave had a standardtemperature that didn't
fluctuate during the day.
And they had them cave becausethe cave had a standard
temperature that didn'tfluctuate during the day.
And they had them in a roomwith dim light, 24 7, and they
had them served by attendantsthat came in that were always
freshly shaven.
They didn't serve them breakfast, lunch and dinner.
They served them lunch, lunchand dinner.
(16:45):
So the participants didn't knowwhat time it was to see what
our the natural was.
And it turns out that ournormal natural cycle is about
24.2 hours.
And what these zeitgebers dolight meals, exercise, change in
temperature is it shortens thatnatural cycle from 24.2 hours
(17:05):
to 24 hours.
If you don't do that, every daygets a little later and a
little later and a little later,and then you have insomnia from
that perspective as well.
Dr. Michael Koren (17:14):
So interesting, so, so interesting.
So, getting back to thatinitial diagnosis, you said it
should take about 20 minutes tofall asleep.
If it's more than 30 minutes,then you may have a problem.
And you're saying that youshould change your environment
after 20 to 30 minutes to see ifyou can find some other way to
get to sleep.
Dr. Mitchell Rothstein (17:36):
But just to interrupt, there's some
other things that you can do.
Also, if your sleep environmentis activating your brain, what
an average person wants to beable to do is they want to open
the door to their bedroom, seetheir bed, and they want their
brain to say to them oh, thankGod, I get to go to sleep.
Now, if you're opening the doorand your brain is saying to you
, oh no, I'm not going to sleepagain, I'm going to be up on
(17:59):
blah, blah, blah, you want tochange that environment.
So we have had people, you know, change their sheets, paint
their room a different color,change the position of their bed
, and that's called, you know,stimulus control therapy.
You want to have that stimulusnot there anymore, that stimulus
that was causing the arousaland the anxiety and the
difficulty falling asleep, andchange it.
(18:20):
So it doesn't do that.
In fact, a lot of people thatsuffer from insomnia find that
they have insomnia every nightwhen they're home.
They go away to a conference orin a hotel room one night they
sleep like a baby.
They come back home and they'rehaving that problem again, and
that's all due to that kind ofassociation with the bedroom not
(18:40):
being a place of relaxation andsleep.
Dr. Michael Koren (18:41):
Interesting, so interesting.
So you mentioned about sleeplogs.
Is something you do as a sleepspecialist.
I would imagine that's a littlebit challenging, because how do
you record how long it takesyou to go to sleep, if you're
sleeping?
So do you recommend devicesnowadays?
Dr. Mitchell Rothstein (18:55):
That's an excellent point.
And sleep is a perceptual issue.
So we have people in the sleeplabs.
So if you came into our sleeplab and you went to bed at nine
and then you woke up at 11, for15 minutes, you went back to bed
.
You woke up at two, you were upfor 15 minutes, went back to
bed and fell asleep and then youwoke up at four and were up for
15 minutes, fell back to sleepand then at seven o'clock I came
(19:17):
in and woke you up and I saidMike, how'd you sleep last night
?
And you go, you son of a bitch.
I was up all night Because,like you said, all you really
remember is the time you'reawake.
You don't remember the timeyou're asleep.
So, since it's a perceptualissue, when we start doing sleep
logs, we also do somethingcalled actigraphy, which is on
everybody's watch now, and itactually will record motion
(19:39):
which is fairly well associatedwith sleep, and we can see how
consistent people are with whatthey think their sleep was like,
with what the actigraph andthat's called sleep stage
misperception.
So you don't remember the timeyou're asleep, you only remember
the time you're awake.
And that separates out peoplethat have actual sleep
(20:00):
deprivation associated insomniafrom people who have the sleep
stage misperception.
Both of them can be associatedwith daytime consequences, but
they're treated a littledifferently.
Dr. Michael Koren (20:11):
Understood.
So the devices that aregenerally available to the
public.
They're usually pretty good atmaking the diagnosis, would you
say.
Dr. Mitchell Rothstein (20:18):
Well, they're pretty good at recording
the difference between sleepand wake, not recording,
obviously, differences in sleepstaging or arousal activity.
And it's really the arousalactivity, the breaking up of
sleep into these 10 to 15seconds, issues- periods that
(20:39):
are not really recognized thefollowing morning but are
associated with generalizedfatigue.
So all of us, during our courseof normal sleep, have arousals.
So during the course of an hourof sleep, an average adult
might have arousals, which aredefined on an EEG as showing
awake activity for 15 seconds orless, but not awakening you so
(21:01):
that you have memory of it, andan average adult might have 15
to 20 of these an hour.
People with insomnia have twicethat or three times that, and
they might sleep through thenight, where some of them might
actually awaken them to fullconsciousness.
But regardless of that, thatsleep fragmentation is
associated with the daytimeconsequences of fatigue and lack
(21:23):
of concentration and the thingsthat people start complaining
about.
Dr. Michael Koren (21:27):
So before we get into some of the medications
in old-time movies people usedto wear those eye shades to help
them go to sleep.
Obviously, they would not besubject to natural light to wake
them up in the morning.
If they're wearing them, isthere still a role for something
like that?
Dr. Mitchell Rothstein (21:42):
Sure, and it's not natural light that
wakes you up in the morning.
What wakes you up in themorning is your own circadian
pacemaker.
So we have these two kind ofopposing processes that help us
sleep during the night.
One is our circadian drive andone is our homeostatic drive.
So the homeostatic drive isdriven by the accumulation in
(22:03):
our brains of adenosine, that'swhat caffeine kind of
counteracts and helps us stayawake.
So during the course of the dayyour homeostatic drive
continues to go up and up, andup and up, until it reaches a
point that kind of tips you overand you go from wakefulness to
sleep.
And that's a compounded with acircadian drive.
So in the morning, when youfirst wake up before you've seen
(22:25):
sunlight, your circadian driveis at its lowest.
And then during the day yourcircadian drive kind of reaches
a peak in mid-afternoon, siestatime.
Dr. Michael Koren (22:35):
Right.
Dr. Mitchell Rothstein (22:35):
And then , interestingly, whether you
take a siesta or not, yourcircadian drive goes away and
you're feel okay again.
So even if you don't sleep, youdon't feel tired anymore, and
that kind of peaks at the sametime that your homeostatic drive
and that adenosine is buildingup during the night and then it
kind of tips you over into sleep, let's say at 11 PM, and then
during the course of the nightyour adenosine level is being
(22:57):
metabolized.
So that's going away, so you'resleeping off your sleep drive,
but the circadian clock iswhat's keeping you asleep and
continuing kind of to pelt yourbrain with GABA to keep you
sleeping till morning, at whichpoint you wake up and that's
when your temperature starts torise and your cortisol starts to
rise, and that's what wakes youup in the morning.
(23:18):
Not the bright light isn't whatwakes you up.
The bright light is actuallywhat tells you when to go to
sleep.
Dr. Michael Koren (23:22):
Got it Okay.
Now you mentioned napping.
I'm a personal big fan ofnapping.
Do you recommend that whenyou're treating insomnia?
So give us some advice aboutthat.
Dr. Mitchell Rothstein (23:34):
So the napping data that's out there
and there were plenty of studiesdone over the last couple of
decades on napping.
Napping is good for you butthere are some kind of
boundaries on it.
So number one is that if youhave difficulty falling asleep
you don't want to reduce yoursleep drives, that adenosine
buildup, and napping is going toreduce your adenosine levels.
So for people that have troublefalling asleep at night we
(23:57):
don't recommend napping and wedon't recommend napping in close
proximity to your regularbedtime because again'll reduce
your sleep drive.
But for average people nappingis refreshing.
We limit naps to about 20minutes and we want to time them
around that kind of siestacircadian bump, which is usually
about 12, 12 noon to about 2 pm, and we limit them to 20
(24:22):
minutes because that preventsyour brain from cycling into
deep sleep.
So I'm sure you've had thatexperience.
I've had it where you wake upat a deep sleep and you don't
know where you are, you have noidea what time it is, where you
are, and that's called sleepdrunkenness and that is because
your brain has cycled intodeeper sleep, which is a
synchronized, non-awake versionof sleep and it's difficult to
(24:45):
kind of get reorganized fromthat.
And when people enter that, thenap becomes unrefreshing,
whereas if they're in lighterstages, of sleep for 20 minutes,
the nap is refreshing,interesting.
Dr. Michael Koren (24:56):
Well, it's about noon right now.
Can we take a break for about20 minutes?
Dr. Mitchell Rothste (24:59):
Absolutely .
Dr. Michael Koren (25:02):
Anyway.
So, getting back to other waysof approaching insomnia, one of
the things that comes up all thetime is what medicines do you
use under what circumstances?
And there are differentcategories.
We have, of course, thesedatives, benzodiazepines being
most common.
We talked about antihistamines.
(25:23):
We talked about melatonin andother quote supplements, and
then now cannabis is beingrecommended as something that
can help a lot of people.
So what's right for people?
How do you figure that out?
Do you combine modalities?
Dr. Mitchell Rothstein (25:37):
Yeah, we definitely combine modalities.
We always combine behavioraltherapy with pharmaceutical
therapy For people that haveresistant insomnia, that have
been following all the rules thecognitive behavioral therapy,
the stimulus control, relaxation, training and they're still
having unrefreshing sleep.
That's associated with daytimeconsequences.
(25:59):
We generally start with a shortcourse of hypnotic and, as you
pointed out, the hypnotics arein different classes and some of
them have benefits over others.
The most recent class ofhypnotics out are these orexin
antagonists.
So these are fascinating drugsand the whole development of
(26:22):
this class and associated withour understanding of how sleep
works and the sleep wake kind oftoggles, which was kind of
pertinent to their discovery.
So, if you think about ingeneral, there's no advantage to
being a drowsy person walkingaround, just like you know, if
you're a drowsy zebra on theafrican veldt, you're not going
to last very long and as aperson, you don't want to be
(26:44):
drowsy.
You either want to be completelyasleep or completely awake, and
these orexin antagonists.
Orexin antagonists inhibitorexin, which appears to be the
flip switch in our brain, fromswitching from wakefulness to
sleep, so it keeps you eitherasleep when you're asleep or
(27:05):
awake when you're awake, and itdoes that by stimulating
different parts of our brainthat act on the wake centers and
the sleep centers.
Now, if you antagonize that,the major thing that orexin does
is enhance arousal.
So if you shut off arousal, youthen will have a more
propensity to go into sleep.
(27:25):
And it seems to work quite well.
It appears to be non-addictive.
They're all expensive and ingeneral, whether we're using
that group or benzodiazepines orthe Z classes of medications,
we want to limit our initial useof hypnotic to about one to two
weeks and during that period oftime, reinforcing the
(27:46):
behavioral activities andhopefully at that time the
patients can stop using thehypnotics and rely on the
behavioral techniques to keepthem asleep.
If that fails, then there's apoint where you make
determinations about whether ornot if you're treating the
underlying issues that areinhibiting sleep mood disorders.
Treating the underlying issuesthat are inhibiting sleep mood
(28:08):
disorders, pain, prostate issues, whatever the issue is, thyroid
disease, hyperadrenalism andall those issues seem to be a
baseline.
There are people who have wecall it primary insomnia, where
their brains are justhyperactive and they're just not
good sleepers.
In fact, there's a family,there's a condition called fatal
familial insomnia, where it'smostly in the Mediterranean
group.
It's an autosomal, dominantdisease and people start having
(28:31):
trouble with insomnia in theirteenage years and it's uniformly
fatal.
People die from chronic sleeploss.
And the problem with insomniais and this was just discovered
in the last decade is that yourbrain clears all these bad
proteins and neurotransmittersduring sleep through something
called the glymphatic system.
Dr. Michael Koren (28:50):
Glymphatic?
Dr. Mitchell Rothst (28:51):
Glymphatic, which is connected to your
lymphatics.
But during sleep theglymphatics, through this
extravascular penetration andconcentration differences, take
out all these prion proteins,adenosine and everything out and
filter it out and clear outyour brain so that during
daytime you can be awake andalert again.
Dr. Michael Koren (29:11):
Interesting.
So breaking it down a littlebit more in terms of those
medication classes and how youstart.
You mentioned that there's anewer class that is expensive,
but is that what you start with?
Or do you start withbenzodiazepine?
And you can mention some names,so people know what categories
you're talking about.
Dr. Mitchell Rothstein (29:30):
-And this is obviously
patient-dependent,cost-dependent.
The traditional oldbenzodiazepines like triazolam,
flurazepam, temazepam areeffective and good.
Dr. Michael Koren (29:43):
Use some of the trade names so people know
Halcyon.
Dr. Mitchell Rothstein (29:44):
Right.
Halcyon and Tamezapam isRestoril.
Those medications and these areclassic benzodiazepines, all
that group are effective ashypnotics.
Dr. Michael Koren (30:00):
They're short-acting drugs in the Valium
class of drugs but they'reshorter-acting yeah.
Dr. Mitchell Rothste (30:04):
Absolutely .
And the problem with that classis they can be addictive and
they can have other consequences.
So that whole class isassociated with not only
hypnosis but anxiolysis,anti-convulsant activity and
myorelaxation and they can havecross-effects with other
medications that people are on.
There's another class calledthe Z medications, which is like
(30:28):
Ambien and Lunesta and thoseare benzodiazepine-like.
They hit the same receptor butthey don't have the anxiolysis
and the muscle relaxant activityand they seem to have less of
the potential for drug-druginteractions but also addictive
less of the potential fordrug-drug interactions, but
also, addictive.
These orexin antagonists don'tappear to have addictive
(30:49):
activity because they don'tactively put you to sleep.
They're not depressing, they'restopping a lot of that arousal
activity from coming in.
Dr. Michael Koren (30:57):
And examples of those?
Dr. Mitchell Rothstein (30:59):
Are things like daridorexant,
suvorexant, lemborexant.
In fact, one of the firststudies I did with the
Jacksonville Center for ClinicalResearch was about using the
orexin antagonist yeah,suvorexant.
Dr. Michael Koren (31:12):
And a trade name for those.
Dr. Mitchell Rothstei (31:14):
Belsomra, Quivivic are the two most
common that are out there that Ican recall [also Dayvigo].
There's also ramelteon, whichis pharmaceutical melatonin, so
that appears to again have aplace for maybe sleep onset in
some patients and for jet lag,for circadian rhythm disorders
(31:35):
and as a hypnotic.
Overall it's still in thatcategory but doesn't seem to be
as powerful as the othermedications.
Dr. Michael Koren (31:42):
So interesting.
And how about cannabis?
That's become something that alot of people are talking about
as a treatment for insomnia.
Dr. Mitchell Rothstein (31:49):
Cannabis ?
I didn't know, but there arecannabinoid receptors in our
brain and they have effects onmuscle tone as well as
electrical activity.
They appear to have theirprimary hypnotic effect through
anxiolysis, so people that areanxious appear to benefit from
(32:09):
them.
There aren't a lot of long-termstudies on whether cannabis is
a good long-term medication forinsomnia, but certainly can be
used in the short term andintermittently.
Dr. Michael Koren (32:23):
Any advice for people You're having trouble
sleeping for a week Should yougo to your local dispensary and
get a joint?
What should you be doing?
Dr. Mitchell Rothstein (32:32):
Well, as a still practicing physician, I
have to offer conservativerecommendations, not ones that I
would necessarily follow, butones that everybody else should.
Dr. Michael Koren (32:43):
Sure.
Dr. Mitchell Rothstein (32:44):
And so I would say in general that the
initial approach to insomnia ifit's transient insomnia, if you
know what's causing it, if youknow that you were upset by
something or you just hadsurgery and you're having
trouble sleeping for a shortperiod of time, a short course
of a hypnotic may be beneficial.
If you have insomnia and youdon't know what's causing it,
(33:08):
that's where you want to thinkabout seeking medical attention,
because that's an investigationalong the lines we just talked
about that should be undertakento help you.
It's a devastating illness.
It affects people's socialactivities, it affects their
whole life, and when your wholelife is about not sleeping well,
(33:30):
that's not the kind of lifemost of us want to live.
Dr. Michael Koren (33:34):
Well, that was a brilliant, brilliant
summary.
Mitch, thank you very much forsharing that information with
the MedEvidence audience.
And fortunately, I don't havethe sleep problem, but I know
people in my life that do and Ifeel that I am now better
prepared to help them.
So, thank you so much.
Dr. Mitchell Rothstein (33:51):
Thank you.
Announcement (33:52):
Thanks for joining the MedEvidence podcast.
To learn more, head over toMedEvidence.
com or subscribe to our podcaston your favorite podcast
platform.
Welcome to MedEvidence, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts Hosted bycardiologist and top medical
researcher, Dr Michael Koren.
Dr. Michael Koren (00:11):
Hello, I'm Dr Michael Koren, the executive
editor of MedEvidence, and I'mhere with my colleague, Dr.
Mitchell Rothstein.
Mitch, thanks for joining usagain on MedEvidence! Always a
pleasure.
And, mitch, I'm going to pickyour brain today for our
audience.
In fact, I'm going to call thisour Medical Wisdom series.
Dr. Mitchell Rothstein (00:30):
Nice, okay, who you can have as a
guest?
Yeah.
Dr. Michael Koren (00:34):
And you are a master clinician.
You have a background inpulmonary medicine and sleep
medicine and critical caremedicine, and I want to talk
about a very common problem andI want to break it down for our
audience so that everybody canview this and have a really good
idea on how to approach it forthemselves or for a family
(00:56):
member.
And that problem is insomnia
Dr. Mitchell Rothstein (01:00):
Common problem.
Dr. Michael Koren (01:01):
You're familiar with that?
Dr. Mitchell Rothstein (01:02):
Very.
Dr. Michael Koren (01:03):
So it's something that a lot of people
talk about.
You go to cocktail parties andpeople talk about it, but I
rarely hear anybody approach itsystematically or approach it
from the way old schoolclinicians used to approach
problems.
So you and I are kind of oldschool clinicians I hate to
admit that, but I guess we areand so let's help people
(01:26):
understand that.
Break it down for people.
All right, All right.
So insomnia you said it's acommon problem.
How common is it?
Dr. Mitchell Rothstein (01:33):
The current estimate is that about
30% of the adult populationsuffers from insomnia Now,
that's not all chronic insomnia.
Of that, 30% about 10% sufferfrom chronic insomnia.
And we define chronic insomniaas having poor sleep on at least
three nights a week for atleast three months.
(01:53):
And when we talk about poorsleep, remember this is
primarily a perceptual issue.
So poor sleep is defined as theperception of inadequate,
insufficient or fragmented sleepassociated with a daytime
consequence, which is somethingthat initially, when we were
treating patients with insomnia,we didn't have included in the
(02:14):
definition.
And that's given an adequateopportunity to sleep Okay.
Dr. Michael Koren (02:19):
So when a person identifies the fact that
they're having sleep problems,should they assume that that's
insomnia in of itself, or arethere specific things that they
should know to understand thatthis is maybe a medical issue
that needs to be looked at?
So help break that down.
(02:40):
First of all, every night thatyou don't sleep well doesn't
mean that you have insomnia.
Dr. Mitchell Rothstein (02:44):
Correct.
So there are common cases oftransient insomnia and I think
every human experiences thoseover time.
For example, when there'strauma, death in a family,
(03:09):
people have difficulty sleepingfor a period of time that may go
on for a week or two, but onceit extends beyond, that is a
point where you have to startconsidering other alternatives,
especially when those daytimeconsequences start to appear.
So, for example, in the UnitedStates right now, we think that
there's probably about 100million adults that have chronic
insomnia.
And that costs, in terms ofproductivity, about $100 billion
in domestic product lossbecause of their presentism at
work, because they're drowsy,because they're making mistakes.
(03:30):
It has huge social impacts, ithas impacts on your health and
well-being and we know that it'sassociated with a number of
medical problems.
So my kind of rule for peoplein general when they were coming
to see me for insomnia aspatients was, if it got to the
point where it was interferingwith your life and it was going
(03:51):
on for more than a month, thatwas the time that you should
seek medical attention.
Dr. Michael Koren (03:56):
Okay, so let's just break that down a
little bit more for people.
So let's have you having a badweek.
You're not sleeping right,you're out of sink, maybe you
are traveling and you haven'tgotten back into your rhythm.
Is that when you call aphysician, or is there some
things you can do to sort ofaddress it before you get
medical advice?
Dr. Mitchell Rothstein (04:17):
There's plenty you can do to address it
before you get medical advice,and the most obvious issue in
our current society is sleepdeprivation.
More people suffer from sleepdeprivation than any other
medical condition out there andyou know that's thanks to
electricity, it's thanks tobeing on the computer and
watching TV and we're going tosee a bump in this as our COVID
(04:41):
generation kind of moves intoadulthood, because they've grown
up in a very poor sleep hygieneenvironment.
You know they were spending alot of time in their rooms, on
their beds, on their computers,and we like people sleep
specialists, like people toassociate seeing the bed with
sleep, not seeing the bed withbeing on the computer or
(05:02):
watching TV or being on yourphone talking to friends, and
that association is lost.
You know, as things go on andwe become more technically
associated.
Dr. Michael Koren (05:12):
When your bed becomes your office, you have a
problem.
Dr. Mitchell Rothstein (05:15):
You can have a problem.
Now there's people that don'thave any problem at all.
You know they can be doingwhatever they can be watching
you know fights on TV, shut offthe lights and go right to sleep
.
There's other people where, ifthey hear you know a drip from
the faucet in the house nextdoor, it keeps them awake all
night because they're worriedabout it.
So there's a number of issuesthat kind of complicate not
(05:40):
really complicate this, thatkind of determine what happens
to people and we kind of, inbroad phrases, we kind of
separate those into predisposingfactors, precipitating factors
and then perpetuating factors.
So, just like everything else,you know people that are that
have high blood pressure or arepredisposed to high blood
pressure.
If they stay away from salt,their blood pressure is fine.
If they eat salt, their bloodpressure goes up.
When people have the same issueswith insomnia, some are
(06:02):
predisposed to this hyperarousal state that they can't
shut their brain off.
And if a precipitating factorhappens, there's an accident,
they end up in the hospital,something changes in their
environment that triggers themover the line and they have
insomnia and then, depending onhow they cope with that,
determines whether the insomniais going to be transient and
(06:23):
goes away after that trauma isover or is going to continue if
they develop bad copingmechanisms.
So kind of to answer yourquestion.
The first thing somebody shoulddo is look at their own sleep
hygiene.
You know what are their sleeppatterns.
When did they get up, when didthey go to bed?
Do they have an adequate sleepperiod?
Is the sleep environment cooland quiet?
(06:43):
Is it conducive to good sleepor not?
And so, once you start lookingat that, if there's a
correctable easy issue there, ifyou know that the light's on in
the hallway and it bothers you,make sure the light's out.
If you stop using caffeine andalcohol six to 10 hours before
bedtime, if you shut off the TVyou know two hours before
(07:05):
bedtime.
If you avoid even dim lightillumination an hour before
bedtime, all those things canhelp you fall asleep.
And if those things aren'tworking, after about a month and
you're recognizing daytimeconsequences, you're not as
sharp as you used to, you havedaytime fatigue, you're
irritable.
That's the point where you needto see a physician.
Dr. Michael Koren (07:27):
Okay Now before we get to the physician
part, are there any homeremedies that you would
recommend?
People talk about melatonin orthings that are- antihistamines
that can help just help theaudience understand what is a
reasonable over-the-counterapproach to that.
Dr. Mitchell Rothstein (07:43):
Yeah, so there's no over-the-counter
approach that's actually beenshown to be effective in any
clinical FDA-approved trial.
That's why they'reover-the-counter.
So the issues with melatonininitially we thought melatonin
was going to be a great drugbecause melatonin drives the S
phase of sleep and our circadianrhythms, but as it turns out it
(08:08):
seems to have a very limitedapplication and it might be
helpful for people with jet lag,maybe in the elderly at low
dose to help sleep onset, butdoesn't really seem to have any
real clinical effectiveness.
Antihistamines work by ourmajor alerting neurotransmitter
(08:29):
in our brain is histamine.
So when you take anantihistamine you're dulling our
major alerting process and theproblem with antihistamines is
there's hangover and there'svery rapid habituation, so
people become tolerant to it andthen there are side effects.
I mean it's largely an elderlypopulation that has glaucoma or
(08:49):
large prostates and you get intoa lot of problems with that.
Magnesium has been touted as asleep aid and for people who are
magnesium deficient it mightwork, but in general large
trials it doesn't seem to reallyhave any proven effectiveness
with either sleep onset or sleepmaintenance.
Dr. Michael Koren (09:08):
Okay.
So just to get a littlegranular, if you're having a bad
week, you're not sleeping well.
Do you pop three milligrams ofmelatonin?
Do you pop 10 milligrams?
Do you pop 25 mg of Benadryl?
Just help people with thosedose ranges and what would be
reasonable before you getmedical attention.
Dr. Mitchell Rothstein (09:24):
Well, I would say that in general, if
you're going to use melatonin,most of the data suggests that
for somebody under the age of 50, they need a dose of at least 5
milligrams.
And if you're going to use anantihistamine, usually 25
milligrams is the recommendeddose.
But I don't really want torecommend either of those to
(09:46):
people.
There is a placebo effect thatmay help them fall asleep and
from that aspect, maybe they'llbe effective.
If you're going to use anantihistamine, I wouldn't use it
for more than a week.
Dr. Michael Koren (09:56):
Okay, and magnesium you mentioned, is
there a dose that you recommend?
Dr. Mitchell Rothstein (10:00):
Not really, so there's-
Dr. Michael Koren (10:02):
Magnesium oxide 400 before you go to sleep
can't hurt.
Dr. Mitchell Rothstein (10:06):
It can.
I think that's the right answer.
It CAN hurt so now and the samething.
There's also things that areavailable over the counter
without prescriptions that candefinitely help, and that's
cognitive behavioral therapy,and there's actually online
programs for free where, if youGoogle cognitive behavioral
therapy for insomnia, they'llhook you up with a program and
(10:28):
you can go through the steps ofthe program for behavioral
training, which has definitelyproven to help people with
insomnia.
Dr. Michael Koren (10:35):
Okay, and how about devices putting a pillow
over your head?
Yeah, tell me about those typeof approaches.
Dr. Mitchell Rothstein (10:43):
Well, I think most of these kind of
external issues really are formsof relaxation therapy and to
some degree some of themedications are a form of
relaxation therapy.
If you believe that anantihistamine, you know Tylenol
pm, is going to help you sleep,it has a better chance of
working than if you don'tbelieve that it's going to help
(11:04):
you.
And the same goes true withlike noise generating devices
and other sound generatingdevices.
Those can help peopletransition from an activated,
aroused state to a more relaxedstate that's conducive to sleep
onset.
Dr. Michael Koren (11:21):
What about a shot of Jack Daniels before you
go to sleep?
Does that work?
Dr. Mitchell Rothstein (11:24):
Well, it will help you fall asleep, but
as alcohol is metabolized, itsbyproducts will actually wake
you up.
So people don't sleep throughthe night and then they take
another shot of alcohol.
They'll sleep through the restof the night.
Dr. Michael Koren (11:35):
Okay.
So you're past that one weekmark and you're still struggling
.
It's been a month and you'rejust having trouble.
You're not sleeping well.
You either wake up earlyspontaneously or you have
difficulty getting to sleep inthe first place.
So what are your next steps?
Should you go to your primaryphysician, go to a sleep
specialist?
(11:57):
Google something?
What's the next step?
And help people understand thedifference between difficulty
falling asleep and people whowake up spontaneously?
Dr. Mitchell Rothstein (12:06):
So the next step is a good question.
I think it's largely insurancedependent right.
So if you have insurance thatrequires you to see your primary
care physician.
That would be your next stepand in the ideal world you would
see a sleep specialist.
And as a sleep specialist, thefirst job of the sleep
specialist is to figure out ifwhat you're dealing with is
insomnia or insufficient sleep.
(12:28):
So the first thing we do islook at a sleep log and we have
the patients fill out a sleeplog of when they go to bed, when
they get up, their awakeningsduring the night and their
estimate as to how much sleepthey're getting per night.
For about two weeks and whenthe patients come back, we know
that if the patient truly hasinsomnia, the most common
(12:48):
underlying issue is a mooddisorder.
We know that 50% of patientswith insomnia either suffer from
anxiety and or depression andwe'll usually do a depression
scale or an anxiety scale and ifthat's the case, we'll treat
that underlying mood disorder.
If that's not the case, then wewant to rule out other things
(13:09):
that can interfere with sleep.
So in an aging population, themost common, prevalent
underlying condition thatinterferes with sleep is pain.
So people have arthritic painsthat will wake them up.
We evaluate them for that.
We evaluate them for bladderissues that might wake them up,
for bowel issues that might wakethem up at night.
We want to make sure that theirenvironment is like we talked
(13:32):
about before, is adequate and inall those cases, regardless of
what the underlying etiology isfor insomnia, the first step is
always cognitive behavioraltherapy, which includes teaching
people how to relax, teachingpeople that the stimulus, that
their sleep environment can'tact as an arousal stimulus, and
(13:56):
teaching people what to do ifthey're waking up during the
night.
So, for example, if your issueis a sleep onset issue, if you
go to bed and you're doing theright things to help your brain
relax and you're not enteringsleep after minutes, we have you
get out of bed, go in anotherroom.
You can't do somethingstimulating, you know you can't
turn the tv on.
(14:16):
You can listen to music, youcan read in a dim light and then
we have you retry bed, but wedon't let you then extend your
morning awakening past its usualtime.
So the biggest problem thatpeople have with inadequate
sleep hygiene is they don't havea regular wake-up time and
that's important, not becausethat's when you wake up, but
(14:37):
it's important because that'sassociated with your first
exposure to bright natural light.
So one of the things people cando that suffer from insomnia is
pick a regular wake-up time ispick a regular wake-up time,
usually before 9 am.
Get outside in natural sunlight, because that natural sunlight
hits your retina.
The retina is connected to yourhypothalamus and in your
(15:00):
hypothalamus is this organcalled the suprachiasmatic
nucleus which is the pacemakerfor your entire body.
It tells your body that after myfirst bright light exposure,
which usually has to be about20, 000 lux, which transfers to
being outside in natural light,you don't have to sunbathe, you
can sit in the shade, just bearound natural light, no
(15:20):
sunglasses, and you can't be hot, be behind uv protective glass,
because that eliminates that400 wave blue green light that
you need.
And your brain knows that about12 hours after that first
bright light exposure is whenI'm going to start secreting
melatonin, because that meansthat my day is over and I'll be
(15:43):
going to sleep.
So if you sleep in, or if youget up at 8 in the morning but
you don't go outside till noon,your brain thinks noon is 7
o'clock in the morning and thenyou're up at 8 in the morning
but you don't go outside tillnoon, your brain thinks noon is
7 o'clock in the morning andthen you're up till 5 in the
morning.
Dr. Michael Koren (15:54):
So you have to reset those circadian rhythms
.
So interesting, so you dorecommend that you use natural
light to help you wake up in themorning.
Dr. Mitchell Rothstein (16:01):
Yeah, and actually we call it natural
light, and you'll like thisbecause I know you like language
is a zeitgeber.
So zeit- is time and -geber isgiver or gatekeeper, and so the
most powerful zeitgeber we haveis exposure to natural bright
light.
But there's other zeitgebersthat occur all during the day.
In fact, in the early 1970sthey did a study where they took
(16:24):
eight men and they put them ina cave and they had this cave
because the cave had a standardtemperature that didn't
fluctuate during the day.
And they had them cave becausethe cave had a standard
temperature that didn'tfluctuate during the day.
And they had them in a roomwith dim light, 24 7, and they
had them served by attendantsthat came in that were always
freshly shaven.
They didn't serve them breakfast, lunch and dinner.
They served them lunch, lunchand dinner.
(16:45):
So the participants didn't knowwhat time it was to see what
our the natural was.
And it turns out that ournormal natural cycle is about
24.2 hours.
And what these zeitgebers dolight meals, exercise, change in
temperature is it shortens thatnatural cycle from 24.2 hours
(17:05):
to 24 hours.
If you don't do that, every daygets a little later and a
little later and a little later,and then you have insomnia from
that perspective as well.
Dr. Michael Koren (17:14):
So interesting, so, so interesting.
So, getting back to thatinitial diagnosis, you said it
should take about 20 minutes tofall asleep.
If it's more than 30 minutes,then you may have a problem.
And you're saying that youshould change your environment
after 20 to 30 minutes to see ifyou can find some other way to
get to sleep.
Dr. Mitchell Rothstein (17:36):
But just to interrupt, there's some
other things that you can do.
Also, if your sleep environmentis activating your brain, what
an average person wants to beable to do is they want to open
the door to their bedroom, seetheir bed, and they want their
brain to say to them oh, thankGod, I get to go to sleep.
Now, if you're opening the doorand your brain is saying to you
, oh no, I'm not going to sleepagain, I'm going to be up on
(17:59):
blah, blah, blah, you want tochange that environment.
So we have had people, you know, change their sheets, paint
their room a different color,change the position of their bed
, and that's called, you know,stimulus control therapy.
You want to have that stimulusnot there anymore, that stimulus
that was causing the arousaland the anxiety and the
difficulty falling asleep, andchange it.
(18:20):
So it doesn't do that.
In fact, a lot of people thatsuffer from insomnia find that
they have insomnia every nightwhen they're home.
They go away to a conference orin a hotel room one night they
sleep like a baby.
They come back home and they'rehaving that problem again, and
that's all due to that kind ofassociation with the bedroom not
(18:40):
being a place of relaxation andsleep.
Dr. Michael Koren (18:41):
Interesting, so interesting.
So you mentioned about sleeplogs.
Is something you do as a sleepspecialist.
I would imagine that's a littlebit challenging, because how do
you record how long it takesyou to go to sleep, if you're
sleeping?
So do you recommend devicesnowadays?
Dr. Mitchell Rothstein (18:55):
That's an excellent point.
And sleep is a perceptual issue.
So we have people in the sleeplabs.
So if you came into our sleeplab and you went to bed at nine
and then you woke up at 11, for15 minutes, you went back to bed
.
You woke up at two, you were upfor 15 minutes, went back to
bed and fell asleep and then youwoke up at four and were up for
15 minutes, fell back to sleepand then at seven o'clock I came
(19:17):
in and woke you up and I saidMike, how'd you sleep last night
?
And you go, you son of a bitch.
I was up all night Because,like you said, all you really
remember is the time you'reawake.
You don't remember the timeyou're asleep.
So, since it's a perceptualissue, when we start doing sleep
logs, we also do somethingcalled actigraphy, which is on
everybody's watch now, and itactually will record motion
(19:39):
which is fairly well associatedwith sleep, and we can see how
consistent people are with whatthey think their sleep was like,
with what the actigraph andthat's called sleep stage
misperception.
So you don't remember the timeyou're asleep, you only remember
the time you're awake.
And that separates out peoplethat have actual sleep
(20:00):
deprivation associated insomniafrom people who have the sleep
stage misperception.
Both of them can be associatedwith daytime consequences, but
they're treated a littledifferently.
Dr. Michael Koren (20:11):
Understood.
So the devices that aregenerally available to the
public.
They're usually pretty good atmaking the diagnosis, would you
say.
Dr. Mitchell Rothstein (20:18):
Well, they're pretty good at recording
the difference between sleepand wake, not recording,
obviously, differences in sleepstaging or arousal activity.
And it's really the arousalactivity, the breaking up of
sleep into these 10 to 15seconds, issues- periods that
(20:39):
are not really recognized thefollowing morning but are
associated with generalizedfatigue.
So all of us, during our courseof normal sleep, have arousals.
So during the course of an hourof sleep, an average adult
might have arousals, which aredefined on an EEG as showing
awake activity for 15 seconds orless, but not awakening you so
(21:01):
that you have memory of it, andan average adult might have 15
to 20 of these an hour.
People with insomnia have twicethat or three times that, and
they might sleep through thenight, where some of them might
actually awaken them to fullconsciousness.
But regardless of that, thatsleep fragmentation is
associated with the daytimeconsequences of fatigue and lack
(21:23):
of concentration and the thingsthat people start complaining
about.
Dr. Michael Koren (21:27):
So before we get into some of the medications
in old-time movies people usedto wear those eye shades to help
them go to sleep.
Obviously, they would not besubject to natural light to wake
them up in the morning.
If they're wearing them, isthere still a role for something
like that?
Dr. Mitchell Rothstein (21:42):
Sure, and it's not natural light that
wakes you up in the morning.
What wakes you up in themorning is your own circadian
pacemaker.
So we have these two kind ofopposing processes that help us
sleep during the night.
One is our circadian drive andone is our homeostatic drive.
So the homeostatic drive isdriven by the accumulation in
(22:03):
our brains of adenosine, that'swhat caffeine kind of
counteracts and helps us stayawake.
So during the course of the dayyour homeostatic drive
continues to go up and up, andup and up, until it reaches a
point that kind of tips you overand you go from wakefulness to
sleep.
And that's a compounded with acircadian drive.
So in the morning, when youfirst wake up before you've seen
(22:25):
sunlight, your circadian driveis at its lowest.
And then during the day yourcircadian drive kind of reaches
a peak in mid-afternoon, siestatime.
Dr. Michael Koren (22:35):
Right.
Dr. Mitchell Rothstein (22:35):
And then , interestingly, whether you
take a siesta or not, yourcircadian drive goes away and
you're feel okay again.
So even if you don't sleep, youdon't feel tired anymore, and
that kind of peaks at the sametime that your homeostatic drive
and that adenosine is buildingup during the night and then it
kind of tips you over into sleep, let's say at 11 PM, and then
during the course of the nightyour adenosine level is being
(22:57):
metabolized.
So that's going away, so you'resleeping off your sleep drive,
but the circadian clock iswhat's keeping you asleep and
continuing kind of to pelt yourbrain with GABA to keep you
sleeping till morning, at whichpoint you wake up and that's
when your temperature starts torise and your cortisol starts to
rise, and that's what wakes youup in the morning.
(23:18):
Not the bright light isn't whatwakes you up.
The bright light is actuallywhat tells you when to go to
sleep.
Dr. Michael Koren (23:22):
Got it Okay.
Now you mentioned napping.
I'm a personal big fan ofnapping.
Do you recommend that whenyou're treating insomnia?
So give us some advice aboutthat.
Dr. Mitchell Rothstein (23:34):
So the napping data that's out there
and there were plenty of studiesdone over the last couple of
decades on napping.
Napping is good for you butthere are some kind of
boundaries on it.
So number one is that if youhave difficulty falling asleep
you don't want to reduce yoursleep drives, that adenosine
buildup, and napping is going toreduce your adenosine levels.
So for people that have troublefalling asleep at night we
(23:57):
don't recommend napping and wedon't recommend napping in close
proximity to your regularbedtime because again'll reduce
your sleep drive.
But for average people nappingis refreshing.
We limit naps to about 20minutes and we want to time them
around that kind of siestacircadian bump, which is usually
about 12, 12 noon to about 2 pm, and we limit them to 20
(24:22):
minutes because that preventsyour brain from cycling into
deep sleep.
So I'm sure you've had thatexperience.
I've had it where you wake upat a deep sleep and you don't
know where you are, you have noidea what time it is, where you
are, and that's called sleepdrunkenness and that is because
your brain has cycled intodeeper sleep, which is a
synchronized, non-awake versionof sleep and it's difficult to
(24:45):
kind of get reorganized fromthat.
And when people enter that, thenap becomes unrefreshing,
whereas if they're in lighterstages, of sleep for 20 minutes,
the nap is refreshing,interesting.
Dr. Michael Koren (24:56):
Well, it's about noon right now.
Can we take a break for about20 minutes?
Dr. Mitchell Rothste (24:59):
Absolutely .
Dr. Michael Koren (25:02):
Anyway.
So, getting back to other waysof approaching insomnia, one of
the things that comes up all thetime is what medicines do you
use under what circumstances?
And there are differentcategories.
We have, of course, thesedatives, benzodiazepines being
most common.
We talked about antihistamines.
(25:23):
We talked about melatonin andother quote supplements, and
then now cannabis is beingrecommended as something that
can help a lot of people.
So what's right for people?
How do you figure that out?
Do you combine modalities?
Dr. Mitchell Rothstein (25:37):
Yeah, we definitely combine modalities.
We always combine behavioraltherapy with pharmaceutical
therapy For people that haveresistant insomnia, that have
been following all the rules thecognitive behavioral therapy,
the stimulus control, relaxation, training and they're still
having unrefreshing sleep.
That's associated with daytimeconsequences.
(25:59):
We generally start with a shortcourse of hypnotic and, as you
pointed out, the hypnotics arein different classes and some of
them have benefits over others.
The most recent class ofhypnotics out are these orexin
antagonists.
So these are fascinating drugsand the whole development of
(26:22):
this class and associated withour understanding of how sleep
works and the sleep wake kind oftoggles, which was kind of
pertinent to their discovery.
So, if you think about ingeneral, there's no advantage to
being a drowsy person walkingaround, just like you know, if
you're a drowsy zebra on theafrican veldt, you're not going
to last very long and as aperson, you don't want to be
(26:44):
drowsy.
You either want to be completelyasleep or completely awake, and
these orexin antagonists.
Orexin antagonists inhibitorexin, which appears to be the
flip switch in our brain, fromswitching from wakefulness to
sleep, so it keeps you eitherasleep when you're asleep or
(27:05):
awake when you're awake, and itdoes that by stimulating
different parts of our brainthat act on the wake centers and
the sleep centers.
Now, if you antagonize that,the major thing that orexin does
is enhance arousal.
So if you shut off arousal, youthen will have a more
propensity to go into sleep.
(27:25):
And it seems to work quite well.
It appears to be non-addictive.
They're all expensive and ingeneral, whether we're using
that group or benzodiazepines orthe Z classes of medications,
we want to limit our initial useof hypnotic to about one to two
weeks and during that period oftime, reinforcing the
(27:46):
behavioral activities andhopefully at that time the
patients can stop using thehypnotics and rely on the
behavioral techniques to keepthem asleep.
If that fails, then there's apoint where you make
determinations about whether ornot if you're treating the
underlying issues that areinhibiting sleep mood disorders.
Treating the underlying issuesthat are inhibiting sleep mood
(28:08):
disorders, pain, prostate issues, whatever the issue is, thyroid
disease, hyperadrenalism andall those issues seem to be a
baseline.
There are people who have wecall it primary insomnia, where
their brains are justhyperactive and they're just not
good sleepers.
In fact, there's a family,there's a condition called fatal
familial insomnia, where it'smostly in the Mediterranean
group.
It's an autosomal, dominantdisease and people start having
(28:31):
trouble with insomnia in theirteenage years and it's uniformly
fatal.
People die from chronic sleeploss.
And the problem with insomniais and this was just discovered
in the last decade is that yourbrain clears all these bad
proteins and neurotransmittersduring sleep through something
called the glymphatic system.
Dr. Michael Koren (28:50):
Glymphatic?
Dr. Mitchell Rothst (28:51):
Glymphatic, which is connected to your
lymphatics.
But during sleep theglymphatics, through this
extravascular penetration andconcentration differences, take
out all these prion proteins,adenosine and everything out and
filter it out and clear outyour brain so that during
daytime you can be awake andalert again.
Dr. Michael Koren (29:11):
Interesting.
So breaking it down a littlebit more in terms of those
medication classes and how youstart.
You mentioned that there's anewer class that is expensive,
but is that what you start with?
Or do you start withbenzodiazepine?
And you can mention some names,so people know what categories
you're talking about.
Dr. Mitchell Rothstein (29:30):
-And this is obviously
patient-dependent,cost-dependent.
The traditional oldbenzodiazepines like triazolam,
flurazepam, temazepam areeffective and good.
Dr. Michael Koren (29:43):
Use some of the trade names so people know
Halcyon.
Dr. Mitchell Rothstein (29:44):
Right.
Halcyon and Tamezapam isRestoril.
Those medications and these areclassic benzodiazepines, all
that group are effective ashypnotics.
Dr. Michael Koren (30:00):
They're short-acting drugs in the Valium
class of drugs but they'reshorter-acting yeah.
Dr. Mitchell Rothste (30:04):
Absolutely .
And the problem with that classis they can be addictive and
they can have other consequences.
So that whole class isassociated with not only
hypnosis but anxiolysis,anti-convulsant activity and
myorelaxation and they can havecross-effects with other
medications that people are on.
There's another class calledthe Z medications, which is like
(30:28):
Ambien and Lunesta and thoseare benzodiazepine-like.
They hit the same receptor butthey don't have the anxiolysis
and the muscle relaxant activityand they seem to have less of
the potential for drug-druginteractions but also addictive
less of the potential fordrug-drug interactions, but
also, addictive.
These orexin antagonists don'tappear to have addictive
(30:49):
activity because they don'tactively put you to sleep.
They're not depressing, they'restopping a lot of that arousal
activity from coming in.
Dr. Michael Koren (30:57):
And examples of those?
Dr. Mitchell Rothstein (30:59):
Are things like daridorexant,
suvorexant, lemborexant.
In fact, one of the firststudies I did with the
Jacksonville Center for ClinicalResearch was about using the
orexin antagonist yeah,suvorexant.
Dr. Michael Koren (31:12):
And a trade name for those.
Dr. Mitchell Rothstei (31:14):
Belsomra, Quivivic are the two most
common that are out there that Ican recall [also Dayvigo].
There's also ramelteon, whichis pharmaceutical melatonin, so
that appears to again have aplace for maybe sleep onset in
some patients and for jet lag,for circadian rhythm disorders
(31:35):
and as a hypnotic.
Overall it's still in thatcategory but doesn't seem to be
as powerful as the othermedications.
Dr. Michael Koren (31:42):
So interesting.
And how about cannabis?
That's become something that alot of people are talking about
as a treatment for insomnia.
Dr. Mitchell Rothstein (31:49):
Cannabis ?
I didn't know, but there arecannabinoid receptors in our
brain and they have effects onmuscle tone as well as
electrical activity.
They appear to have theirprimary hypnotic effect through
anxiolysis, so people that areanxious appear to benefit from
(32:09):
them.
There aren't a lot of long-termstudies on whether cannabis is
a good long-term medication forinsomnia, but certainly can be
used in the short term andintermittently.
Dr. Michael Koren (32:23):
Any advice for people You're having trouble
sleeping for a week Should yougo to your local dispensary and
get a joint?
What should you be doing?
Dr. Mitchell Rothstein (32:32):
Well, as a still practicing physician, I
have to offer conservativerecommendations, not ones that I
would necessarily follow, butones that everybody else should.
Dr. Michael Koren (32:43):
Sure.
Dr. Mitchell Rothstein (32:44):
And so I would say in general that the
initial approach to insomnia ifit's transient insomnia, if you
know what's causing it, if youknow that you were upset by
something or you just hadsurgery and you're having
trouble sleeping for a shortperiod of time, a short course
of a hypnotic may be beneficial.
If you have insomnia and youdon't know what's causing it,
(33:08):
that's where you want to thinkabout seeking medical attention,
because that's an investigationalong the lines we just talked
about that should be undertakento help you.
It's a devastating illness.
It affects people's socialactivities, it affects their
whole life, and when your wholelife is about not sleeping well,
(33:30):
that's not the kind of lifemost of us want to live.
Dr. Michael Koren (33:34):
Well, that was a brilliant, brilliant
summary.
Mitch, thank you very much forsharing that information with
the MedEvidence audience.
And fortunately, I don't havethe sleep problem, but I know
people in my life that do and Ifeel that I am now better
prepared to help them.
So, thank you so much.
Dr. Mitchell Rothstein (33:51):
Thank you.
Announcement (33:52):
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