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Some Drugs That Interfere With Sleep

Cause Example
Drug use Alcohol

Anticonvulsants (eg, phenytoin)

Antimetabolite chemotherapy

Certain antidepressants of the SSRI, SNRI, MAOI, and TCA classes

CNS stimulants (eg, amphetamines, caffeine)

Oral contraceptives


Steroids (anabolic steroids, corticosteroids)

Thyroid hormone preparations

Drug withdrawal Alcohol

Certain antidepressants of the SSRI, SNRI, MAOI, and TCA classes

CNS depressants (eg, barbiturates, opioids, sedatives)

Illicit drugs (eg, cocaine, heroin, marijuana, phencyclidine)

MAOI = monoamine oxidase inhibitor; SNRI = serotonin-norepinephrine reuptake inhibitor;
TCA = tricyclic antidepressant.

Epworth Sleepiness Scale

Sitting and reading
Watching TV
Sitting inactive in a public place
Riding as a car passenger for 1 h continuously
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
Sitting in a car stopped for a few minutes in traffic
For each situation, probability of dozing is self-rated as none (0), slight (1), moderate (2), or high
(3). A score of ≥10 suggests abnormal daytime sleepiness.
Sleep Hygiene
Measure Implementation
Regular sleep/wake Bedtime and particularly wake-up time should be the same each
schedule day, including weekends. Patients should not spend excessive time
in bed.
Appropriate use of the bed Limiting time in bed improves sleep continuity. If unable to fall
sleep within 20 min, patients should get out of bed and return
when sleepy. The bed should not be used for activities other than
sleep or sex (eg, not for reading, eating, watching television, or
paying bills).
Avoidance of daytime naps, Daytime naps may aggravate sleeplessness in patients with
except by shift workers, the insomnia. However, naps decrease the need for stimulants in
elderly, and patients with patients with narcolepsy and improve performance in shift
narcolepsy workers. Naps should be taken at the same time each day and
limited to 30 min.
Regular routine before A pattern of activities—brushing teeth, washing, setting the alarm
bedtime clock—can set the mood for sleep. Bright lights should be avoided
before bedtime and during nocturnal awakenings.
Sleep-conducive The bedroom should be dark, quiet, and reasonably cool; it should
environment be used only for sleep and sexual activity. Heavy curtains or a
sleep mask can eliminate light, and earplugs, fans, or white-noise
devices can help eliminate disturbing noise.
Pillows Pillows between the knees or under the waist can increase
comfort. For patients with back problems, helpful positions
include lying supine with a large pillow under the knees and
sleeping on one side with a pillow between the knees.
Regular exercise Exercise promotes sleep and reduces stress, but if done in the late
evening, it can stimulate the nervous system and interfere with
falling asleep.
Relaxation Stress and worry interfere with sleep. Reading or taking a warm
bath before bedtime can aid relaxation. Techniques such as visual
imagery, progressive muscle relaxation, and breathing exercises
can be used. Patients should not watch the clock.
Avoidance of stimulants and Drinking alcoholic or caffeinated beverages, smoking, eating
diuretics caffeinated foods (eg, chocolate), and taking appetite suppressants
or prescription diuretics—especially near bedtime—should be
Bright light exposure while Light exposure during the day can help rectify circadian rhythms,
awake but if light exposure is too close to bedtime, it can interfere with
Guidelines for the Use of Hypnotics
Define a clear indication and treatment goal.
Prescribe the lowest effective dose.
Except for specific hypnotics and patients, limit duration of use to a few weeks.
Individualize the dose for each patient.
Use lower doses in patients also taking a CNS depressant, in the elderly, and in patients with
hepatic or renal disorders.
Avoid* if patients have sleep apnea or respiratory disorders or a history of sedative abuse, if they
are drinking alcohol, or if they are pregnant.
For patients who need longer-term treatment, consider intermittent therapy.
Avoid abruptly stopping the drug if possible (ie, taper it).
Re-evaluate drug treatment regularly; assess efficacy and adverse events.
*Ramelteon is an exception; it can be given to patients with mild to moderate obstructive sleep
apnea or COPD or a history of sedative abuse. Low-dose doxepin also has no abuse liability.