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Sleep Disorders

Chronic Insomnia

12/02/2008

Question:

I have been "suffering" with chronic insomnia. This started after I had a spinal fusion with titanium implants. Three (3) doctors have acknowledged that the titanium does cause insomnia in some people but no one can come up with a remedy for the insomnia. I have been on hundreds of medications, and I am not kidding. Benzapin`s, opiates, sleeping pills, nothing helps. I have gone to a hypnotist, and I was the first person in 15 years that she could not get to go under. I have had accupuncture for six months, and it did not help. I just need to sleep for more than 15 minutes. Can you help? Any suggestions, please.

Answer:

Insomnia is very common in modern society with an estimated 1/3 of Americans suffering from insomnia at any one point in time. Fortunately, the majority of cases are short-term and resolve within weeks, rarely requiring prolonged therapy. However, up to 20 million Americans complain of problems with chronic insomnia that may significantly effects their life, so you are not alone.

Insomnia has multiple underlying causes. Identifying the underlying factors that are contributing to insomnia are extremely important to ensure appropriate treatment. It’s of interest that you mention your insomnia started after spinal fusion surgery with titanium implants. While I don’t have much experience with titanium implants, I was unable to find anything in the medical literature suggesting a link between titanium or implants and insomnia. It would be interesting to hear more about your doctors experience in this regard.

Insomnia can usually be divided into two broad categories: trouble falling asleep at the start of the night (also known as sleep onset insomnia) and difficulty staying asleep during the night (also known as sleep maintenance insomnia). Some individuals may experience problems with both. Factors affecting one’s ability to fall asleep at the start of the night, as you describe, are quite varied and may include one or more of the following; a poor sleep environment (i.e. the bedroom is too noisy, too bright or too warm), learned poor sleep habits (i.e. watching TV to fall asleep), excessive use of stimulants (both medications and common substances such as caffeine and nicotine), certain medications, stress or anxiety, pain, medical conditions that may make it uncomfortable or difficult to breath well when lying down, heartburn, restless legs syndrome (an irresistible need to move the legs when awake at night) and circadian rhythm disturbances (when the body’s biologic rhythms are out of synchrony or delayed). The problem of maintaining sleep, or staying asleep once you fall asleep, has other underlying causes such as; depression, substance abuse (especially alcohol use, that can result in withdraw in the middle of the night), certain medications, pain, medical conditions that cause frequent urination throughout the night, heartburn, breathing disturbances in sleep, leg jerks in sleep and circadian rhythm disturbances (when the biologic rhythms are advanced earlier in the night). Shift workers are particularly vulnerable to changes in their circadian rhythms that may create problems with insomnia. Occasionally some individuals will not have any of these underlying causes contributing to their insomnia and their condition is often labeled as “idiopathic insomnia” or insomnia for which a cause can not be found.

As you can see, insomnia is a complex problem that requires a detailed evaluation to help sort out important underlying factors that may need to be addressed. In your case, further history should be obtained to try to pinpoint any specific causes of your insomnia before labeling this as idiopathic insomnia. This type of evaluation often starts with your primary care physician, but may require the help of specialist in insomnia. Referral to a Sleep Specialist is necessary in some cases. A Sleep Specialist will take a detailed history and perform a physical examination. Based on this information, they will determine if further testing is needed or if a treatment strategy can be initiated.

Most cases of chronic insomnia can be managed without the use of sleep-inducing medications. If a specific cause of the insomnia can be identified, then treatment should be directed at that issue. Often times, behavioral therapy can be very effective for patients whose insomnia is the result of a poor sleep environment, poor sleep habits or psychological conditions. Some of the techniques used for behavioral treatment of insomnia include stimulus control therapy and sleep restriction. If interested, you should discuss these techniques with your physician. Improving “Sleep Hygiene” can make a dramatic impact in some cases (see the “Steps You Can Take to Improve Your Sleep” on the website).

Drug therapy is required to manage insomnia for some individuals, though caution should be exercised with long-term use of some medications. Certain sleep agents, such as benzodiazepines, are often accompanied by daytime sleepiness, fatigue and problems with tolerance (or losing effectiveness over time). These effects may be seen less with some of the newer sleep-inducing medications such as zolpidem (Ambien), zaleplon (Sonata), or eszopiclone (Lunesta), though chronic long-term use of these agents has not been well-studied. Melatonin, a naturally occurring sleep-inducing substance, has been found to be variably effective for treating insomnia. It may play a role in treating some individuals who have insomnia and are lacking normal melatonin secretion, but this does not appear to be common. It is probably most effective in treating those who have problems related to their underlying biologic or circadian rhythms, as melatonin will help to regulate these. Usually a dose of 1 mg at bedtime is adequate. Users of melatonin should be aware that this drug is not regulated by the FDA. Recently, a new melatonin-like substance, ramelteon (Rozerem), was approved for the treatment of insomnia. This medication appears to be fairly well-tolerated and is the first uncontrolled medication approved by the FDA for the treatment of insomnia.

To learn more about insomnia or other sleep disorders, please visit the American Academy of Sleep Medicine website. In addition to information, the website contains a list of Sleep Centers across the country so that you may locate one near you. Good luck and here's to good sleep!

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Response by:

Dennis   Auckley, MD Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University