WHAT ABOUT SLEEP MEDICATIONS? ARE THEY SAFE?

Over-the-counter medications promoted as sleep aids are primarily anti-histamines & work well for many with mild sleep disorders (especially if you have a chronic sinus allergies). Some people experience side effects of daytime drowsiness, disorientation, blurred vision or dry mouth, which makes this otherwise safe medication too difficult to tolerate. They do not provide effective and sustained relief for more severe sleep disorders.

The "benzodiazepines" are the most widely used prescription medications indicated for short-term treatment of anxiety and/or insomnia. These prescription medications bind to the GABA receptor complex reducing anxiety, inducing muscle relaxation and inhibiting convulsions as well as promoting sleep.

They are generally safe and effective for short-term use. They include Temazepam (Restoril), Triazolamm (Halcion), & Lorazepam (Ativan). Their possible side effects include decreased daytime alertness, energy, concentration, and/or memory functioning, and possibly even depressed mood. With regular use for more than several weeks at a time, these medications may significantly reduce time spent in REM sleep, resulting in these and other side effects including mood swings, irritability, temper outbursts, anxiety, and (ironically) insomnia.

Because they are potentially habit-forming or addictive, regular use of benzodiazepines for more than several weeks at a time should be avoided, except in rare cases. In addition to the side effects noted above, the negative consequences long-term daily use include the need for increased dose to achieve the desired effects (becoming "immune" to the medication or "tolerance"); the urge to take more medication than is prescribed ("abuse"); and the uncomfortable and potentially dangerous withdrawal symptoms on attempts to discontinue the medication (due to "physiologic dependence").

Care should be taken when by anyone with liver and kidney disease to those who are heavy snorers, and to the elderly. These medications have been associated with birth defects when taken by pregnant women. It is extremely important for women of childbearing age to use the most reliable methods of contraception possible when taking these medications.

Zaleplon (Sonata) & Zolpidem (Ambien) are non-benzodiazepine prescription medications for insomnia. They have minimal adverse effects on sleep architecture, and no evidence of rebound insomnia at recommended doses. Side effects can include memory impairment, sleepwalking, and morning drowsiness.

For chronic insomnia associated with other symptoms of Clinical Depression, I have had excellent results with the so-called "anti-depressant" medications. They are not habit-forming, restore sleep architecture to normal, have minimal to no side-effects when properly selected and dosed. They tend to improve all symptoms of the syndrome of Clinical Depression, as well as reducing a wide variety of aches & pains. Examples include Trazodone (Desyrel), Amitriptyilne (Elavil), and Remeron (Mirtazapine).

Regarding “anti-depressant” medications, talk to your healthcare provider about trying the lowest dose possible and about gradual increase of the dose until your symptoms are resolved. These agents can potentially have a wide variety of side effects, including daytime drowsiness & decreased impaired daytime energy, which are usually minor and temporary. In some individuals, these medications can actually worsen sleep disturbance & mood.

Remember: what counts is how you feel, not how many hours of sleep you've had. If you are alert, feel rested, and function well during the day, chances are you're getting enough sleep.

Sweet Dreams!

For more information: National Sleep Foundation http://www.sleepfoundation.org

How We Measure Pain: The “Four A’s”

Because we don’t have a blood test or x-ray that measures pain, it can be difficult to explain, evaluate, and track. So, how can we “measure” in the doctor’s office?

One of the best methods that we have is to follow the “Four A’s:” Analgesia (pain relief), Activities of Daily Living (functioning at home & work), Adverse Effects (medication side effects), and “Aberrant Behaviors” (warning signs for addiction).

For “Analgesia” (pain relief), the standard method at this time is to use the “1-to-10” scale, where “10 is the worse pain you can imagine” and “1 is barely noticeable pain.” Variations on this scale include pictures of the scale with more detailed descriptions of each level of pain.

For many people, this is not an easy scale to use. But it is an important tool to help the healthcare provider to understand how much relief a person is getting from their current treatment. I often suggest “imagine that we stop all of your medication…let’s call that a ’10’…so, WITH the medication you are now taking, how far away from a ‘10’ does that get you? Is there a 50% reduction in your pain, or 20%, 80%...?”

This scale is a tool to help the healthcare provider understand if the pain is better or worse since the last change in medication dosage. It is also important to communicate about changes in how much medication was actually taken, any unauthorized dosage increases, or running out of medication early, and how changes in the amount of medication taken affected the pain.

“Activities of Daily Living” (ADL’s) refer to a person’s ability to perform usual activities in important areas of their life: as parent, spouse, friend, family member, work, leisure, and community activities. Sometimes, the level of pain does not change because the person will increase their activity until they get to a certain level of pain. So, if pain has stayed the same but the person is able to do twice as much activity as before, this would be considered a positive treatment outcome.

“Adverse Effects” refer to medication side effects. It is important for those taking medication to inform their healthcare provider of any symptoms that get worse with an increase in any medication dosage. Some Adverse Effects are not medically dangerous (such as dry mouth), what I think of as “nuisance” side effects. Others can be medically dangerous, such as heart rhythm abnormalities, or changes in liver or kidney functioning. Some medications have Adverse Effects can be detected early only with blood work, and can cause severe illness if the one waits until they feel sick before they investigate.

The most important thing here is the communication between healthcare provider and the patient regarding any worsening of any symptoms, and being informed about any “routine” tests which should be performed for medication(s) being taken on a regular basis.

“Aberrant Behaviors” is a term that healthcare providers use to refer to those behaviors that may be a “warning sign” for addiction, which can occur with narcotic pain medication (or other potentially habit-forming medication) in genetically susceptible individuals.

Examples of “Aberrant Behaviors” include taking pain medications for symptoms other than pain (such as anxiety or sleep); unauthorized dosage increases, adverse effects on mood, irritability, anxiety, or sleep; intoxication; or motor vehicle accidents. Each of these alone would not result in a diagnosis of addiction, but it is best for the healthcare provider, the person taking the medication, and the family should all “be on the lookout” for any adverse behavior changes that continue or worsen over time when taking any potentially habit-forming medication on a regular basis. It is also important to avoid drinking alcohol with narcotic pain medication.

Healthcare providers can provide safe and effective treatment for pain conditions, but only with good communication about “the Four A’s” can the best possible treatment outcomes be safely achieved.

Acetaminophen: Miracle Drug or Liver Toxin?

Acetaminophen: Miracle Drug or Liver Toxin?

Today we are reading reports that the Food and Drug Administration (FDA) “assembled 37 experts to recommend ways to reduce deadly overdoses with acetaminophen, which is the leading cause of liver failure in the US and sends 56,000 people to the emergency room annually.”

As a physician who specializes in Pain Medicine for the last 20 years, I routinely order blood work to measure liver function studies at least once/year in those who are taking acetaminophen on a regular basis.

In my experience, everyone I have seen who has liver damage due to taking too much acetaminophen has either intentionally overdosed on acetaminophen or taken large doses of acetaminophen with pre-existing liver disease from other causes, such as Hepatitis C or alcoholic liver disease.

For those with pre-existing liver disease due to Hepatitis C, long term alcohol abuse, or other causes, I would recommend that they avoid acetaminophen completely. In my experience, acetaminophen will certainly “pour gasoline on the fire” of any pre-existing liver disease.

As the news reports correctly point out, acetaminophen is contained in many non-prescription medications (such as cold remedies, pain medications) as well as prescription medications (such as Vicodin, Lortab, Lorcet, Percodan, & Percocet).

Some people with severe pain conditions take more than the recommended maximum dosage of acetaminophen (two 500mg tablets up to 4 times daily) in order to get relief from their pain without going to a doctor or having to take prescription medications. I would certainly recommend against this.

BOTTOM LINE

If you have liver disease from other causes, such as Hepatitis C, regular alcohol use, or other causes, avoid regular use of significant amounts of acetaminophen and get blood work to track changes in liver function studies.

If you do not have liver disease, occasional use of acetaminophen is safe as long as you’ve never had an allergic reaction.

If you take acetaminophen on a regular basis, either alone or as an ingredient contained in other medications, speak with your healthcare provider about getting blood work to measure you liver function studies.

If your liver function studies are normal, then there is no evidence that your current intake of acetaminophen is doing harm. If they are elevated, then discuss this with your healthcare provider. Consider stopping acetaminophen & alcohol, and ask your healthcare provider about further investigation into other possible causes of liver disease, including other medications that can cause liver enzyme elevations.

Pain Treatment Outcomes: The “4 A’s”

“Treatment outcomes” is the term used by healthcare providers that refers to benefits as well as side effects that result from a particular treatment, or combination of treatments, at a particular point in time. For chronic pain conditions, one way to categorize these is known as the “4 A’s”:

Analgesia (pain relief), Activities of Daily Living (ability to do things that you want or need to do), Adverse Effects (side effects), and Aberrant Behaviors (behaviors that may be warning signs for a problem with addiction).

The first “A” stands for “Analgesia” which refers to the amount of pain relief from current treatments. The standard measurement for this is the “1 to 10 scale.” Some people find this difficult to use, but it is an important tool for communication between the person who suffers from the pain condition and their treating physician. “10/10” represents “the worst pain you can imagine.” I often suggest that the chronic pain sufferer “imagine that all medication has been stopped--THIS would be 10/10.”
So to assess analgesia, or the amount of pain relief, the question becomes:
“WITH THE MEDICATION YOU ARE NOW TAKING, HOW MUCH LESS THAN 10/10 IS YOUR PAIN LEVEL? HOW MUCH BENEFIT ARE YOU GETTING FROM YOUR MEDICATION?”

The second “A” stands for “Activities of Daily Living, which refers to your ability to do things that you want or need to do. This begins with basic issues of taking care of yourself, and extends to your ability to perform activities as parent, spouse, friend, family member, work, hobbies, & community member, including religious activities. The goal here is for treatment to increase your ability to function in these areas.

Very often there are physical problems with being able to do things that you want or need to do, because some of these activities make pain worse, and may even do physical damage to bones, discs, joints, or soft tissues (tendons, ligaments)

Managing Pain: Nursing Diagnosis & Decision Making presented at Baptist Memorial Hospital Nursing Staff

I enjoyed the opportunity to speak to a group of 40 nurses at Baptist Memorial Hospital in East Memphis regarding an important area of interest to them: how to administer enough narcotic pain medication to relieve suffering, while avoiding potential adverse medical & behavioral effects that these medications can have.


We discussed the nursing decision-making process, which involves not only assessment of the type & severity of the pain, but also the warning signs that additional dosages of narcotic pain might actually result in more side effects than benefits. They received a handout that included signs and symptoms of narcotic side effects, toxicity, & withdrawal.


As with any issue dealt with by healthcare professionals, understanding important aspects of the patient’s recent & past medical history is essential for achievement of best possible clinical outcomes. These include:

• Since your last dose of pain medication, in what way(s) are you feeling better, and in what way(s) are you feeling worse?


• Is this pain relatively recent in onset, or has this been present for months, or even years, prior to this hospitalization?


• Have you been taking pain medication on a regular basis, & for a long time? How much pain medication have you taken in the last week, or the last month?


• Which medication(s) have worked well in the past? Which have had adverse side effects?


• What about non-medication techniques?

Another concern was that some patients seem to request narcotic pain medications in order to feel better emotionally, as well as physically. This leads to the question of whether a particular patient may have a problem with addiction, with or without “real” physical pain. We discussed the warning signs of inappropriate use of these medications by patients, diagnostic criteria for addiction, and how nursing staff can intervene when concerned about this.

We also spoke about different routes of administering medication: IV vs oral, and the importance of making the transition to oral medications as discharge approaches.

One theme that consistently emerged during our discussion was communication. Communication with the patient, getting the point of view of concerned family member(s), keeping physicians informed about issues of concern, and keeping patients informed regarding their decisions about how & when to take or not take narcotic pain medications, including preparation for transition to home after discharge.

As always, the nursing staff enjoyed the opportunity to ask questions & learn about important clinical issues that concern their ability to provide the best possible care to their patients in the hospital, who face difficult & complex illnesses. Their highest concern was to improve their ability to provide the most effective possible treatment, while following the first rule of healthcare: “do no harm.”