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So I am in quite a nasty situation.  Over 3 months ago I was able to kick my addiction to heroin with therapy and Suboxone. Also, I successfully got my bipolar II under control with Lithium ER 900mg and Seroquel XR 300mg.

For the last 6 weeks I am having fragmented sleep. I am able to fall asleep relatively easily only to wakeup after 2hrs.  I then go back to sleep and from then on I wake up roughly 5 times a night. 

I've eliminated all caffeine from diet, I don't smoke cigarettes within 2hrs of bed and I don't watch TV or use any other screen before retiring. 

My addiction specialist has tried me on

trazadone 150mg--did nothing

Doxepin 75-150mg--only makes me sleeoy

Ambien CR (w/ doxepin)--barely any change. I think it slightly improves the quality of sleep in between waking up.

 

Does anyone have any recommendations for a sleep maintenance medication?  I prone to rapid weight gain from AP's and dont want to double up as I am taking quetiapine already. 

For what it's worth....my sleep hygiene is very good. I've started exercising in the morning before work.  I work as a credit analyst and sit in front of a computer from 9 to 5.  HOWEVER...my insomnia is causing me to nod off at my desk which is unacceptable. 

Any tips/ideas/recommendatins are welcome. Mikl_pls I'm looking your way as you are the resident amateur psychopharmacologist. ;-)

Edited by tommy215
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I forgot to mention...

My doctor and I are both open to using benzodiazepines.  I realize they carry risks for people in recovery like myself however my doctor feels that the lack of sleep outweighs the risks of using benzodiazepines.

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Have you tried Remeron (mirtazapine)? It is an antidepressant that is very sedating. Unfortunately, it also has a side effect of appetite increase. I know you said that you are prone to gaining weight from antipsychotics, but Remeron is not an antipsychotic and you won't gain weight if you control what you eat. When I took Remeron, I had to get at least 9 hours of sleep each night. For me, the sedation was far greater than from any benzo I have ever taken. When I first started taking it, it hit me like a sledgehammer.

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Trazodone is my main sleep med....However, I take 200mg........I also take 2mg Klonopin at night, too, so I think a benzo might help you at least somewhat if your doc is open to it.

My doc would prescribe up to 300mg Traz if I needed it, so upping the dosage of Trazodone might be something you could try if your doc agrees.

There's also Lunesta (eszoplclone), which is related to Ambien, but might be worth a try.....There's another fairly new sleep med called Belsomra, that works well for some folks.

Remeron (mirtazipine) helps some people, too, as jt mentioned above.

Edited by CrazyRedhead
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4 hours ago, tommy215 said:

Over 3 months ago I was able to kick my addiction to heroin with therapy and Suboxone. Also, I successfully got my bipolar II under control with Lithium ER 900mg and Seroquel XR 300mg.

Congratulations for overcoming such a feat! I think I can speak on all our behalves that not only are we glad that you sought treatment for both your addiction and your bipolar and was successful, but also found CB! Also, as for the diagnosis of BP, it seems difficult to get it right for some people. I've had it probably since adolescence, but wasn't diagnosed and treated for it until I was 25.

4 hours ago, tommy215 said:

For the last 6 weeks I am having fragmented sleep. I am able to fall asleep relatively easily only to wakeup after 2hrs.  I then go back to sleep and from then on I wake up roughly 5 times a night.

I, too, suffer from this problem... I've yet to quite figure out what to do about it. I was on Belsomra, a med @CrazyRedhead mentioned, and it was the best sleep med I have ever taken, but my insurance was like "yeah we're not going to pay for this anymore, so yeah, just go ahead and stop taking that and ask your doctor for a similar medicine and that'd be great." There are no medicines similar to Belsomra, it's a medicine in a class to its own! Sorry. But yeah. I'll mention some possible meds and med combinations.

4 hours ago, tommy215 said:

For what it's worth....my sleep hygiene is very good. I've started exercising in the morning before work.  I work as a credit analyst and sit in front of a computer from 9 to 5.  HOWEVER...my insomnia is causing me to nod off at my desk which is unacceptable.

You may want to have a sleep study performed. I'm not insinuating you have sleep apnea, I think there might be some other things involved. You could have restless leg syndrome, periodic limb movement disorder, or even seizures in your sleep (which is my case), which all can disrupt your sleep cycle and cause you to feel fatigued throughout the day and leave you with sleep that doesn't feel refreshing or energizing. Or it could be primary insomnia, or secondary insomnia (due to [...]). My first sleep doctor diagnosed me with idiopathic hypersomnia, but now because they know I have nocturnal seizures, they rediagnosed me with hypersomnia, unspecified (the hypersomnia is secondary to the seizures, really). So your insomnia could be secondary to one to a plethora of things. Getting to the bottom of the root cause of your insomnia and treating that first would be preferable rather than slapping a Band aid on it with a benzo or another type of sleep medicine leaving the root cause to be untreated and possibly worsen with time. If treating the root cause doesn't work with multiple trials of different medications and dosages and even polypharmacy (or devices), then something like a stimulant or eugeroic (wakefulness promoter) like Provigil or Nuvigil might be added to help promote daytime wakefulness and/or a sedative of some sort (GABAergic, antihistaminergic, antidopaminergic, etc.) may be indicated.

For example, if you have a circadian rhythm sleep disorder, like shift work sleep disorder or something, that would qualify you (as far as a PA for insurance) for one of the eugeroics so you'll be alert and focused during the day and perhaps even help regulate your sleep-wake cycle so you can actually sleep peacefully and continuously at night. If you have RLS, they would prescribe a dopamine agonist and/or gabapentin/Lyrica to help with that. If you have periodic limb movement disorder, they might use carbidopa/levodopa, dopamine agonist, or anticonvulsants, I think. But my point is these all cause disturbances in sleep and daytime sedation and their treatment doesn't indicate a sedative (at least to my knowledge).

That's why a sleep study might be in your best interest.

However, a list of medications and medication combinations that might help you with sleep maintenance...

  • Does Seroquel XR make you drowsy or sleepy at 300 mg? It's supposed to last all night and I think the next day if I'm not mistaken. Maybe you could ask your pdoc about that, since I'm not sure, and ask him if there's any benefit in raising the dose to see if it helps with your sleep continuity.
  • Some good suggestions have been put out there already by @jt07 and @CrazyRedhead.
    • Remeron (mirtazapine) is an antidepressant, but it's a very unique one in that it doesn't cause reuptake inhibition of any neurotransmitters. It just blocks certain receptors to enhance release of serotonin and norepinephrine. At low doses though, it mostly acts like a very, very potent antihistamine (I think I read somewhere that it's the most potent antihistamine on the market right now, prescription or OTC). Antihistaminergic action will make you sleepy (but can also make you eat more and get fat), and you're already getting quite a lot of antihistaminergic action from Seroquel XR, so maybe it might be worth it to look for another mechanism of action to synergize with the Seroquel XR.
    • I'm surprised you took doxepin given your sentiments regarding weight gain (I feel the same about it too... and doxepin didn't work for me either... lol)
  • Trazodone: You tried it up to 150 mg, but maybe just an extra 50 mg might work? Going up to 300 mg is going into antidepressant territory and can actually be a little stimulating if you take 300 mg or above all at once.
  • Belsomra: YES. If you can get your hands on a prescription of this, and they have a copay coupon, YES. This is definitely worth a try in my opinion. A lot of people seem to hate it, but I loved it. *shrugs*
  • Benzodiazepines: these will actually disturb your sleep architecture, and are really meant for short-term use, but people use them for years with no problem. But it might be a good idea to go on a "benzo" holiday, similar to how people with ADHD ought to go on "stimulant" holidays (but I never do because without a stimulant I'm useless...)
    • Halcion (triazolam) is the shortest-acting benzo, and is more for sleep initiation, so probably wouldn't work well for sleep maintenance.
    • Restoril (temazepam) is indicated for insomnia. It does a decent job. It pooped out pretty quickly for me, but our brain chemistry likely differs vastly. I think this one is considered a mid-acting benzo according to Epocrates.
    • ProSom (estazolam) is another indicated for insomnia. This is a strange one. It can either work quickly or slowly, depending on the person. But it's a mid-acting benzo too. I wanted to like this one but it just didn't work, but I'm very benzo resistant.
    • Ativan (lorazepam) has many indications, and one of them happens to be insomnia. I can't attest for its effectiveness because it does nothing for me. But apparently many people take it for insomnia and love it. It's a mid-acting benzo, and I've heard it acts quickly, like almost as quick as Xanax, and I've heard it can take at least 1-2 hours to take effect, so I guess it depends on the person.
    • Klonopin (clonazepam) (as @CrazyRedhead mentioned): this one isn't indicated for sleep, but it's often used for it. It's rather slow passing the blood-brain barrier and about the same coming off in effects, so it's good if you think you're liable to become addicted or dependent on a benzo.
    • Dalmane (flurazepam) is a benzo that my pdoc refuses to prescribe me. She has told me that it's dangerous for many reasons I can't remember, but it has an extremely long half-life and can supposedly build up in your system if you use it every night. This one isn't one to play around with from what she's told me. It acts quick, and stays in your system for at least 5 days according to Epocrates.
  • Nonbenzodiazepines:
    • @CrazyRedhead also suggested Lunesta (eszopiclone), and if it works for you, it should be a fantastic medicine, because it's designed, like I think Ambien CR is, to work quickly to help you fall asleep, and stay in your system just long enough to get a good night's sleep and not be in your system anymore by the time you wake up so you won't have that residual hang-over-like feeling. Personally, I hate to admit, but one time I took an inordinate number of Lunesta tablets and I laid awake in bed all night until the sun came up in the morning. I highly advise not to do that regardless of your response to it.
    • Ambien (zolpidem): if you didn't respond to Ambien CR, I don't think this would be worth bothering with.
      • Edluar (zolpidem sublingual): a new product, may or may not be able to be covered by insurance without a PA. May work better than regular Ambien.
      • Zolpimist (zolpidem oral spray): another new Ambien product. I swear by this one. I thought I was resistant to all of this class of meds, but Zolpimist 10 mg knocks me out, and if I do have to get up in the night, say to go to the bathroom or get a glass of water, I go right back to bed until morning. This stuff is amazing. Expensive! But amazing. It requires a PA with my insurance, not sure about yours. But I'd definitely check this out!
    • Sonata (zaleplon): a very short-acting one designed for sleep initiation. It actually works quite well for me, but I always wake up in the middle of the night/early morning.

5-HT2A antagonism also causes sedation, but you've already got that going on with your 300 mg Seroquel XR.

So Seroquel XR gives you antihistamine + 5-HT2A antagonism, + a GABAergic with a semi-long half-life (temazepam, estazolam, lorazepam, eszopiclone, or try Zolpimist! if possible that is). To top it off, if you can get your hands on Belsomra, the antiorexigenic action on top of that would be the ultimate OMG-I'M-GOING-TO-BED-NOW combo. BUT, it may be overkill to get all that together, which is precisely why you need to talk to your pdoc or addiction specialist about it.

4 hours ago, tommy215 said:

Mikl_pls I'm looking your way as you are the resident amateur psychopharmacologist. ;-)

Aw man, thanks... I'm both flattered and humbled. I don't feel I deserve to be called that though... lol :3

Best of luck to you in finding something(s) that help you! Let us know!

 

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@mikl_pls thank you for your input. I'm going to request a proper sleep study. In the meantime, I'm going to stick with doxepin 75mg and ask for ProSom (estazolam) and/or Restoril (temazepam) I've been doing some extensive reading on them and they seem to be the next best choice(s).  I checked my formulary and Belsomra is non preferred brand...so maybe I'll ask for 5 day trial or something and pay cash. My physician offered Dalmane as the next choice but I'll reserve that for later if needed.

I forgot to mention that I've tried mirtazapine. It's great for sleep induction but that's about it...at least for me. 

@CrazyRedhead and @JT1234thank you guys for the recommendations. Also to everyone else I may have forgotten. 

I'll report back with my results of the temazepam or estazolam!

 

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18 hours ago, tommy215 said:

I checked my formulary and Belsomra is non preferred brand...so maybe I'll ask for 5 day trial or something and pay cash

You can get a copay coupon on their website I believe. They come in sample packs of 3 pills per pack.

Good luck!

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