Is there a role for Xyrem in refractory insomnia?

[firedoor]

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When all GABA and melatonin receptors have been agonized, all histamine receptors antagonized, there is no substance abuse, strict sleep hygiene is complied with and all iatrogenic and medical causes are ruled out, may there be a role for Xyrem in refractory insomnia?

Or should Na channels be attacked first? Opiod/catecholamine/5-HT receptors?

P.S. I'm not touching propofol (RIP MJ).

 

[michaelrack]

there are anecdotal reports of xyrem for primary insomnia and I used it once this way several yrs ago (it worked well for a few months, and then the patient was lost to follow up)

 

[9point75]

I once had a patient swear by Chloral Hydrate as a cure to her insomnia, but that was in NH

 

[billypilgrim37]

I had to talk the PICU out of using chloral hydrate on a 3 year old last weekend. I recommended using something first synthesized after the American Civil War.

 

[Technotronic]

🙂

 

[ghost dog]

When all GABA and melatonin receptors are agonized, all histamine receptors antagonized, there is no substance abuse, strict sleep hygiene is complied with and all iatrogenic and medical causes are ruled out, may there be a role for Xyrem in refractory insomnia?

Or should Na channels be attacked first? Opiod/catecholamine/5-HT receptors?

P.S. I'm not touching propofol (RIP MJ).

Is this for short or long term use?

A pain doc around my neck of the woods was using this for (seemingly) all of his FM pts, and then tapered all of them off it following some study recommendation. It was a loooong taper. Some patients had a tough time getting off it, and the one patient of his that I saw had lost 80 pounds. Apparently this is a potential side effect of this med. She also informed me that it had failed to provide restorative sleep, and neither had it yielded pain control. Why had she been on it for so long? Who knows?

So what does her family MD script her next ? A benzo - sigh.

 

[firedoor]

Is this for short or long term use?

Long-term (chronic insomnia).

 

[Manicsleep]

there are anecdotal reports of xyrem for primary insomnia and I used it once this way several yrs ago (it worked well for a few months, and then the patient was lost to follow up)

Hmm. I have never used it for insomnia. Doubt I ever would.

Did you do a PSG before writing the prescription?

 

[Manicsleep]

Is this for short or long term use?

A pain doc around my neck of the woods was using this for (seemingly) all of his FM pts, and then tapered all of them off it following some study recommendation. It was a loooong taper. Some patients had a tough time getting off it, and the one patient of his that I saw had lost 80 pounds. Apparently this is a potential side effect of this med. She also informed me that it had failed to provide restorative sleep, and neither had it yielded pain control. Why had she been on it for so long? Who knows?

So what does her family MD script her next ? A benzo - sigh.

That indication was not approved, I remember the trials (about 2 years ago I think). A few of the local docs were asking me about the drug.

 

[Manicsleep]

When all GABA and melatonin receptors have been agonized, all histamine receptors antagonized, there is no substance abuse, strict sleep hygiene is complied with and all iatrogenic and medical causes are ruled out, may there be a role for Xyrem in refractory insomnia?

Or should Na channels be attacked first? Opiod/catecholamine/5-HT receptors?

P.S. I'm not touching propofol (RIP MJ).

Fatal familial insomnia or you need to check again because you missed something.

 

[Manicsleep]

When all GABA and melatonin receptors have been agonized, all histamine receptors antagonized, there is no substance abuse, strict sleep hygiene is complied with and all iatrogenic and medical causes are ruled out, may there be a role for Xyrem in refractory insomnia?

Or should Na channels be attacked first? Opiod/catecholamine/5-HT receptors?

P.S. I'm not touching propofol (RIP MJ).

Plus why do care. Didn't you think sleep wasn't part of psychiatry?

And its amazing how quickly you became an attending. 😎

 

[kugel]

When all GABA and melatonin receptors have been agonized, all histamine receptors antagonized, there is no substance abuse, strict sleep hygiene is complied with and all iatrogenic and medical causes are ruled out, may there be a role for Xyrem in refractory insomnia?

Or should Na channels be attacked first? Opiod/catecholamine/5-HT receptors?

P.S. I'm not touching propofol (RIP MJ).

Collateral info from others in the home.
Review records from concurrent/previous providers.
Surprise drug screen.
Consider Restless Leg Syndrome
CBT
Hypnosis
Watch C-Span
Watch "The Hours"

 

[ghost dog]

When all GABA and melatonin receptors have been agonized, all histamine receptors antagonized, there is no substance abuse, strict sleep hygiene is complied with and all iatrogenic and medical causes are ruled out, may there be a role for Xyrem in refractory insomnia?

Or should Na channels be attacked first? Opiod/catecholamine/5-HT receptors?

P.S. I'm not touching propofol (RIP MJ).

Zyrem is incredibly expensive, and I wonder if a pt's insurance would cover this for off label use / insomnia?

I once had a pt request medical MJ , stating that he was waking up "50 times a night" due to pain post whiplash ( 1 yr ago).
He had no physicial findings whatsoever, and sat comfortably throughout the entire 60 min assessment. Oh, and he was a public transit bus driver.

Some people seem to think we are either stupid, incompetent or give out meds like we don't care.

 

[michaelrack]

Hmm. I have never used it for insomnia. Doubt I ever would.

Did you do a PSG before writing the prescription?

I think I did. it was a while ago

 

[firedoor]

Plus why do care. Didn't you think sleep wasn't part of psychiatry?

And its amazing how quickly you became an attending. 😎

I have no idea where you're coming from but you are way out of line.

 

[OldPsychDoc]

Plus why do care. Didn't you think sleep wasn't part of psychiatry?

And its amazing how quickly you became an attending. 😎

I have no idea where you're coming from but you are way out of line.

Let's keep it civil, folks.

firedoor's questioning is legit to the purpose of the forum. They may be newer to the forum, but as (s)he identified as a 4th yr resident in one of their first posts, I'll take as face value that they are a newly-minted attending.

That said, firedoor, Manicsleep has a year and ~700 posts of seniority on you, as well as being self-identified as a sleep specialist. (See here) Maybe he's feeling cranky late on a Friday afternoon. Nevertheless, try to develop the fine art of being thick-skinned.

OK everybody...back to your regularly scheduled show. Or in other words--Don't make me come down there! (Because I AM cranky...and on call...and have a nasty cold to boot!)

 

[michaelrack]

I once had a patient swear by Chloral Hydrate as a cure to her insomnia, but that was in NH

I once prescribed chloral hydrate for insomnia about 5 years ago. Probably would not use it today.

 

[michaelrack]

I had to talk the PICU out of using chloral hydrate on a 3 year old last weekend. I recommended using something first synthesized after the American Civil War.

Although I don't see children under 13 anymore, my understanding is that chloral hydrate is commonly used for pediatric sedation in an inpatient setting.

 

[billypilgrim37]

Although I don't see children under 13 anymore, my understanding is that chloral hydrate is commonly used for pediatric sedation in an inpatient setting.

But not for temper tantrums!

 

[OldPsychDoc]

But not for temper tantrums!

Oh. But it works so well!
Aww Shoot. Back to the Benedryl.

Unless maybe I can find a helpful child fellow to prescribe me some handy-dandy Risperdal... 😉

 

[firedoor]

That said, firedoor, Manicsleep has a year and ~700 posts of seniority on you, as well as being self-identified as a sleep specialist. (See here) Maybe he's feeling cranky late on a Friday afternoon. Nevertheless, try to develop the fine art of being thick-skinned.

Wow. My skin is plenty thick and it is appropriate to let someone know that you will not tolerate disrespect. I hadn't realized that having "~700 posts of seniority" justifies not only rudeness, but even further lodging personal attacks against other posters ("...it's amazing how quickly you became an attending").

I'm dissapointed that as a moderator you have chosen to explain away Manicsleep's behavior (maybe he's "feeling cranky", has "seniority", is a "[self-identified] sleep specialist") while implying that somehow I have overreacted ("...try to develop the art of being thick-skinned") because I simply and justifiably stated that (s)he was "out of line", which is unquestionable. That is not impartial.

Spin my assessment however you wish, but your words speak for themselves.

 

[Technotronic]

🙂

 

[OldPsychDoc]

Wow. My skin is plenty thick and it is appropriate to let someone know that you will not tolerate disrespect. I hadn't realized that having "~700 posts of seniority" justifies not only rudeness but even further lodging personal attacks against other posters ("...it's amazing how quickly you became an attending").

I'm dissapointed that as a moderator you have chosen to explain away Manicsleep's behavior (maybe he's "feeling cranky", has "seniority", is a "[self-identified] sleep specialist") while implying that somehow I have overreacted ("...try to develop the art of being thick-skinned") because I simply and justifiably stated that (s)he was "out of line", which is unquestionable. That is not impartial.

Spin my assessment however you wish, but your words speak for themselves.

Some time ago you wrote:

Just because someone challenges your statements doesn't mean that they are rigid. Nor does it mean that they're personally attacking you or that they even necessarily disagree. Personally speaking, I like to argue here (in the diplomatic sense) in order to understand different viewpoints and to learn, as I believe most here do as well.

You are correct that "words speak for themselves". In most cases, words are all that we have to judge someone on on an anonymous internet forum. We make our judgments about the person based on the statements they post over time. Manicsleep is a sleep specialist, and replied on-topic to your question before the unfortunate aside that brought you offense. I can't speak to manicsleep's intent in that post. You will note, that though you do not refer to it above, I did call manicsleep on his perceived dismissal of your professional level.

It is indeed best to try to maintain an air of civility and respect, but frequently we let out our frustrations when we are anonymous on these forums. I hope no one is calling CPS based on my asides about chloral hydrate above!

I would note that manicsleep had also apparently questioned "why you should care"--I surmise he was referring to your words in a previous post (bolding mine):

In my REM world the following would be exluded from the DSM-5:

Rett's
Elimination Disorders
Childhood Disintegrative Disorder
Somatization Disorder
Sleep Disorders
ODD/Conduct
Paraphilias

...and there would be a separate child vs. adult DSM... Ahhh 🙄 Anyone else?

So yes, words do speak for themselves. And to paraphrase your words--just because someone does not take indignation at the words that you find offensive, does not mean that they are not being impartial in their moderation of this forum.

 

[Manicsleep]

deleted

 

[firedoor]

All that and the person still can't sleep?

Something tells me everything is not accurate.

This (elderly) patient reports on average 3 hours of sleep in 24 hours, with difficult onset and fragmentation. They do in fact have MDD (with anxiety) which is in partial remission. Notably their mood and anxiety symptoms are the best they've been in decades. Aside from the (chronic) insomnia, only mild mood and anxiety symptoms persist.

 

[Manicsleep]

That was the quote I was referring to.

The older post and the current post are however, related which would lead you back to the my question. Why do you care (and ask questions about xyrem) if as your previous post indicates...you don't care.

As far as irritability. I am being harassed by a new employee for picking Peyton Manning as my fantasy QB. I think I will be irritable for a while.

 

[firedoor]

I was referring to this quote. It was a while ago but I have a pretty good memory. In case this is a lack of education about where insomnia falls...

www.ncbi.nlm.nih.gov
Insomnia is difficulty getting to sleep or staying asleep, or having nonrefreshing sleep for at least 1 month.



I won't bother explaining why sleep disorders are a crucial and integral part of psychiatry, just like I didn't back then. The older post and the current post are however, related which would lead you back to the previous post. Why do you care if as your previous post indicates...you don't care.

It's funny how 5 minutes ago you made this exact same post under the screenname "technotronic" before changing it to your "Manicsleep" account. Nice try at good cop/bad cop.

It's really the definition of hypocrisy when without basis you publicly challenge the authenticity of my profile status as an attending physician while you deceitfully post under multiple usernames, isn't it? As I'm writing this there is a lot of post editing occuring under both the "Manicsleep" and "technotronic" handles (which is the same person) in an attempt cover this up, but I know better 😉.

Nonetheless...I have responded nicely to your more cordial "technotronic" persona.

 

[firedoor]

So yes, words do speak for themselves.

Exactly.

 

[Ibid]

Funny how 5 minutes ago you made this exact same post under the screenname "technotronic" before changing it to your "Manicsleep" account. Nice try at good cop/bad cop.

It's really the definition of hippocracy when you challenge the veracity of my online status as an attending while deceitfully posting under multiple usernames, isn't it? As I'm writing this there is a lot of post-editing occuring under both the "Manicsleep" and "technotronic" handles (which is the same person) in an attempt cover this up, but I know better 😉 .

.

This is what the internet does to you. You are just touching the tip of the iceburg anyway. This board only has ten people tops. The whole of SDN is just a handful of college kids, about 50, working night and day to create the whole thing.

 

[OldPsychDoc]

That was the quote I was referring to.

The older post and the current post are however, related which would lead you back to the my question. Why do you care (and ask questions about xyrem) if as your previous post indicates...you don't care.

As far as irritability. I am being harassed by a new employee for picking Peyton Manning as my fantasy QB. I think I will be irritable for a while.

Well, possibly both you and technotronic need to join the unfortunate Mr. Manning on the sidelines for awhile?

Disappointed....

 

[Ibid]

Well, possibly both you and technotronic need to join the unfortunate Mr. Manning on the sidelines for awhile?

Disappointed....

But they chat to each other on this thread?
http://forums.studentdoctor.net/showthread.php?p=11068294#post11068294

unconvinced....

 

[billypilgrim37]

Wouldn't we expect ManicSleep to have biposter disorder?

(even a bad joke for me)



[Square brackets, my friend.] -OPD
(and yes...very, very bad.)

 

[firedoor]

But they chat to each other on this thread?
http://forums.studentdoctor.net/showthread.php?p=11068294#post11068294

Which demonstrates the depth, duration and desperateness of the deceit employed. If someone is willing to go to the lenghts of posting under different identities, would it not serve their purpose to create a fake dialogue between them?

Administrators have access to edited posts and hence know the facts.

 

[9point75]

Wow, Manicsleep is technotronic. Technotronic is Manicsleep.

Lois is Einhorn. Einhorn is Lois?

First there are kisses.... Then there are tears...

 

[michaelrack]

This Manicsleep/firedoor disagreement is confusing to me, a self-identified sleep specialist who has seniority over both of them (but not OldPsychDoc). I would probably side with OldPsychDoc if I knew what was going on.

 

[Technotronic]

It's funny how 5 minutes ago you made this exact same post under the screenname "technotronic" before changing it to your "Manicsleep" account. Nice try at good cop/bad cop.

You figured it out. 🙂

-ManicSleep/Technotronic

Also, which one is good cop? We (the royal) are confused.

 

[9point75]

Has anybody successfully used opiates for the chronic insomniac? I feel that opiate therapy is a vastly untapped resource in our armarmentarium.

 

[OldPsychDoc]

This Manicsleep/firedoor disagreement is confusing to me, a self-identified sleep specialist who has seniority over both of them (but not OldPsychDoc). I would probably side with OldPsychDoc if I knew what was going on.

How do we know you're NOT OldPsychDoc? If you were I might reply to you to make it look like I'm not you... Wait. How do *I* know that *I'm* not you? 😱

 

[Ibid]

How do we know you're NOT OldPsychDoc? If you were I might reply to you to make it look like I'm not you... Wait. How do *I* know that *I'm* not you? 😱

Well I’ve heard that when the real OldPsychDoc logs in, clocks in Sweden slow down, women in Paris begin to ovulate and polar bears retreat to their holes. That’s how you know for sure.....

 

[Manicsleep]

Yes we are the same person. I am several other people on this forum as well.

-ManicSleep

I have multiple poster disorder not biposter disorder. It's the only explanation.

 

[Manicsleep]

Which demonstrates the depth, duration and desperateness of the deceit employed. If someone is willing to go to the lenghts of posting under different identities, would it not serve their purpose to create a fake dialogue between them?

Administrators have access to edited posts and hence know the facts.

Nice alliteration. 'Deceptive dialogue' delivers more definitively.

 

[nitemagi]

Has anybody successfully used opiates for the chronic insomniac? I feel that opiate therapy is a vastly untapped resource in our armarmentarium.

Um, no.

Is this a real question?

Anyone who did this must have very little exposure to substance abusing populations. And is well on their way to a medical board ding.

 

[Majesty]

This (elderly) patient reports on average 3 hours of sleep in 24 hours, with difficult onset and fragmentation. They do in fact have MDD (with anxiety) which is in partial remission. Notably their mood and anxiety symptoms are the best they've been in decades. Aside from the (chronic) insomnia, only mild mood and anxiety symptoms persist.

When all GABA and melatonin receptors have been agonized, all histamine receptors antagonized, there is no substance abuse, strict sleep hygiene is complied with and all iatrogenic and medical causes are ruled out, may there be a role for Xyrem in refractory insomnia?

Or should Na channels be attacked first? Opiod/catecholamine/5-HT receptors?

P.S. I'm not touching propofol (RIP MJ).

Send them to a pulmonary doctor.

 

[firedoor]

Has anybody successfully used opiates for the chronic insomniac? I feel that opiate therapy is a vastly untapped resource in our armarmentarium.

Opiods have been used to treat refractory restless legs syndrome.

 

[nitemagi]

This (elderly) patient reports on average 3 hours of sleep in 24 hours, with difficult onset and fragmentation. They do in fact have MDD (with anxiety) which is in partial remission. Notably their mood and anxiety symptoms are the best they've been in decades. Aside from the (chronic) insomnia, only mild mood and anxiety symptoms persist.

How long have the mood symptoms been under control. Sleep can be the last thing to normalize.

 

[firedoor]

Send them to a pulmonary doctor.

Please tell me why. A sleep study has ruled out sleep apnea.

 

[firedoor]

How long have the mood symptoms been under control. Sleep can be the last thing to normalize.

Approximately 8 weeks.

 

[Majesty]

Maybe you should turf it to a sleep specialist. Doesn't look like things are going well. Or even a psychiatrist who is more comfortable with sleep and sees it as part of day-to-day practice.

 

[michaelrack]

what benzo's/doses have been tried? Sometimes I have to go above the recommended dose when treating insomnia.

also, have all the selective benzo agonists been tried (includng sonata)?

 

[michaelrack]

I also like sleep restriction for difficult cases (although this may be inappropiate for some pts with bipolar). what are the patient's usual bed hours?