Insomnia

31-year-old Male BACKGROUND This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia. SUBJECTIVE Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient's medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed. MENTAL STATUS EXAM The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented. Decision Point One Select what you should do: Zolpidem: 10 mg daily at bedtime T\razodone 50 mg po at bedtime Hydroxyzine: 50 mg daily at bedtime Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes. At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature. Introduction to the case (1 page) • Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient. Decision #1 (1 page) • Which decision did you select? • Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. • Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature). • Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. Decision #2 (1 page) • Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. • Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature). • Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. Decision #3 (1 page) • Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. • Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature). • Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. Conclusion (1 page) • Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Sample Solution

Introduction to the Case

This case presents a 31-year-old male patient with insomnia. The patient's insomnia has gotten progressively worse over the past 6 months after the sudden loss of his fiancé. This is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient recently has been using alcohol to help him fall asleep, approximately four beers prior to bed.

Full Answer Section

The patient's medical history and current presentation raise a number of concerns that may impact his pharmacokinetic and pharmacodynamic processes. The patient's history of opiate abuse is a significant concern, as opiate use can alter the metabolism of other medications. Additionally, the patient's alcohol use may interact with certain medications, including benzodiazepines. Finally, the patient's insomnia may be exacerbated by his mental state, as grief and depression are common risk factors for insomnia. When prescribing medication for this patient, it is important to consider the following factors:

The patient's history of opiate abuse
The patient's current alcohol use
The patient's mental state
The potential for interactions with other medications
The patient's risk of dependence and abuse

Decision #1 The three medication options provided in the exercise are:

Zolpidem: 10 mg daily at bedtime
Trazodone 50 mg po at bedtime
Hydroxyzine: 50 mg daily at bedtime

Zolpidem is a short-acting benzodiazepine sedative-hypnotic. It is effective for the treatment of insomnia, but it is also associated with a risk of dependence and abuse. The patient's history of opiate abuse and his current alcohol use make him at an increased risk of developing dependence on zolpidem. Additionally, zolpidem can interact with alcohol, increasing the risk of side effects such as drowsiness, dizziness, and impaired coordination. Trazodone is a tetracyclic antidepressant with sedative properties. It is an effective treatment for insomnia, and it is less likely to cause dependence and abuse than benzodiazepines. However, trazodone can have anticholinergic side effects, such as dry mouth, blurred vision, and constipation. Additionally, trazodone can interact with a number of other medications, including antidepressants, antipsychotics, and antiarrhythmics. Hydroxyzine is a first-generation antihistamine with sedative properties. It is an effective treatment for mild to moderate insomnia, and it is less likely to cause dependence and abuse than benzodiazepines. However, hydroxyzine can have anticholinergic side effects, and it can also cause drowsiness and dizziness. Additionally, hydroxyzine can interact with a number of other medications, including antidepressants, antipsychotics, and antiarrhythmics. Recommendation: I recommend prescribing trazodone 50 mg po at bedtime for this patient. Trazodone is an effective treatment for insomnia, and it is less likely to cause dependence and abuse than benzodiazepines. Additionally, trazodone is less likely to interact with other medications than hydroxyzine. Rationale: The patient's history of opiate abuse and his current alcohol use make him at an increased risk of developing dependence on zolpidem. Additionally, zolpidem can interact with alcohol, increasing the risk of side effects such as drowsiness, dizziness, and impaired coordination. Hydroxyzine is a viable option for this patient, but it is less effective for the treatment of insomnia than trazodone. Additionally, hydroxyzine has more potential for drug interactions than trazodone. Treatment Goals: The goals of treatment for this patient are to improve his sleep quality and reduce his daytime symptoms of fatigue and impaired concentration. Trazodone is an effective treatment for insomnia, and it is less likely to cause daytime side effects than benzodiazepines or hydroxyzine. Communication with the Patient It is important to communicate with the patient about the risks and benefits of trazodone. The patient should be informed about the potential for anticholinergic side effects and drug interactions. Additionally, the patient should be aware that trazodone can cause drowsiness and dizziness, and he should avoid driving or operating machinery until he knows how the medication affects him.

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