Assessing and Treating Patients with Sleep-Wake Disorder This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.

Assessing and Treating Patients with Sleep-Wake Disorder

In this case study, we are presented with a 31-year-old male patient with a chief complaint of worsening insomnia. Over the past six months, the patient has experienced difficulties falling asleep and staying asleep at night. As a forklift operator at a local chemical company, his sleep problems negatively affect his job performance and daily functioning. The patient had previously used diphenhydramine to address his sleep issues but discontinued it due to undesirable side effects.

Several patient-specific factors come into play when considering medication options for this individual. Firstly, his history of opiate abuse is essential, as it may impact his response to certain medications and raise concerns about potential substance interactions. While the patient hasn’t used opiate analgesics for the past four years, there may still be considerations regarding his previous substance use (Wheeler, 2020). Secondly, the patient’s dislike for the morning-after effects of diphenhydramine, a sleep aid he used in the past, indicates a preference for alternative medications with fewer undesirable side effects (Wheeler, 2020). The patient’s use of alcohol to help him fall asleep is another significant factor. Alcohol consumption can interact with sleep medications and affect their efficacy and safety. Therefore, medication choices must account for this aspect of the patient’s sleep hygiene (Sateia et al., 2017). Moreover, the patient’s occupation as a forklift operator emphasizes the importance of selecting a sleep medication that doesn’t impair his alertness or job performance during the day.

The mental status exam indicates that the patient is alert, oriented, and mentally stable, with no signs of hallucinations or suicidal ideation. These findings suggest that the patient’s insomnia is likely a reaction to his recent loss rather than a symptom of an underlying mental health disorder (American Psychiatric Association, 2013). However, his emotional state should still be considered when prescribing medications, as the treatment plan needs to be sensitive to his grief and overall psychological well-being.

Given these patient-specific factors, the decision-making process for prescribing medication for this patient should prioritize safety, efficacy, and compatibility with his medical history and emotional state. It is essential to consider medications with a proven track record in managing insomnia while minimizing potential side effects and interactions with alcohol or substances. Close monitoring and patient education will also play a vital role in ensuring the best possible treatment outcome and addressing any concerns or adverse effects that may arise during treatment.

Decision #1

I decided to prescribe Trazodone 50 mg PO at bedtime for the patient’s insomnia.

Reasoning

I chose Trazodone as the initial medication for the patient’s insomnia based on its well-established efficacy in treating sleep disturbances, which aligns with the patient’s primary complaint. Trazodone is a serotonin antagonist and reuptake inhibitor with sedative properties, commonly prescribed for sleep disorders due to its ability to improve sleep latency and maintenance (Sateia et al., 2017). Moreover, it effectively managed sleep disturbances in patients with a history of substance abuse, which is relevant to our patients with a history of opiate abuse (Wheeler, 2020).

Reasons for Not Selecting Other Options

Zolpidem (Ambien)

While Zolpidem is effective for short-term insomnia, it is associated with a higher risk of tolerance, dependence, and rebound insomnia, which may not be ideal for a patient with a history of substance abuse (Winkleman, 2015). Additionally, Zolpidem may have interactions with alcohol, which the patient is currently using to help with sleep.

Hydroxyzine

Although Hydroxyzine has sedative properties and is sometimes used off-label for insomnia, it is primarily an antihistamine with potential anticholinergic side effects. Given the patient’s report of not liking the side effects of diphenhydramine, a similar antihistamine, Hydroxyzine, might not be the best choice (Winkleman, 2015).

Expected Outcome

With Trazodone, my goal was to improve the patient’s sleep quality, reduce the time it takes to fall asleep, and minimize nighttime awakenings. The patient’s daytime functioning, job performance, and overall quality of life should improve by achieving better sleep (Sateia et al., 2017).

Ethical Considerations

Given the patient’s history of opiate abuse, there