B0038M1ADS EBOK (18 page)

Melatonin-like prescription medication: One medicine called ramelt-
eon (Rozerem) acts on the same nerve pathways in the brain that melatonin acts on. This medicine is not addictive and has minimal side effects,
so it's worth considering before trying other medicines. However, it's only
been shown to be effective for falling asleep. If you tend to wake in the
middle of the night and not be able to fall back asleep, then it's unlikely
this medicine will be helpful.

Blood pressure medicine to help control nightmares: Medicines designed
to reduce blood pressure have nothing to do with sleep, with one exception. An older medicine called prazosin (Minipress), which reduces blood pressure and slows heart rate, has been shown to have benefits in reducing
the degree to which a warrior's body is revved up at night by adrenaline.
For warriors, nightmares are often associated with increased blood pressure,
pounding heart rate, and being revved up. Prazosin helps to reduce these
physiological reactions, which in turn can help with the nightmares. Some
warriors find that this medicine alone is sufficient to give them more restful
sleep by reducing the number or intensity of nightmares. Side effects can
include low blood pressure and slow heart rate, but there is a wide range
of doses that can be used, and the medicine quickly leaves the body, so this
usually isn't a persistent problem. The blood pressure medicines called betablockers also may be of use in the same way as prazosin.

New antipsychotic medicines: There are several new medicines for
treating schizophrenia and bipolar disorder that are being used for purposes not approved by the U.S. Food and Drug Administration, including
depression, sleep problems, and nightmares associated with PTSD. The
problems with this include potentially serious side effects and a lack of evidence for effectiveness of this class of medications for these purposes. One
medication in this group that is gaining widespread use, quetiapine (Sero-
quel), has been prescribed to warriors for sleep problems unresponsive to
other medications. Although used in doses much lower than required to
treat schizophrenia or bipolar disorder, there have been many concerns
with this medication, including the possibility that it may contribute to
diabetes, heart problems, and weight gain. For these reasons, it's important to carefully consider the risks and not rush into a decision to take this
medication unless there are no good alternatives.

Sedative or hypnotic sleep medicines: These are the strongest medications for sleep and the ones with the most side effects and potential for
addiction. These medicines work on specific nerve endings in the brain,
called benzodiazepine receptors, which act by slowing down the nervous system.

These medicines should be avoided unless absolutely necessary. They
can quickly cause dependency because in many ways, they act just like
alcohol. Some warriors find that these are the only medicines that seem to
help their sleep, but in the long run, these medicines can make the sleep
problems worse.

There are two classes of sedative-hypnotics: benzodiazepines and nonbenzodiazepines. Benzodiazepines include medications marketed specifically for sleep, like estazolam (ProSom), flurazepam (Dalmane), quazepam
(Doral), temazepam (Restoril), and triazolam (Halcion), and medicines
marketed for anxiety that also may have effects on sleep, including alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), and diazepam (Valium).

Benzodiazepines have a high risk of dependence and generally should
be avoided at all costs by warriors. They're also sold on the street as downers, tranks, V's, Z bars, roofies, and various other names. Their use can
lead to drug tolerance (the need to use increasing amounts to achieve the
same effect), drug dependence (inability to sleep without the medicine,
or inability to stop the medicine), and withdrawal symptoms (worsening
of sleep or other physical effects, such as nausea, sweating, shaking, or
seizures when you try to stop the medicine).

Non-benzodiazepine sedative-hypnotics are a newer class of sleep
medicines that include medications like zolpidem (Ambien), eszopi-
clone (Lunesta), or zaleplon (Sonata). Although they also act on benzodiazepine receptors in the brain, they're more specific for sleep (they
don't have antianxiety properties), and are considered to have a lower
potential for dependency and fewer side effects. Nevertheless, they still
have the potential to become habit-forming, and many warriors who start
using them for sleep find it very difficult to quit and sleep without them.

Sedative-hypnotics have many side effects, contraindications, and interactions with other drugs (sometimes life-threatening), and it's important to
discuss all concerns with your doctor, take them only as prescribed, and read
the package inserts. Side effects can include daytime sleepiness, trouble concentrating, memory problems, dizziness, unsteadiness, headache, muscle
aches, constipation, dry mouth, impaired judgment, and rebound insomnia
(increased sleeping difficulty if you try to stop the medicine). Don't increase
the dose to try to achieve a stronger effect without consulting your doctor. Increasing it on your own can carry very serious risks. The medications
should never be used with alcohol, or while driving. Some of these medicines have been associated with nighttime behaviors, similar to a blackout, in which the warrior may do dangerous things while under the influence of
the medication (including getting in a car and driving), when they have no
conscious awareness of doing this and retain no memory of it.

The sedative-hypnotic sleep medicines are generally prescribed for
short-term use (a few days), and should be used sparingly, only when
needed. However, once a warrior has started using one of these medicines
and finds it helpful, it can be very difficult or impossible to come off of
them. Doctors will often continue to prescribe them despite the fact that
they are generally only recommended for short-term use.

Warriors frequently find themselves between a rock and a hard place
regarding these sleep medicines. If sleep hygiene practices or over-thecounter medicines haven't worked, then doctors will frequently prescribe
one of the sedative-hypnotics. The non-benzodiazepine sedative-hypnotics
are preferred over the benzodiazepine forms, but warriors need to understand that extreme caution is warranted for all of these. There's a high
likelihood that the medication will help initially, particularly with falling
asleep, much like alcohol can help initially. But over time, the medicines
can lose their effectiveness and become habit-forming. In the end, if
they're used long enough, they can lead to more sleep difficulties.

If you use one of these medications, pay attention both to how quickly
you fall asleep and how long you stay asleep. The medicines may help you
fall asleep quickly, but not help with the problem of nighttime awakening
and not being able to fall back asleep. Sometimes this is related to the
medicine having a short-term effect in the body. Several of these medicines are cleared out of the body very quickly. If this happens, doctors can
switch you to one designed to stay in the body longer. However, this may
lead to drowsiness the next day. The bottom line is that if you use any of
these medicines, give yourself time to test them out first in the safety of
your home-for instance, on a weekend-when there is sufficient time
to see their effect the following day. It's also wise to let a friend or family
member know you're trying this out.

If you choose to use a sleep medicine, understand the risks and the
potential for dependence. If it's necessary and nothing else has worked,
you can certainly try one of these sleep medicines under the supervision of your doctor, but use them sparingly, only when most needed. Try to
use them only occasionally. Don't use them every day.

One more thing: Never use these medications at the same time that
you're consuming alcohol, and make sure you check with your doctor
about using these in combination with other medications, particularly
pain medicines. These medications don't mix with anything else that can
make you drowsy.

SKILL 5. LEARN HOW ALCOHOL OR DRUGS AFFECT
YOUR REACTIONS

Some warriors drink heavily or use drugs after returning from deployment
for reasons including relaxing, socializing with friends, helping with sleep,
coping with wartime memories, enjoyment, or just because it's there. However, many warriors don't realize the degree to which alcohol or drugs
can affect their ability to successfully transition home from combat. This
section focuses on alcohol, since that's the most widely used recreational
"drug," but any drug use (illegal, or misuse of prescription medications)
can have similar effects on the body, and the advice in this section concerns drugs as well. Like alcohol, most drugs have some combination of
stimulating and sedative effects that can seriously affect wartime reactions,
worsen sleep, and make the transition process difficult.

Alcohol has a calming effect, can seem to help with sleep, and goes
together with socializing and partying. However, it's a trap. Alcohol also
has a strong stimulating effect on the body, which is why conversations
get louder and more spirited with alcohol, and why risky behaviors and
aggression are common while under the influence. After the stimulating
effect there is a sedative effect, and alcohol can result in falling asleep or
"passing out." Over time alcohol actually worsens sleep. There's a rebound
effect that makes it more likely that you'll wake up after only a few hours of
sleep, and more difficult to fall back asleep after waking.

Sleep is characterized by periods of dreaming (rapid eye movement
[REM] sleep, which happens even if you don't remember your dreams)
and periods of deeper sleep without dreams. During a night of sleep, you normally cycle through REM and deeper sleep a number of times, with
very brief periods of waking between cycles (not usually remembered).
Feeling rested the next day requires the right balance between these different periods of sleep. If the sleep cycle is disrupted in some way, the
overall quality of sleep, or the ability for sleep to restore your energy and
make you feel rested, is negatively affected.

Alcohol can cause you to initially fall asleep; right after falling asleep,
it reduces the amount of time spent dreaming. For warriors who experience nightmares, this may seem like a good thing. However, within two to
four hours (and sometimes after only an hour), alcohol begins to clear out
of the body, and the brain tries to "catch up" on the periods of dreaming
sleep. This can result in increased dreams and nightmares, which may be
accompanied by feeling revved up and coming out of sleep and waking up.
It's common in the second half of the night to toss and turn fitfully or wake
up and not be able to fall back asleep.

After drinking alcohol the normal sleep cycles and quality of sleep
are disrupted, which results in being much less rested when you wake up.
This may lead to the temptation to take a bigger "dose" of alcohol the
next night, which would only make things worse. People may not realize
that alcohol use, even in modest amounts, is the most common cause of
sleep disturbance. Alcohol also fuels irritability and anger, and worsens the
cognitive effects of stress. It's also a common cause of high blood pressure.
People may not realize that a person can have an alcohol problem even if
they don't drink every day. People who can stop drinking easily may still
have a significant problem.

The quantity or frequency of alcohol use isn't what defines the problem, although higher use is obviously worse. Research shows that five or
more drinks for a man, or four or more for a woman, on a single occasion is
probably too much. If you hold your liquor well, meaning that you can drink
five or more drinks without feeling much of an effect, your liver (which
clears alcohol out of the body) has gotten used to working overtime; this is
probably a sign of an alcohol problem. Definite signs of a problem are getting a DUI; a work problem caused by alcohol; a loved one often telling you
that you're drinking too much; blackouts (people telling you about things you did under the influence of alcohol that you don't remember doing); or
drinking before noon to get yourself going. If you have any of the problems
just described but are convinced that you don't have an alcohol problem,
then you probably have an alcohol problem, because denial is the numberone defense when alcohol is involved.

Take the following short survey and assess whether or not you may
benefit from further evaluation for an alcohol problem:

In the past month: