View Full Version : Turns out sleep is complex

01-16-17, 01:52 PM
So I got some Suvorexant (Belsomra brand) a few months ago, and it's great. To recap on this drug:

No physical dependency - no tolerance, no addiction
No way to get high - huge doses will make you sleepy and groggy the next day
No notable side-effects - grogginess and vivid dreams are a given; the standard warnings about sleep-driving and other sedative behaviors are there, but seem to not actually happen

Suvorexant is an Orexin antagonist (-orexant), versus GABA drugs like Ethanol, Phenobarbitol, Valium, Zolpidem, and Eszopiclone. Different kind of drug. It has a long half-life, which is troublesome: large doses can be touchy, and a small nudge up past an effective dose can leave you with enough in your blood to keep a receptor suitably-saturated for 18 hours instead of just twice as long (e.g. works for 4 hours? Bumping from 15mg to 20mg might make you tired all freaking day).

Suvorexant: The "Off" Switch

Suvorexant has been shown to reduce latency to sleep onset (LSO) by 7 minutes, and increase total sleep time (TST) by around 15 minutes. Like all sleep drugs, this gets a lot of articles bashing the drug from people who don't understand sleep.

In my case, when tired, I'll toss and turn for 2-3 hours. I'll be tired at 10pm and still trying to sleep at midnight or 1am. My mind is active regardless of the state of my body, and this causes trouble.

15mg of Suvorexant gives me a 20-minute sleep latency, for real. I combine it with Melatonin because I'm just wide awake after 10pm for no known reason (circadian rhythm disorder?); and the Melatonin doesn't put me to sleep without the Suvorexant. If I don't try to sleep, I don't sleep: Suvorexant makes me fall asleep like a normal person, I guess.

High Activity

So here's the other problem:

Those "REM" cycles seem to be "AWAKE" for me. I sleep okay in the first half of the night; I wake up in the second half--a lot.

That tells me something else is wrong. It's like this whole graph is moved up. I'm going to have to ask my psychiatrist about this; I'll try a GABA drug, if I can get him to prescribe one.

GABA drugs are problematic. The only option is Eszopiclone, and I want it in 1mg low dose to add to Suvorexant. Given the above, it looks like Suvorexant is doing something important: it's allowing me to sleep, rather than sedating me. The problem now is I'm not sufficiently-sedate when I sleep, and Eszopiclone is a sedative. Clubbing myself into unconsciousness with a high dose of either drug doesn't seem to target the underlying problem.

Why is Eszopiclone the only option?

Diphenhydramine - H1 Histamine central antagonist. Physical dependency in 3 days.
Zolpidem - GABA agonist. Physical dependency in 10 days.
Eszopiclone - GABA agonist. Long-term studies show no tolerance or dependency when taken daily for 6 months; presumably safe for daily use for at least 6 months.

I can't take Ambien every day. GABA drugs go right back through Benzodiapezines (Valium, Lorazepam), Barbituates (Phenobarbitol), and Ethanol (something called Vodka)--never combine any of these with any other of these.

The Big Picture

The above suggests a number of things:

Different sleep drugs now do different things;
My sleep system is experiencing multiple errors;
Treating a sleeping disorder is difficult

Eszopiclone, fortunately, costs like $31 for 90 pills; if my insurance will authorize Belsomra, I can get Eszopiclone out-of-pocket cheaper than my actual prescription plan. My psychiatrist does give me some latitude, although I keep reminding him I'm not a psychiatrist (something of which he's well-aware anyway) because I do stuff like this. Still, I think he'll at least agree that the sleep system isn't a one-stop shop where we shoot one receptor and fix everything--even if the sledgehammer approach seems to sort-of work (yeah 6mg of Eszopiclone will probably put me to sleep good, but not optimally; and it's eventually going to cause tolerance and dependency at high doses).

When I started, I wanted to avoid combining drugs due to risk of interaction. I'm starting to change that opinion, looking to leverage interactions based on careful analysis--and a double-check with someone who actually knows what he's doing, since I am not a psychiatrist. The insurance company might not like taking two drugs "for insomnia", but they're not "sleeping drugs"--they're a non-selective Orexin receptor antagonist and a Benzodiapezine receptor agonist. If two knobs are misadjusted, overcompensating one to try and mask the other problem is the wrong way to go about it.

We'll see how it pans out.

01-21-17, 11:44 AM
Psychiatrist says to not mix Suvorexant with Eszopaclone, so I'm not doing that.

He wrote me a 3mg prescription, not 1mg :eek: On the other hand, it didn't work well--I slept, but not great. Still, I did sleep, and I wasn't tired; I was actually pretty restless. Suvorexant only lets me sleep if I'm already tired, which usually means Melatonin (although the first couple Atomoxetine made me exhausted and worked just as well).

Melatonin is known-safe in combination with GABA drugs (lots of experiments with 5mg IR melatonin + 20mg IR Zolpidem). Suvorexant should be, but my psychiatrist wasn't willing to chance that combination as-is. Since Suvorexant was only able to put me to sleep and Eszopaclone can do that, I don't need the Suvorexant in the stack.

Oddly, Eszopiclone didn't make me tired, or high, or anything. I could tell I was on something, but it's like if you could tell you'd had 1 beer (you can't). It did leave a nasty metallic taste in my mouth everywhere it had touched; Mylan doesn't coat their tablets.

I wonder if I can get my pharmacy to fill Teva instead of Mylan. They stock them; honestly I don't like Mylan.

01-22-17, 06:20 AM
Hey Blue, I cant remember if you shared this but, have you ever had a sleep study done?

02-22-17, 01:00 PM
Hey Blue, I cant remember if you shared this but, have you ever had a sleep study done?

Nope. Too expensive for now. I'm doing my own analysis for the moment. It seems I snore through my nose, but not through my throat, so no sleep apnea at least.

I'm trying to write software to pull actigraphy (Fitbit, Jawbone, EightSleep), heart rate, breathing rate (EightSleep), and EEG (Kokoon) together for polysomnography, but it's hard and I have to learn math. Linear algebra will do me good, though; I can always use more power. (I actually want that software to incorporate things like study time, Duolingo growth, exercise and activity time, and so forth to track things like attention and motivation. All kinds of data are useful to parameterize an individual.)

By the by, you know that thing about alcohol?

Oddly, Eszopiclone didn't make me tired, or high, or anything. I could tell I was on something, but it's like if you could tell you'd had 1 beer (you can't).

I was still in a hypnotic state 20 hours after taking the stuff. At 6pm on my 12th dose (10pm the prior night!), I saw a car trying to pass me in the McDonalds drive thru, and drove on anyway--almost crashed into him, but he stopped.

When you're under the influence of a hypnotic, you will identify things, but not recognize the need to alter your behavior in response--for example, you'll see the cars in front of you have stopped, and continue driving along the interstate at 70mph because you're cruising and you haven't made the connection between "stopped traffic" and "I now must stop". You just continue cruising.

So yeah, I stopped taking that. Withdrawal was horrible but lasted one day. Burning sensation like sunburn, fever, chills, fatigue (oddly enough), anxiety, depression, and possibly a minor myocardial infarction (I didn't die! I'm getting better at not dying!). No big deal. I took sick leave from work because I was definitely not going anywhere.

I should have processed that when I said it: you can't tell you're impaired. You think you're not. I drove around like that for 12 days; how many incidents did I simply not notice?

Conversely, Belsomra/Suvorexant has zero side-effects for me, and works incredibly. I'm starting to think I have a particular disorder that hasn't been medically explored yet--might be a nice opportunity for my psychiatrist to get himself published (again?). I'm going to see about bumping that to the maximum dose, and doing other things.

Atomoxetine has almost eliminated my need for melatonin--sometimes none, sometimes 1mg SL; before I had tried TR 1mg, 2mg, 3mg, 5mg, 6mg, 8mg, 10mg, 13mg, 15mg, 18mg, 20mg, and 25mg, and found 20mg let me sleep while 18mg and 25mg both interrupted my sleep. Same with 1mg-3mg SL, no use unless I was WASO and topping off a huge TR dose. ATX interrupts my sleep if I take it late, and makes me tired if I take it early; it jacks my heart rate up for a 3 hour climb followed by 1.5 hours of falling back to normal.