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Solving the Sleep Puzzle
Takes More than Medications

Dr. Charles Ferzli, of the TMJ and Sleep Therapy Centre in Cary, views sleep problems as a puzzle with many different pieces. “It is often a complex puzzle to solve,” he says. “And, unfortunately, most often people leap to the easiest—but not necessarily the best—solution when they have trouble sleeping. In other words, they reach for a sleeping pill.”

Dr. Ferzli, here with a patient, frequently measures bodily functions related to proper and healthy breathing in order to determine causes—and solutions—for sleep problems.

Fifty to seventy million adults, particularly women and older adults, suffer from chronic sleep and wakefulness disorders, notes Dr. Ferzli. “The most common problem we see in our practice is insomnia. And many of our new patients come in with sleeping pill prescriptions from other practi-tioners. Regrettably, most of those prescriptions were written without the thorough investigation that would occur with any other health ailment.

“In other cases, people are simply self-medicating with over-the-counter sleeping pills. But whether they’re using a prescription medicine or an over-the-counter remedy, if there is no understanding of the underlying issues causing insomnia, medication might well exacerbate the problem.
“The right thing to do is to find out why you’re not sleeping well,” emphasizes Dr. Ferzli. “That’s where my exam comes in and why we offer many resources to fix sleep.”

The Roots of Insomnia

“Sleep apnea—which is an involuntary cessation of breathing while sleeping—is a very serious problem and one of the first things we look for,” says Dr. Ferzli. “But many doctors will stop with ‘You don’t have sleep apnea, so you’re fine.’ They don’t understand that you could be helped, even though you don’t have sleep apnea. And that’s where patients often turn to pills, because they don’t realize there are other options to relieve their sleep problems.”

In fact, notes Dr. Ferzli, “there are many problems that can disrupt sleep, even for people who don’t have sleep apnea. And these are problems we can address.”

Upper airway resistance syndrome (UARS) is one example, he says. “It’s caused by a narrowing of the airway that can cause a disruption of sleep and thus fatigue. We will often make an oral appliance to optimize the airway, so it doesn’t get any smaller, eliminating the problem.”

Mouth breathing is another habit that can cause more frequent awakening, explains Dr. Ferzli. “And stress is certainly a factor. But sometimes the causes of insomnia are very simple. For example, Vitamin D deficiency, smoking, and alcohol consumption all affect sleep quality. The blue light emitted by screens on cell phones, computers, tablets, and televisions is known to interfere with sleep. And even eating a heavy meal or the wrong foods at night can affect sleep; you may toss and turn a lot if you go to bed with a lot of carbs in your system,” he warns.

“We check vitamin D levels first with people who have trouble falling asleep, as well as other nutrition issues,” he says, “because that can be an easy fix.”


Still, Dr. Ferzli finds inflammation to be the most common culprit for insomnia—and it’s typically not an easy fix. “It can be a vicious cycle,” he says. “People have pain or chronic inflammation, which causes them to create excess cortisol, a stress hormone. The increased cortisol keeps them awake or disrupts sleep, so they wake up feeling unrefreshed, and that increases cortisol still more during the day.”

In treating sleep problems, says Dr. Ferzli, “we first investigate the sleep patterns and habits that may contribute to inflammation, which can range from diet and allergies, to too much screen time at night, or even to improper breathing patterns. Other health conditions also can contribute to sleep problems—either from the condition itself or its treatment. Patients with high blood pressure, for example, often have sleep problems, because blood pressure medication can cause dryness in the mouth.”

Dr. Ferzli also treats patients with TMJD (temporomandibular joint disorder), which is often related to sleep issues. “With TMJ patients, it often happens that the pain wakes them, causing what’s known as secondary insomnia. They might take medication or muscle relaxers to ease the pain, but some of these medications also affect sleep. Again, not having refreshing sleep at night only furthers the inflammatory cycle.”

Medications and Sleep

“Many different kinds of medication impact sleep,” notes Dr. Ferzli. “For example, some of the medications to treat depression and anxiety—selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines—may help the condition at the expense of quality sleep. SSRIs can even cause teeth clenching in patients at night or make it harder to fall asleep in the first place, so switching to another form of medication can sometimes resolve those issues.

“Benzodiazepines, including valium and several other medications typically taken for anxiety, can kill your REM sleep,” warns Dr. Ferzli. “And many other drugs—including opiates like hydrocodone, tramadol, Percocet, and beta blockers—will suppress REM sleep and dreaming. But it’s worth noting,” he says, “that the reverse is true. Improving sleep can sometimes decrease the need for those medications, or lower the amount needed.”
Benzodiazepines, SSRIs, and pain medication are certainly not the only medications that affect the sleep cycle. Amphetamines, neuroleptics and anticonvulsants can all also trigger sleep bruxism (teeth clenching). Common medications like aspirin and NSAIDs also affect sleep, and ironically, even Ambien (a common sleep medication) harms REM sleep.

Alcohol is another sleep-stealing culprit that is often overlooked. “Alcohol will affect your sleep frequency, which means you’ll fall asleep faster,” explains Dr. Ferzli, “but it will also decrease your REM sleep.”

What to do about it?

Dr. Ferzli takes a systematic approach to solving the sleep puzzle, explaining, “the key is to evaluate both the awakened state and the sleep state to figure out how to best help the person.”

He notes that there are a variety of natural options to help people fall asleep, such as chamomile tea, a remedy in use for centuries. “Proper nasal breathing technique is another useful tool to calm down the nervous system so people can sleep,” he says. “And I will also recommend melatonin for older patients, whose bodies make less of it, although that’s not the answer for younger people.” Biofeedback therapy, classical music, and even stretching before bed, he notes, are all simple techniques that can help with insomnia.

“But—despite many options—we still have some patients who need to be medicated to fall asleep,” says Dr Ferzli. He stresses that these medications are best prescribed by a sleep physician, who will determine the dosage and type of sleep medicine that a person needs.

Medications Play a Limited Role

While medications can play a role in sleep issues, acknowledges Dr. Ferzli, they’re usually a smaller piece of the puzzle. “Other than as a last resort, we may also use medications early on, to help manage patients’ symptoms while waiting for oral appliances or other remedies to take effect. For example, I rarely prescribe muscle relaxers, but they can be an excellent short-term support for pain.”

Dr. Ferzli typically uses orthotics and even lasers to calm down inflammation and the nervous system. “As the patient heals, they can do without those medications down the road. And that’s always our goal—to enable them to sleep well without being dependent on drugs.”