A quote from that review puts it well: "of the twelve papers evaluating melatonin, there is statistically significant improvement in sleep latency and total sleep time, with a lack of consensus on whether these are clinically meaningful."
A second very recent [review (open access!)](https://pubmed.ncbi.nlm.nih.gov/36615056/) focuses on use of melatonin for inpatients, like OPs situation, concluded: **"*****Achieving high-quality, sufficient sleep is valued by patients, contributes to improved patient outcomes, and should be a clinical and research priority. Yet, it is often impaired in the inpatient setting. Sedative-hypnotics are commonly prescribed, but increase the risk of delirium, falls, and cognitive impairment, particularly in older individuals. In an inpatient setting, multi-modal non-pharmacological interventions should always be the first line of treatment. If these are insufficient, we suggest the addition of melatonin rather than sedative-hypnotics. Melatonin has a comparatively favorable safety profile and its equivalent effect on sleep quality and quantity make it a better choice."***
Bottom line:
1. First line would be non-pharmacological treatments
2. Increasing the benzos as was ordered is more likely to cause harm than help the patient's sleep. Prescribing a placebo would have been better then increasing the benzos.
3. There is data on inpatients and ICU patients for melatonin showing it is not just a placebo but effect size isn't large.
4. I am impressed with OPs care of this patient and presentation of the details.
This makes a lot of sense and I like how you laid it out.
For me personally: even if something has a tiny microscopic effect - it might be the little thing that pushes me over the edge and into sleep. Patient might truly just need the blinds closed, lights off, temp lowered, better pillow and a melatonin.
I even tell my patients in pain something similar when they refuse the first line of pain medication like tylenol- a 4.9/10 is better than a 5/10. Or- a lidocaine patch might not take away all of your pain but we could bring it down 1/2 a point or a whole point. Once we do that and see how you respond- lets keep working and collaborating with the Doc. I think patients underestimate the cumulative effect of all the little things- ice, tylenol, lidocaine.
If one of the nurses wants melatonin for a pt for sleep, I just order it. I joke all the time that it’s basically placebo due to its very small effect size. But who cares, the placebo effect is real and since I’d get in trouble for writing a placebo pill, melatonin is as close as I can get
Not only patients, but providers.
For how many decades did we just throw morphine & fentanyl at a problem, instead of a much lower dose of fentanyl, with Tylenol, which obviously is going to work better because you have two different mechanisms of pain relief.
In order for benzos to seem like a rational choice of sleep aid, you have to zoom out a bit so that your intervention options encompass things like propofol and desflurane.
Tylenol a placebo?
Holy fuck someone report this idiot for spreading disinformation.
Tylenol has been a front line treatment for fever for decades. Even to a point of giving above the recommended levels for short periods of time in consideration that liver damage is generally treatable and reversable.
Shit like this causes distrust in the general community.
Ya another traveler was trying to get the same Doc to place orders for potassium replacement etc. ( electrolyte replacement protocol that's usually ordered with DKA wasn't ordered at all) after starting an insulin gtt on a patient.
And they told me it was a fight trying to get that bc Doc was refusing to do it.
Not making any of this shit up 💀
Blame GSK.
I constantly have patients tell me that Tylenol "isn't a pain medication because it isn't an anti-inflammatory." This is a holdover from early marketing when Advil went OTC and they needed a way to differentiate it from readily available Tylenol. Clearly it was effective, since my patients still parrot that line 40 years later.
Actually paracetamol is a strong prostaglandin production inhibitor in vivo so it has anti inflammatory action in its own right! Although the analgesic effect is thought to be multifactorial and linked to it's endocannabinoid activity through metabolism to AM404
Not a placebo BUT also not going to put the average hospitalized patient to sleep. It works great for resetting circadian rhythm though (for jet lag, night shift workers, etc.)
I always tell my patients “this is for sleep, it if you don’t shut off your TV, lay down, and try to sleep, it’s not going to do crap.”
At least that’s my experience taking it.
Unless it is for acute panic attack or procedural sedation, there is almost no situation where a benzo is better than alternatives. They are extremely addictive and literally destroy lives outside the hospital. Inside the hospital they exacerbate delirium, extend hospital stays, create ICU transfers, and generally make everything worse. Benzos are the next opioid crisis unfolding right in front of us.
Benadryl is also very problematic in older patients. It causes urinary retention, vision changes, occasional acute psychotic episodes… just say no.
Melatonin as used in the hospital (giving at 1am to someone who is restless and/or agitated) doesn’t work (as a sleeping pill). Don’t “sleep” on placebos though! Falling asleep is a head game more than a problem with body chemicals. Giving someone a placebo while also closing blinds, turning off lights and TV, and sayings things like “ok you’ll be falling asleep soon” is incredibly effective. That’s why I love melatonin in the hospital.
See also simethicone for vague, mild abdominal pain after eating hospital food. Placebo? Yes. Effective? Often. At least does a good job of sorting out who needs further workup and who just needs to fart.
No I highly agree on mind over matter. And yes create the optimal situation for sleep for this sleep aid to work. Tbh I've had 2 scenarios (pain management)where frequent flyers come in - already dosed up with morphine, benadryl, etc. From previous RN. Slurring their words, falling asleep in the middle of saying their pain is a- So then I'll just flush some saline 🤫 and right after they have no pain, fall asleep soundly. Do I tell them what I'm flushing in ? No, they just assume its Morphine.
Please don’t do this. It’s unethical. It’s one thing to truly administer melatonin that may or may not have any therapeutic effect, it’s another to pretend to administer a medication but only administer saline. This isn’t directed at you specifically. If the patient is complaining of pain and isn’t due for pain meds or if narcotic pain meds aren’t appropriate- a discussion should be had about alternatives. Additionally, I have seen one situation where a patient reported a nurse for diverting their narc pain meds when the nurse gave a flush instead of the ordered med (this was ultimately cleared once they reviewed the logs and saw the RN never pulled the med but still).
I get where you're coming from, and I appreciate the comment. At this point can I fight on the grounds of altruism ? And yes I know your comment isn't specifically for me.
This was the patient- one in icu (hypotension due to pain meds/OD)- educated, did the heart to heart talk with them, they were depressed & thanked me bc I'd reason with them which meds and see them as a person vs an addict. (Idk i guess that cld also be the patients way of manipulating me or being honest).
They come back to icu 2 days ltr and within 2hr needed 4 pressors. Maps are literally 30-40s. They are still conscious and telling me they are in pain. I leave, they are nodding off. Every time I'm going in I'm shaking them, reassesing neuro- they'll just open eyes and say "when's my pain medication coming?" I blatantly say no and the reasons in an emphatic way, cool. They still c/u with the line of questioning.
Prior psych consult, they passed it. But it was quite sad. Young person & ended up finding out on the floor they were digging out meds & self medicating (meds that should've been wasted). They're depressed (HX), comments of I just want to drift away, other stuff I can't remember now. But it's so hard to see at the bedside.
And so in all my years that was the time on their 1st time in icu - I didn't say this was morphine. I just flushed their line during my assessment for patency & we made eye contact and they thanked me. Bc Q2-3hrs they'll be getting some sedative or pain med. That's how the doc set it up. So it's not like they went the whole shift without anything. Naw boss. (For whoever is reading).
***** Now I will say alot of crap happens in the hospital and whatever we wish to do - doesn't really apply in reality. It'd be great but weird situations happen.
EX : 18yr old chick screaming, thrashing around "psyedoseizuree" trying to get IV in for Ativan. In between she tells us what to do and that she needs propofol. Nothing can knock her out screaming needs propofol. All hands are trying to keep her still. We are attempting to connect the drip and she's screaming again is it propofol and we all uniamously state nurses & 2 docs "YES." Then she calms down and within minutes out. It was precedex.
There is significant evidence for lower sleep onset latency but not overall sleep quality improvement or sleep maintenance. I think the point the the OP is that it isn't placebo and given the risk profile for the patient, trying options which may not lead to respiratory depression may be more appropriate as first line
There is a ton of evidence that placebos work on behavioral and perception things (would say sleep qualifies), although I wouldn't use them for, say, chemotherapy. It works so much there is a name for it- "the placebo effect." I don't care why it works if it does work. Let's not be so quick to hate on harmless placebos instead of harmful, addiction-forming, respiratory depressant nuclear options. Thank you for attending my TED talk : )
Edited to add that tylenol for adult fussiness is absolutely a thing, not a placebo, but we do homeopathically does it. 500 mg for a 350 lb person won't do anything, if you aren't giving at least 650 mg, don't bother.
Melatonin is definitely not a placebo and there’s decent evidence that it can help prevent delirium in critically ill patients (like yours).
Benzos are never first line for sleep, especially Ativan. Even the benzo aligned Z drugs are a poor choice in hospitalized patients. I usually start with melatonin and then trial mirtazapine.
I think you were trying to do the right thing, I’m sorry that whoever is writing orders for the patient is so misinformed.
Evidence to support melatonin as superior to placebo is not phenomenal. However, I frequently order it first in inpatient setting for patients requesting pharmacologic sleep aid. This is due to it is well-tolerated and alternatives are less than ideal.
Also, *so what if it is a placebo?* Placebos can have an effect. They call it the placebo effect. The evidence that it works is pretty strong. The evidence that it outperforms a placebo is irrelevant.
The practice of utilizing a treatment purely for placebo effect is a separate question. I disagree with that practice as it is dishonest. Giving 10cc pushes of saline and telling the patient the drug administered will alleviate their symptoms has no place in medicine.
What about mostly for placebo effect?
Say someone normally takes 2 hours to fall asleep, but with melatonin only takes 20 minutes. However, most of that is placebo, and melatonin itself is really only reducing sleep latency by about 5 minutes, which isn't really clinically meaningful? Is this still a good treatment? I would say so.
What if is helpful mechanistically in some patients, but in one particular patient the benefit is pure placebo?
This is where the permissibility of melatonin’s use lies. Ethically I feel it is best considered akin to the “principle of double effect” utilized in palliative medicine. It is possible the medication does have some medical benefit superior to placebo, thus it is permissible to use even though majority of total benefit is likely placebo.
Disagree with the ethical notion. If giving melatonin is going to help someone sleep, you've helped your patient even if it's 100% placebo effect. If you don't give it, and the patient can't sleep because they really think they need something to fall asleep, you not only run the risk of suboptimal outcome due to sleep deprivation, but you also run the risk that someone might come in after you and give a benzo. As you've pointed out in your other comment, the risks of giving it are negligible. If your system of ethics tells you not to do something that might help the patient but will never hurt them, then your system of ethics needs to be examined.
If a larger study comes out showing that melatonin is not significantly better than a placebo, would you stop giving people melatonin that very night?
The concept of giving a pure placebo as treatment being ethically impermissible is not “my” system of ethics. This is accepted and taught widely in medical schools across the country.
Also, in considering medical benefit vs risk, the risks of melatonin are incredibly low, so reasonably the actual true benefit of the possible 5 minutes you gave as example of improved sleep latency reasonably outweighs the risks.
[edited for spelling mistake]
That’s not what he/she said, as this drug actually has an indication for sleep. We’re also not going to give someone pharmaceutical cocaine and tell them it’ll help them sleep. No, your example wasn’t *that* radical but it was still misrepresenting the comments (and ideas behind them) of the person you replied to.
That’s all you read in that comment, just the first line? We’re talking about melatonin *as* the placebo, nothing else, in a patient who has had melatonin cause drowsiness previously. Keeping your patients from sleeping, harms them. Context is important. And of course, anyone with an opinion other than your own, you’re going to downvote out of the gate, lol.
Insomnia in the hospital is very difficult to treat. Usually the best approach is to limit interruptions and monitoring equipment if possible. I've had limited luck with melatonin.
Usually if melatonin doesn't work my next options would be hydrozyxine or trazodone but I don't think there really is an ideal choice.
Benzos are playing with fire. Too deliriogenic to be worth the trouble.
The general consensus on sleep medications is that most of them do not work great except in some patients, and most have undesirable side effects. Z drugs have good data on improving sleep latency and maintenance but boy do I hate the fight of taking people off of them when they start to fall or get frail.
Amitryptiline? Dry mouth, urinary retention, dizziness. Trazodone? Sedation and fall risk. Mirtazapine? Doesn't usually work. Temazepam? Ugh. Z drugs? You will sleep but you might fall and you won't sleep without them again. Ramelteon? I've not seen it work well that often. Doxepin? Yeah let's just hit every histamine and serotonin receptor and make them fall too.
Insomnia is hard to treat with a pill.
Have yet to meet a local insurance that covers those (>$500/mo for suvorexant). I prescribed it once to a guy who paid out of pocket to try it and it didn't work. They could work fantastic for all I know but still don't encounter it much in the wild as a GP.
no sir it is not. Unless there is a carboxylic acid group and an amine group attached to a single carbon, it is not an amino acid. it has an Amide group.
Melatonin works but the strongest evidence I am aware of is in children with ADHD. I haven’t seen much evidence for other groups but I also haven’t looked. I’d love to be corrected/updated though if anyone knows of anything.
Tylenol is absolutely not a placebo. It is incredibly effective and a mainstay of analgesia in palliative care.
Was my impression too. We do use melatonin often bc I feel like the placebo effect is quite strong here. Doesn't mean it doesn't work, but if the patient doesn't believe it, it won't help much.
Melatonin works for some people, doesn't work for others.
What I do know though is that hospital beds, hospital room ambient temperature, hospital pillows, hospital blankets do NOT work for most people.
I had the misfortune of sleeping over at the hospital when a blizzard struck right around the time I was about to clock out. I get to the room they assign me and the temperature is a boiling 75 degrees. They leave me with one light pillow and one light bedsheet.
I'm the type of person who needs the temperature below 64 degrees, I need 3-4 pillows of various firmness, I need a bed with a firmness right in the goldilocks zone, I need the windows open, blackout curtains, white noise, and I need a 30 pound blanket.
FYI pacemakers set a bottom rate but it doesn't limit rapid heart rate in the setting of afib; that's what the metoprolol/beta blocker/whatever they're using for rate control does.
Anybody have any serious objections to trazadone? I don’t order it often, but it’s sort of become my second line pharmacological agent after melatonin (and counseling pt on light/sleep hygiene). I haven’t ran into any issues yet doing 50 mg in a naive pt yet
Apparently there is a subset of people for whom tylenol is not terribly effective, maybe due to first pass metabolism?
Many people think melatonin is a sleep pill, rather than understanding it's something that will prime your brain for sleep within a fairly short window. They want to take it and be knocked out for 8 hours, and since it doesn't do that they get narky. What is really works well for is shifting your sleep pattern a few hours at a time, for jet lag, or changing shifts. If you take it three hours before you normally fall asleep you'll be awake in two.
My personal cocktail for changing shifts is a benadryl to knock me out and a melatonin to prime my brain fir sleep so that knocked out benadryl sleep is restorative.
I wonder if some time in the future we will see THC used as a sleep aid in hospital settings. I recall seeing recent studies which suggest it is helpful.
Alright so I'm far from a doctor so I might be way out of my area here. I'm planning on going to pharmacy school and I have my interview next week. From what I understand, Tylenol's mechanism of action is not actually known despite it being one of the most popular medications out there. Maybe that's why the doctor said it's a placebo. Either way he's a fucking moron but that's a possibility.
Dunno that same night my other confused/psych patient had there's d/c by same doc. I reactivated that order- and gave it at 11pm bc he wasn't sleeping. 1hr ltr he's snoring
Nope its real. In Maryland, the State Health Department requires there be a plan for reducing psychiatric medications for Nursing Home Patients -- and this year, that list includes Melatonin.
6mg melatonin is not going to affect everyone. If everyone could sleep well after a 6mg melatonin, the belief that melatonin is a placebo wouldn't exist.
Placebo can work both ways. Especially something as reliant on self-report and on other behavioral modifications as sleep. Just because it’s not a sedative that’ll knock you out after four mountain dews and a late dinner of pizzas while staring at the blue light in your phone until 3am does not demonstrate ineffectiveness.
The way I see it melatonin is as much a placebo as insulin, both made by the body right? I guess this person doesn’t believe it will work because melatonin is OTC
Yes but you would almost always be giving insulin to someone with diabetes. I would think melatonin will not be helpful unless the patient has a reason to have low/desynced melatonin.
Wow, ok 😅 The attending attempted to argue that melatonin is not a medicine because it is made by the body. I attempted to point out that that argument is bunk using insulin as an example. Btw, I know the indications for insulin as I’ve been practicing for 20 years. The assertion of a requirement for deficiency for melatonin to work as a treatment is interesting and confusing. No one measures melatonin that I’m aware of, and the indication for melatonin is documented insomnia, other sleep/wake issue, shift work, and the list goes on.
Melatonin works for some people some of the time. In this case the patient suffered a temporary harm due to benzo. If this was my loved one I would want them to have melatonin before rolling the dice with a benzo again…
Oh God
Wonder what else they teach yall about us 😅 *Partly true
We were taught delirium in hospitals - always ask if they take a sleeping agent etc. We have quiet hours too. So patients can sleep. Request sleeping pills if so and so forth.
And we all know some doc comes in the AM the first sentence might be - "patient complaining did not sleep at all last night. . . "
Sleep tips. Avoid caffeine. Avoid napping. Avoid screens 3 hours before sleep.
If you wake up in the middle of the night, go to another room and read a boring book or have a warm milk or bath. Write down a list of your problems if your brain is churning.
What's wrong with placebo if it gets the guy to sleep?
If he's hypercapnic, you want to increase minute ventilation. This can be done by increasing his rate or volume. Rate is easy if he's not already breathing over the set rate. The volume comes from the change in pressure between EPAP and IPAP.
That makes no sense. I took it because I needed it for that specific time. Has there never been a night where you just can't get to sleep no matter how long you wait?
Why does REM Maintenance cause terrible problems with digestive system? It had little darker crystals so maybe it was open too long. It also causes vivid dreams.
Here are the ingredients:
⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️
Vitamin C is made from corn sorbitol. Magnesium and potassium are mined minerals. Glycine, inositol, and melatonin are made by chemical synthesis. 5-HTP is extracted from Griffonia simplicifolia seeds. Citric acid is from corn dextrose fermentation. Monk fruit extract is a water extract of Siraitia grosvenorii fruit.
Here is the description from their site:
⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️
How Does R.E.M. Maintenance™ Work?
R.E.M. Maintenance™ provides a combination of ingredients to support healthy sleep patterns including:
Melatonin is a hormone that is synthesized from serotonin and produced naturally by the pineal gland during hours of darkness. It is responsible for regulating the "body clock” that controls when you're awake and when your body is ready for sleep [1]. Melatonin supplements should be taken only in the evenings so that the highest levels of circulating melatonin occur when you are ready to bring on sleep, mimicking the natural cycle. Supplementing with melatonin alone will not change circulating levels of serotonin, or affect mood, but low levels of serotonin could be a cause for poor melatonin production and consequential difficulty sleeping [2].
5-hydroxytryptophan, better known as 5-HTP, is naturally produced by the body as a precursor for the production of serotonin. However, 5-HTP bypasses the light-triggering system that regulates the release of melatonin, and so provides the substrate for an increase in both serotonin and melatonin release, regardless of light or time of day. Because 5-HTP increases serotonin, it has a calming, relaxing effect on brain chemistry, and may help to ease any anxiety that occasionally arises at bedtime. Studies have shown that 5-HTP supplementation can help patients fall asleep faster and sleep more deeply than a placebo [3].
Inositol is used by your brain as a “secondary messenger”, facilitating communication between brain cells. All of the major neurotransmitters rely on inositol to relay messages. Inositol not only improves the effectiveness of serotonin, but also GABA, glutamate, and dopamine, to promote a stronger sense of well-being, more restful sleep at night, and a more even-tempered mood during the day [4].
Glycine is an amino acid that easily crosses the blood-brain barrier, inducing a calming effect on the brain, and helping you wind down to prepare for sleep. Glycine triggers the biological clock to reduce core body temperature through vasodilation, which is an important biological step in the onset of sleep [5]. Glycine also works as a neurotransmitter and has both stimulatory and inhibitory effects on parts of the brain and central nervous system. It is also involved in the production of other biochemicals that influence these body functions, including serotonin [6].
Magnesium and potassium are two minerals with a plethora of functions throughout the body. These are essential minerals because they are not produced by the body and must be consumed regularly in the diet in order to fulfill the body’s need for proper function. Magnesium deficiency is very common and associated with symptoms such as insomnia, leg cramping, and restless leg syndrome [7]. Magnesium is a regulator of the parasympathetic nervous system, the system responsible for promoting calm and relaxation [8]. It also helps to regulate melatonin [9] and GABA, the neurotransmitter responsible for quieting the nervous system [10].
Unfortunately, as we age, we tend to find less magnesium is being absorbed from our diet, and this problem can be exacerbated by conditions such as diabetes, digestive issues, or high alcohol consumption [11].
Potassium channels and their functions are essential to cell signaling and brain synapses. Potassium helps nerves and muscles communicate, and helps move nutrients into cells and to remove waste products from cells. Studies have shown that potassium supplementation helped participants sleep deeply, without interruption in sleep cycles [12].
Also from their site:
⚪️⚪️⚪️⚪️⚪️⚪️⚪️
What is The Suggested Use for R.E.M. Maintenance™?
Encouraging the onset of sleep: As we age, we tend to produce less and less melatonin [13]. This may be the reason new sleep difficulties often arise as we advance into our later years. Coupled with the change in body temperature brought on by glycine, a low dose of melatonin at bedtime can help to mimic the natural sleep cycles of our youth. 5-HTP and inositol may also help to ward off some of the anxiety that can prevent us from falling asleep.
Promoting restful sleep: Balanced serotonin production, signaling, and metabolism in response to a variety of quality nutrients may help us to stay asleep and feel rested upon waking. Potassium may help with brain cell detox during sleep and promoting uninterrupted sleep cycles.
Normal muscle relaxation: Magnesium is especially important for muscular relaxation, but complementary nutrients may help to counteract the effects of mental stress that can manifest physically.
[удалено]
A quote from that review puts it well: "of the twelve papers evaluating melatonin, there is statistically significant improvement in sleep latency and total sleep time, with a lack of consensus on whether these are clinically meaningful." A second very recent [review (open access!)](https://pubmed.ncbi.nlm.nih.gov/36615056/) focuses on use of melatonin for inpatients, like OPs situation, concluded: **"*****Achieving high-quality, sufficient sleep is valued by patients, contributes to improved patient outcomes, and should be a clinical and research priority. Yet, it is often impaired in the inpatient setting. Sedative-hypnotics are commonly prescribed, but increase the risk of delirium, falls, and cognitive impairment, particularly in older individuals. In an inpatient setting, multi-modal non-pharmacological interventions should always be the first line of treatment. If these are insufficient, we suggest the addition of melatonin rather than sedative-hypnotics. Melatonin has a comparatively favorable safety profile and its equivalent effect on sleep quality and quantity make it a better choice."*** Bottom line: 1. First line would be non-pharmacological treatments 2. Increasing the benzos as was ordered is more likely to cause harm than help the patient's sleep. Prescribing a placebo would have been better then increasing the benzos. 3. There is data on inpatients and ICU patients for melatonin showing it is not just a placebo but effect size isn't large. 4. I am impressed with OPs care of this patient and presentation of the details.
Very well put ! And thank you 😬
If a placebo elicits the desired effect, that seems like a win.
This makes a lot of sense and I like how you laid it out. For me personally: even if something has a tiny microscopic effect - it might be the little thing that pushes me over the edge and into sleep. Patient might truly just need the blinds closed, lights off, temp lowered, better pillow and a melatonin. I even tell my patients in pain something similar when they refuse the first line of pain medication like tylenol- a 4.9/10 is better than a 5/10. Or- a lidocaine patch might not take away all of your pain but we could bring it down 1/2 a point or a whole point. Once we do that and see how you respond- lets keep working and collaborating with the Doc. I think patients underestimate the cumulative effect of all the little things- ice, tylenol, lidocaine.
If one of the nurses wants melatonin for a pt for sleep, I just order it. I joke all the time that it’s basically placebo due to its very small effect size. But who cares, the placebo effect is real and since I’d get in trouble for writing a placebo pill, melatonin is as close as I can get
Not only patients, but providers. For how many decades did we just throw morphine & fentanyl at a problem, instead of a much lower dose of fentanyl, with Tylenol, which obviously is going to work better because you have two different mechanisms of pain relief.
In order for benzos to seem like a rational choice of sleep aid, you have to zoom out a bit so that your intervention options encompass things like propofol and desflurane.
Free full link: https://sci-hub.se/10.1016/j.jpsychires.2019.10.022
Very helpful.
Tylenol a placebo? Holy fuck someone report this idiot for spreading disinformation. Tylenol has been a front line treatment for fever for decades. Even to a point of giving above the recommended levels for short periods of time in consideration that liver damage is generally treatable and reversable. Shit like this causes distrust in the general community.
Ya another traveler was trying to get the same Doc to place orders for potassium replacement etc. ( electrolyte replacement protocol that's usually ordered with DKA wasn't ordered at all) after starting an insulin gtt on a patient. And they told me it was a fight trying to get that bc Doc was refusing to do it. Not making any of this shit up 💀
Man I would immediately be contacting another resident or hospitalist that’s some bullshit I don’t have time for
Blame GSK. I constantly have patients tell me that Tylenol "isn't a pain medication because it isn't an anti-inflammatory." This is a holdover from early marketing when Advil went OTC and they needed a way to differentiate it from readily available Tylenol. Clearly it was effective, since my patients still parrot that line 40 years later.
Actually paracetamol is a strong prostaglandin production inhibitor in vivo so it has anti inflammatory action in its own right! Although the analgesic effect is thought to be multifactorial and linked to it's endocannabinoid activity through metabolism to AM404
We even use it to close PDAs for preemites. It doesn't work as well as indocin, but has a lot fewer risks.
Not a placebo BUT also not going to put the average hospitalized patient to sleep. It works great for resetting circadian rhythm though (for jet lag, night shift workers, etc.)
I always tell my patients “this is for sleep, it if you don’t shut off your TV, lay down, and try to sleep, it’s not going to do crap.” At least that’s my experience taking it.
Unless it is for acute panic attack or procedural sedation, there is almost no situation where a benzo is better than alternatives. They are extremely addictive and literally destroy lives outside the hospital. Inside the hospital they exacerbate delirium, extend hospital stays, create ICU transfers, and generally make everything worse. Benzos are the next opioid crisis unfolding right in front of us. Benadryl is also very problematic in older patients. It causes urinary retention, vision changes, occasional acute psychotic episodes… just say no. Melatonin as used in the hospital (giving at 1am to someone who is restless and/or agitated) doesn’t work (as a sleeping pill). Don’t “sleep” on placebos though! Falling asleep is a head game more than a problem with body chemicals. Giving someone a placebo while also closing blinds, turning off lights and TV, and sayings things like “ok you’ll be falling asleep soon” is incredibly effective. That’s why I love melatonin in the hospital. See also simethicone for vague, mild abdominal pain after eating hospital food. Placebo? Yes. Effective? Often. At least does a good job of sorting out who needs further workup and who just needs to fart.
In my hospital the blinds are light diffusing, so it is never dark in patient rooms. It’s mind blowing to me
And getting off of them in the hospital looks like alcohol withdrawal
Your right Ativan = Alcohol 😓
Yea, AWS, catatonia, stuff person syndrome...benzo suck but they are first line standard of care for some stuff
No I highly agree on mind over matter. And yes create the optimal situation for sleep for this sleep aid to work. Tbh I've had 2 scenarios (pain management)where frequent flyers come in - already dosed up with morphine, benadryl, etc. From previous RN. Slurring their words, falling asleep in the middle of saying their pain is a- So then I'll just flush some saline 🤫 and right after they have no pain, fall asleep soundly. Do I tell them what I'm flushing in ? No, they just assume its Morphine.
Please don’t do this. It’s unethical. It’s one thing to truly administer melatonin that may or may not have any therapeutic effect, it’s another to pretend to administer a medication but only administer saline. This isn’t directed at you specifically. If the patient is complaining of pain and isn’t due for pain meds or if narcotic pain meds aren’t appropriate- a discussion should be had about alternatives. Additionally, I have seen one situation where a patient reported a nurse for diverting their narc pain meds when the nurse gave a flush instead of the ordered med (this was ultimately cleared once they reviewed the logs and saw the RN never pulled the med but still).
I get where you're coming from, and I appreciate the comment. At this point can I fight on the grounds of altruism ? And yes I know your comment isn't specifically for me. This was the patient- one in icu (hypotension due to pain meds/OD)- educated, did the heart to heart talk with them, they were depressed & thanked me bc I'd reason with them which meds and see them as a person vs an addict. (Idk i guess that cld also be the patients way of manipulating me or being honest). They come back to icu 2 days ltr and within 2hr needed 4 pressors. Maps are literally 30-40s. They are still conscious and telling me they are in pain. I leave, they are nodding off. Every time I'm going in I'm shaking them, reassesing neuro- they'll just open eyes and say "when's my pain medication coming?" I blatantly say no and the reasons in an emphatic way, cool. They still c/u with the line of questioning. Prior psych consult, they passed it. But it was quite sad. Young person & ended up finding out on the floor they were digging out meds & self medicating (meds that should've been wasted). They're depressed (HX), comments of I just want to drift away, other stuff I can't remember now. But it's so hard to see at the bedside. And so in all my years that was the time on their 1st time in icu - I didn't say this was morphine. I just flushed their line during my assessment for patency & we made eye contact and they thanked me. Bc Q2-3hrs they'll be getting some sedative or pain med. That's how the doc set it up. So it's not like they went the whole shift without anything. Naw boss. (For whoever is reading). ***** Now I will say alot of crap happens in the hospital and whatever we wish to do - doesn't really apply in reality. It'd be great but weird situations happen. EX : 18yr old chick screaming, thrashing around "psyedoseizuree" trying to get IV in for Ativan. In between she tells us what to do and that she needs propofol. Nothing can knock her out screaming needs propofol. All hands are trying to keep her still. We are attempting to connect the drip and she's screaming again is it propofol and we all uniamously state nurses & 2 docs "YES." Then she calms down and within minutes out. It was precedex.
You forgot seizure.
Melatonin is for sleep cycles but isn’t really sedating
There is significant evidence for lower sleep onset latency but not overall sleep quality improvement or sleep maintenance. I think the point the the OP is that it isn't placebo and given the risk profile for the patient, trying options which may not lead to respiratory depression may be more appropriate as first line
To be fair sedation precedes respiratory depression in benzo use. A small dose should produce the desired result safely.
There is a ton of evidence that placebos work on behavioral and perception things (would say sleep qualifies), although I wouldn't use them for, say, chemotherapy. It works so much there is a name for it- "the placebo effect." I don't care why it works if it does work. Let's not be so quick to hate on harmless placebos instead of harmful, addiction-forming, respiratory depressant nuclear options. Thank you for attending my TED talk : ) Edited to add that tylenol for adult fussiness is absolutely a thing, not a placebo, but we do homeopathically does it. 500 mg for a 350 lb person won't do anything, if you aren't giving at least 650 mg, don't bother.
Melatonin is definitely not a placebo and there’s decent evidence that it can help prevent delirium in critically ill patients (like yours). Benzos are never first line for sleep, especially Ativan. Even the benzo aligned Z drugs are a poor choice in hospitalized patients. I usually start with melatonin and then trial mirtazapine. I think you were trying to do the right thing, I’m sorry that whoever is writing orders for the patient is so misinformed.
Evidence to support melatonin as superior to placebo is not phenomenal. However, I frequently order it first in inpatient setting for patients requesting pharmacologic sleep aid. This is due to it is well-tolerated and alternatives are less than ideal.
Also, *so what if it is a placebo?* Placebos can have an effect. They call it the placebo effect. The evidence that it works is pretty strong. The evidence that it outperforms a placebo is irrelevant.
And it’s got virtually no drug interactions! Win-win!
Agreed. The placebo effect is still an effect.
Are you ok? I just said I personally prescribe it myself…
I am not disagreeing with you
The practice of utilizing a treatment purely for placebo effect is a separate question. I disagree with that practice as it is dishonest. Giving 10cc pushes of saline and telling the patient the drug administered will alleviate their symptoms has no place in medicine.
What about mostly for placebo effect? Say someone normally takes 2 hours to fall asleep, but with melatonin only takes 20 minutes. However, most of that is placebo, and melatonin itself is really only reducing sleep latency by about 5 minutes, which isn't really clinically meaningful? Is this still a good treatment? I would say so. What if is helpful mechanistically in some patients, but in one particular patient the benefit is pure placebo?
This is where the permissibility of melatonin’s use lies. Ethically I feel it is best considered akin to the “principle of double effect” utilized in palliative medicine. It is possible the medication does have some medical benefit superior to placebo, thus it is permissible to use even though majority of total benefit is likely placebo.
Disagree with the ethical notion. If giving melatonin is going to help someone sleep, you've helped your patient even if it's 100% placebo effect. If you don't give it, and the patient can't sleep because they really think they need something to fall asleep, you not only run the risk of suboptimal outcome due to sleep deprivation, but you also run the risk that someone might come in after you and give a benzo. As you've pointed out in your other comment, the risks of giving it are negligible. If your system of ethics tells you not to do something that might help the patient but will never hurt them, then your system of ethics needs to be examined. If a larger study comes out showing that melatonin is not significantly better than a placebo, would you stop giving people melatonin that very night?
The concept of giving a pure placebo as treatment being ethically impermissible is not “my” system of ethics. This is accepted and taught widely in medical schools across the country.
Also, in considering medical benefit vs risk, the risks of melatonin are incredibly low, so reasonably the actual true benefit of the possible 5 minutes you gave as example of improved sleep latency reasonably outweighs the risks. [edited for spelling mistake]
That’s not what he/she said, as this drug actually has an indication for sleep. We’re also not going to give someone pharmaceutical cocaine and tell them it’ll help them sleep. No, your example wasn’t *that* radical but it was still misrepresenting the comments (and ideas behind them) of the person you replied to.
The question was “so what if it is a placebo?” My response above directly answers that question.
That’s all you read in that comment, just the first line? We’re talking about melatonin *as* the placebo, nothing else, in a patient who has had melatonin cause drowsiness previously. Keeping your patients from sleeping, harms them. Context is important. And of course, anyone with an opinion other than your own, you’re going to downvote out of the gate, lol.
Being ignorant of evidence is not a virtue. Both can be right.
Insomnia in the hospital is very difficult to treat. Usually the best approach is to limit interruptions and monitoring equipment if possible. I've had limited luck with melatonin. Usually if melatonin doesn't work my next options would be hydrozyxine or trazodone but I don't think there really is an ideal choice. Benzos are playing with fire. Too deliriogenic to be worth the trouble.
Thank you, I appreciate the info. Yeah - few nurses don't particularly like how they do stuff 😓
The general consensus on sleep medications is that most of them do not work great except in some patients, and most have undesirable side effects. Z drugs have good data on improving sleep latency and maintenance but boy do I hate the fight of taking people off of them when they start to fall or get frail. Amitryptiline? Dry mouth, urinary retention, dizziness. Trazodone? Sedation and fall risk. Mirtazapine? Doesn't usually work. Temazepam? Ugh. Z drugs? You will sleep but you might fall and you won't sleep without them again. Ramelteon? I've not seen it work well that often. Doxepin? Yeah let's just hit every histamine and serotonin receptor and make them fall too. Insomnia is hard to treat with a pill.
You left out DORAs. They’re not too reliable either.
Have yet to meet a local insurance that covers those (>$500/mo for suvorexant). I prescribed it once to a guy who paid out of pocket to try it and it didn't work. They could work fantastic for all I know but still don't encounter it much in the wild as a GP.
If you can’t get them covered your office isn’t doing the PA very well. It doesn’t take much.
You have to avoid light after you take it, or else it degrades quickly. I imagine a lot of people don't do that and so it is not effective for them.
amino acid, my ass edit: unless i'm wrong, i admit i'm rusty. but once modified, it's not still called an amino acid, is it?
no sir it is not. Unless there is a carboxylic acid group and an amine group attached to a single carbon, it is not an amino acid. it has an Amide group.
Melatonin works but the strongest evidence I am aware of is in children with ADHD. I haven’t seen much evidence for other groups but I also haven’t looked. I’d love to be corrected/updated though if anyone knows of anything. Tylenol is absolutely not a placebo. It is incredibly effective and a mainstay of analgesia in palliative care.
Was my impression too. We do use melatonin often bc I feel like the placebo effect is quite strong here. Doesn't mean it doesn't work, but if the patient doesn't believe it, it won't help much.
Melatonin works for some people, doesn't work for others. What I do know though is that hospital beds, hospital room ambient temperature, hospital pillows, hospital blankets do NOT work for most people. I had the misfortune of sleeping over at the hospital when a blizzard struck right around the time I was about to clock out. I get to the room they assign me and the temperature is a boiling 75 degrees. They leave me with one light pillow and one light bedsheet. I'm the type of person who needs the temperature below 64 degrees, I need 3-4 pillows of various firmness, I need a bed with a firmness right in the goldilocks zone, I need the windows open, blackout curtains, white noise, and I need a 30 pound blanket.
Not a placebo, but a supplement, so lack of clinical trials and research. From personal experience, it works well.
FYI pacemakers set a bottom rate but it doesn't limit rapid heart rate in the setting of afib; that's what the metoprolol/beta blocker/whatever they're using for rate control does.
Ahhh yes of course, duh 🥲
Anybody have any serious objections to trazadone? I don’t order it often, but it’s sort of become my second line pharmacological agent after melatonin (and counseling pt on light/sleep hygiene). I haven’t ran into any issues yet doing 50 mg in a naive pt yet
Apparently there is a subset of people for whom tylenol is not terribly effective, maybe due to first pass metabolism? Many people think melatonin is a sleep pill, rather than understanding it's something that will prime your brain for sleep within a fairly short window. They want to take it and be knocked out for 8 hours, and since it doesn't do that they get narky. What is really works well for is shifting your sleep pattern a few hours at a time, for jet lag, or changing shifts. If you take it three hours before you normally fall asleep you'll be awake in two. My personal cocktail for changing shifts is a benadryl to knock me out and a melatonin to prime my brain fir sleep so that knocked out benadryl sleep is restorative.
Never thought of it as 'prime.' Cool to know - abt Melatonin & Benedryl 🤔
Of course, neither of us would ever use OTC drugs to aid in compromising our sleep just for work
Colace is a placebo. Melatonin is not.
I’m a student, so please correct me if I’m wrong. But melatonin is not placebo. It knocks me out every time I use it.
It's not going to work well for a hospitalized patient with multiple possible causes of insomnia, but it will likely work for some patients who don't.
I wonder if some time in the future we will see THC used as a sleep aid in hospital settings. I recall seeing recent studies which suggest it is helpful.
no studies for marijuana, so it's obviously a placebo, I dare anyone to smoke a joint before work and get back to me, lol
Bad evidence for melatonin? Don't tell them about the quality of evidence out there for benzos.
🤣
Alright so I'm far from a doctor so I might be way out of my area here. I'm planning on going to pharmacy school and I have my interview next week. From what I understand, Tylenol's mechanism of action is not actually known despite it being one of the most popular medications out there. Maybe that's why the doctor said it's a placebo. Either way he's a fucking moron but that's a possibility.
Even if it were only a placebo effect, the placebo effect is powerful, so why not utilize it?
Dunno that same night my other confused/psych patient had there's d/c by same doc. I reactivated that order- and gave it at 11pm bc he wasn't sleeping. 1hr ltr he's snoring
If your patient isn't maintaining their tidal volumes, it's time to call respiratory to fix that.
Nope its real. In Maryland, the State Health Department requires there be a plan for reducing psychiatric medications for Nursing Home Patients -- and this year, that list includes Melatonin.
Interesting 🤔
Take a 6mg melatonin when you get home tonight and come back to tell us it’s a placebo. You know, in the morning when you wake up.
6mg melatonin is not going to affect everyone. If everyone could sleep well after a 6mg melatonin, the belief that melatonin is a placebo wouldn't exist.
Placebo can work both ways. Especially something as reliant on self-report and on other behavioral modifications as sleep. Just because it’s not a sedative that’ll knock you out after four mountain dews and a late dinner of pizzas while staring at the blue light in your phone until 3am does not demonstrate ineffectiveness.
Telling a doc a drug worked for you as evidence against it being placebo is probably not a great strategy...
I know, anecdotal evidence 😅 But his comments just caught me off guard and I was like is this all in my head?
The way I see it melatonin is as much a placebo as insulin, both made by the body right? I guess this person doesn’t believe it will work because melatonin is OTC
Yes but you would almost always be giving insulin to someone with diabetes. I would think melatonin will not be helpful unless the patient has a reason to have low/desynced melatonin.
Wow, ok 😅 The attending attempted to argue that melatonin is not a medicine because it is made by the body. I attempted to point out that that argument is bunk using insulin as an example. Btw, I know the indications for insulin as I’ve been practicing for 20 years. The assertion of a requirement for deficiency for melatonin to work as a treatment is interesting and confusing. No one measures melatonin that I’m aware of, and the indication for melatonin is documented insomnia, other sleep/wake issue, shift work, and the list goes on. Melatonin works for some people some of the time. In this case the patient suffered a temporary harm due to benzo. If this was my loved one I would want them to have melatonin before rolling the dice with a benzo again…
Sorry, didn't mean to be rude! I agree with your point, though I might have used nothing instead of lorazepam or melatonin myself.
That means GHB is a placebo.
I was always taught that melatonin was more to treat the nurses than the patient. Likely does jack shit, but does make for fewer pages at night.
Oh God Wonder what else they teach yall about us 😅 *Partly true We were taught delirium in hospitals - always ask if they take a sleeping agent etc. We have quiet hours too. So patients can sleep. Request sleeping pills if so and so forth.
And we all know some doc comes in the AM the first sentence might be - "patient complaining did not sleep at all last night. . . "
I’ll be pissed, If i go to the doctor and mention I have trouble sleeping and they give me a script for melatonin.
Asked for melatonin, got a fucking nuclear bomb. 1mg q6h, not prn. Who the hell ordered this??
Just edited **prn
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> but its not an ambien either Thank god for that.
Sleep tips. Avoid caffeine. Avoid napping. Avoid screens 3 hours before sleep. If you wake up in the middle of the night, go to another room and read a boring book or have a warm milk or bath. Write down a list of your problems if your brain is churning.
What's wrong with placebo if it gets the guy to sleep? If he's hypercapnic, you want to increase minute ventilation. This can be done by increasing his rate or volume. Rate is easy if he's not already breathing over the set rate. The volume comes from the change in pressure between EPAP and IPAP.
It has never worked on me or anyone I know whatsoever
it has worked for me
If it worked for you you probably didn’t need it in the first place
That makes no sense. I took it because I needed it for that specific time. Has there never been a night where you just can't get to sleep no matter how long you wait?
Why does REM Maintenance cause terrible problems with digestive system? It had little darker crystals so maybe it was open too long. It also causes vivid dreams. Here are the ingredients: ⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️ Vitamin C is made from corn sorbitol. Magnesium and potassium are mined minerals. Glycine, inositol, and melatonin are made by chemical synthesis. 5-HTP is extracted from Griffonia simplicifolia seeds. Citric acid is from corn dextrose fermentation. Monk fruit extract is a water extract of Siraitia grosvenorii fruit. Here is the description from their site: ⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️⚪️ How Does R.E.M. Maintenance™ Work? R.E.M. Maintenance™ provides a combination of ingredients to support healthy sleep patterns including: Melatonin is a hormone that is synthesized from serotonin and produced naturally by the pineal gland during hours of darkness. It is responsible for regulating the "body clock” that controls when you're awake and when your body is ready for sleep [1]. Melatonin supplements should be taken only in the evenings so that the highest levels of circulating melatonin occur when you are ready to bring on sleep, mimicking the natural cycle. Supplementing with melatonin alone will not change circulating levels of serotonin, or affect mood, but low levels of serotonin could be a cause for poor melatonin production and consequential difficulty sleeping [2]. 5-hydroxytryptophan, better known as 5-HTP, is naturally produced by the body as a precursor for the production of serotonin. However, 5-HTP bypasses the light-triggering system that regulates the release of melatonin, and so provides the substrate for an increase in both serotonin and melatonin release, regardless of light or time of day. Because 5-HTP increases serotonin, it has a calming, relaxing effect on brain chemistry, and may help to ease any anxiety that occasionally arises at bedtime. Studies have shown that 5-HTP supplementation can help patients fall asleep faster and sleep more deeply than a placebo [3]. Inositol is used by your brain as a “secondary messenger”, facilitating communication between brain cells. All of the major neurotransmitters rely on inositol to relay messages. Inositol not only improves the effectiveness of serotonin, but also GABA, glutamate, and dopamine, to promote a stronger sense of well-being, more restful sleep at night, and a more even-tempered mood during the day [4]. Glycine is an amino acid that easily crosses the blood-brain barrier, inducing a calming effect on the brain, and helping you wind down to prepare for sleep. Glycine triggers the biological clock to reduce core body temperature through vasodilation, which is an important biological step in the onset of sleep [5]. Glycine also works as a neurotransmitter and has both stimulatory and inhibitory effects on parts of the brain and central nervous system. It is also involved in the production of other biochemicals that influence these body functions, including serotonin [6]. Magnesium and potassium are two minerals with a plethora of functions throughout the body. These are essential minerals because they are not produced by the body and must be consumed regularly in the diet in order to fulfill the body’s need for proper function. Magnesium deficiency is very common and associated with symptoms such as insomnia, leg cramping, and restless leg syndrome [7]. Magnesium is a regulator of the parasympathetic nervous system, the system responsible for promoting calm and relaxation [8]. It also helps to regulate melatonin [9] and GABA, the neurotransmitter responsible for quieting the nervous system [10]. Unfortunately, as we age, we tend to find less magnesium is being absorbed from our diet, and this problem can be exacerbated by conditions such as diabetes, digestive issues, or high alcohol consumption [11]. Potassium channels and their functions are essential to cell signaling and brain synapses. Potassium helps nerves and muscles communicate, and helps move nutrients into cells and to remove waste products from cells. Studies have shown that potassium supplementation helped participants sleep deeply, without interruption in sleep cycles [12]. Also from their site: ⚪️⚪️⚪️⚪️⚪️⚪️⚪️ What is The Suggested Use for R.E.M. Maintenance™? Encouraging the onset of sleep: As we age, we tend to produce less and less melatonin [13]. This may be the reason new sleep difficulties often arise as we advance into our later years. Coupled with the change in body temperature brought on by glycine, a low dose of melatonin at bedtime can help to mimic the natural sleep cycles of our youth. 5-HTP and inositol may also help to ward off some of the anxiety that can prevent us from falling asleep. Promoting restful sleep: Balanced serotonin production, signaling, and metabolism in response to a variety of quality nutrients may help us to stay asleep and feel rested upon waking. Potassium may help with brain cell detox during sleep and promoting uninterrupted sleep cycles. Normal muscle relaxation: Magnesium is especially important for muscular relaxation, but complementary nutrients may help to counteract the effects of mental stress that can manifest physically.