Question:

I work third shift and I have shift work sleep disorder. My doctor has had me try several sleep medications and all have failed. Lunesta (3mg) did work longer than the rest, approximately two weeks. After this failed I was put on 5mg, that failed a couple of days after starting it. On a day of frustration I took 7mg of Lunesta and it did not work. I have just been prescribed Trazodone (50mg). I took it at approximately 7 a.m. this morning and went to bed at 8 a.m. I fell into a deep sleep for about 1 1/2 hours. The rest of the day was similar, sleeping for a couple of hours and waking. Will Trazodone help me achieve restful sleep after taking it regularly over a period of time? Can I take Lunesta and Trazodone together?

Answer:

You are not alone as shift work is quite common in modern society due to the 24/7 nature of world. As a result, about 20% of the population is involved in some form of shift work and about 15% of these individuals will have problems with sleep. Since you asked specifically about medications, I will address this, though I would like to spend a little time discussing shift work disorder first.

The body’s circadian rhythms usually cycle over a 24 to 25 hour time period. These rhythms are reset daily to match a 24 hour day by factors such as exposure to daylight and social cues, for example when we eat our meals. The internal clock can be advanced (moved forward so you are sleepy earlier in the evening) or delayed (moved backwards so you are more awake late into the night) by changing the timing of light exposure and other social cues. However, the internal clock can only be adjusted by 1-2 hours in either direction per day with these maneuvers. When individuals try to alter their rhythms by more than this, they tend to feel poorly with fatigue, sleepiness and nausea (as seen with Jet Lag, for example). Furthermore, it often takes several days to fully adjust our circadian rhythms to a new schedule and thus if you are going back and forth between schedules over the course of a few days, it can be difficult to stay awake when you need to and sleep when you are supposed to.

The following is a list of recommendations not involving the use of medications that may help some shift workers:

1) Try to maintain a regular shift and not rotating shifts. Regular shifts lead to more regular sleep times which may help you get more sleep.

2) If you have to rotate shifts, move with the clock. For example, it’s better to rotate days to evenings to night than to go in reverse order. This is because it’s easier for our internal clocks to make our days longer rather than shorter.

3) Try to keep your sleep schedule close in time on days you work and days off. Some individuals also find it easier to work shifts on consecutive days as opposed to having intermittent days off.

4) Scheduled napping when at work may help. This should occur during “low points” in the circadian cycle, namely between 0300-0500 and mid afternoon. Naps should be short (< 30 minutes) to avoid grogginess that comes from getting into deep sleep.

5) Timing of light exposure is important. If working at night, the environment should be as brightly lit as possible, especially early in the shift. Avoid bright light in the several hours before bedtime, including on the drive home (wear sunglasses!).

6) Careful use of caffeine may be helpful. Caffeine containing beverages are best when used early in night shift and avoided in the 6 hours before bedtime.

Regarding the medications, there are a number of approaches that have been tried with varying degrees of success. First, there have been attempts to improve alertness at night with the use of stimulants. A recent study suggested that Provigil (modafinil) taken at night by 3rd shift workers can improve nighttime alertness, though the effect was quite modest. Other stimulants have not been well-studied.

Second, there have been attempts at improving daytime sleep with the use of sleep aids (mainly sedative-hypnotics). Studies generally agree that sedatives can help with daytime sleep in 3rd shift workers, though the effects are variable. In addition, the consequences of long-term use of such medications are not clearly known. Lunesta (eszopiclone), which you been trying, is one of the newer class of sedative agents that are thought to be more effective and better tolerated than traditional benzodiazepines (such as Valium or Restoril). However, as you point out, the effectiveness may vary and other agents may be needed. Desyrel (trazodone) is actually an antidepressant that affects the brains neurotransmitters and has a side effect of drowsiness. Because it is generally well-tolerated and not habit forming, it is sometimes used as a sleep aid. The combination of these 2 agents (Lunesta and Trazodone) can be taken together (they do not interact directly with each other) with the main potential side effects to watch out for being excessive sleepiness, headaches, dizziness and stomach upset.

And finally, some attempts have been made to reorient the underlying circadian rhythm to promote sleep during the day and alertness at night. Aside from the nonpharmacologic approaches mentioned above, melatonin has also been used with varying degrees of success. This would be taken in the morning to try to simulate peaking melatonin levels when you want to go to sleep. Melatonin is over the counter, but caution should be exercised as this drug is not regulated by the FDA and thus there is no guarantee about the quality or quantity of the product sold. A newer melatonin-like medicine, Rozerem (ramelteon), is now available by prescription but has not been well-studied in shift workers.

As you can see, shift work disorder can be complicated and difficult to treat. However, there are a number of approaches that can be attempted. I recommend you try some of the nonpharmacologic measures and discuss your medications further with your Sleep Specialist.

If you would like further information about shift work, circadian rhythms, sleep disorders or sleep itself, I recommend the American Academy of Sleep Medicine website. In addition to information about sleep medicine, the website also contains a list of accredited Sleep Centers and may help you to locate one nearest you. Good Luck!

For more information:

Go to the Sleep Disorders health topic.