All Posts tagged sleep

Stimulants are the new opioids

Over prescribing of ADD and ADHD stimulant medications, especially in adults, is a rapidly exploding issue. Inappropriate use is common at many universities and high pressure jobs. However, there remains a considerable number of patients who have legitimate need and should be cared for within the healthcare community.
Addressing a patient’s need for stimulant medications requires a careful and thoughtful approach. For many disorders, Trinity uses our multifaceted approach to therapy which so often improves, reverses, or even cures the common maladies of modern humankind. We address the three main pillars of health that are required for any person to be remain healthy: good nutrition, good exercise, and good sleep.
Nutritionally, studies have demonstrated that a lower carbohydrate dietary plan improves ADD/ADHD symptoms over other dietary interventions. Omega-3 fatty acids found in fish oil (or actually eating more fish) is one of the few supplements that improves ADD/ADHD symptoms. Vigorous aerobic activity consistently demonstrates improved symptom control especially if challenging tasks are performed within the 90 minute golden window following exercise. Finally, sleep is a critical element to good focus and concentration. Disorders such as sleep apnea, excessive screen time, as well as burning the candle at both ends severely limits the brain’s ability to concentrate for weeks and months on end.
Trinity has adopted the widely published guidelines from the American Academy of Pediatrics and the American Academy of Family Practice concerning the prescribing of stimulant medications These guidelines include such things as the following:
-Stimulants will only be prescribed after an appropriate history and physical is performed which supports the diagnosis
-Secondary causes for the symptoms including poor nutrition, poor exercise, and poor sleep have been fully addressed
-Follow up is required in person on a monthly basis until stable then every three months thereafter
-Medication changes are done in person only
-Regular use of Tennessee’s Controlled Substance Monitoring Database
-Refills are done on time. They are not filled early, after hours, or for long term supplies.
-Urine drug screens are required at random intervals to confirm the use of the prescribed medication as well as the absence of inappropriate chemicals.
-Long term prescribing of medications is not guaranteed and referral to a mental health specialist will be made if the situation warrants.
We feel that with our approach and the use of these guidelines we will continue to provide high quality care for individuals in need and limit the inappropriate use of these medications.

Sleep and Your Health

Sleep – at its best it’s a wonderfully refreshing period where we physically and emotionally get reset for another day. But for an estimated 70 million Americans, one of the over 80 different sleep disorders intrudes on their ability to get a good night’s sleep. Everything from sleep apnea to restless leg syndrome to simple insomnia is included on the list. For our purposes today, we want to look under the covers at insomnia, defined as difficulty initiating or maintaining sleep resulting in daytime impairment.

About 10% of the population would fit the criteria for some level of chronic insomnia, hence the 60 million prescriptions yearly for sleep aids. And this doesn’t include the raft of over-the-counter sleep meds that fly off the shelves.

So is insomnia such a big deal? Well, yes, it is tied into several serious illnesses. Those with insomnia are twice as likely to have congestive heart failure, five times as likely to have anxiety or depression, and have increased rates of diabetes, obesity, motor vehicle accidents, infections, and have impaired memory, thought, and work and school performance. Of course some of these are effects of the insomnia and some are causes.

How much sleep do we really need? The average person needs 7 to 9 hours of good quality sleep. But the average American gets 6.9 hours, leading to a lot of sleep deprivation and all the baggage that comes with it. Some individuals are in bed long enough but don’t wake up refreshed and rested. This often indicates a poor quality of sleep, either through frequent awakenings, sleep apnea or some other sleep disorder that intrudes on the benefits of their sleep.

What are some of the causes of insomnia? For some, it is a built-in condition with a nearly life-long pattern of poor sleep-wake cycles. But there are a number of factors that can worsen the problem. Not surprisingly, children with smart phones, televisions or computers in their bedrooms are generally found to have poorer sleep patterns than those who do not. Certain medications, such as decongestants or corticosteroids can cause insomnia. Even meds that are used to induce sleep, such as antihistamines, can cause an opposite effect in a percentage of individuals, causing prolonged wakefulness.

So, to cut to the chase, what can you do if you notice that you are not sleeping well? Perhaps you awaken unrefreshed and have some daytime sleepiness. First, tune up your sleep habits. In general:

  • avoid daytime napping
  • avoid caffeinated drinks after lunch
  • get some physical exercise or exertion in (preferably early in the day)
  • try to go to bed at approximately the same time daily
  • don’t watch TV or read in bed
  • give yourself a set amount of time (perhaps 20 minutes) to fall asleep
  • if you don’t fall asleep in the set time, get out of bed and read in a chair until you feel you may be tired enough to sleep. Then get back into bed and give yourself 20 minutes again.

If after 1-2 weeks of this approach you aren’t seeing good results, you may benefit from consulting your physician. Certain medications may be an issue, or health issues such as hyperthyroidism, anxiety or depression.

If other issues are ruled out and the problem is persisting, prescription sleep aids can be considered as well as something called cognitive behavioral therapy, though this can be harder to access. Sleep meds include everything from the well-known Ambien (zolpidem) to sedating anti-depressants such as trazodone, antihistamines such as diphenhydramine (Benadryl), to benzodiazepines such as temazepam (Restoril), and even stronger, less-often-needed meds such as Seroquel. Incidentally, it was recently found that for females the 10 mg. dose of Ambien was associated with a 30% higher incidence of motor vehicle accidents the next morning. This led to the recommendation that women limit their Ambien dose to 5 mg, especially if they will be driving the next morning.

Over-the-counter meds such as Tylenol PM and Advil PM often use the sedating antihistamine, diphenhydramine, which leaves many with some left over morning grogginess. Melatonin has been found to be mildly effective in shift workers, but not very effective for typical insomnia. And the list goes on.

The bottom line is that there are pros and cons to each treatment option, including the option of just trying to ignore this problem and not treat it. So if insomnia is plaguing your nights, it’s worth some attention. Good sleep and good health tend to go together.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835




You can’t out supplement poor eating

Many of our patients are on a slew of supplements for which they have spent a pretty penny and while some supplements have their place in health; they can’t make up for a poor diet.

There are many parts of overall health:

(healthy eating, exercise, adequate sleep, supplements when necessary, stress reduction, etc.).


We tend to focus on our strongest areas of health and shy away from the others.  Your health is only as strong as the weakest link.  For me, it’s the exercise thing. I know that exercise  is important and vital to good health (I preach it every single day in the office!!).  But… I would not miss my 8 hours of sleep per night.  It is much easier for me to tweak our menus and simplify our outside commitments to reduce stress than to exercise.

I have seen hundreds of patients who do great with the diet, supplements, and even exercise but have trouble reducing stress or getting enough sleep.  Some spend hundreds of dollars on supplements each month but can’t afford “real, whole” foods and still purchase processed snacks.

Now.. I do think there are certainly areas that carry more weight than others, but all  of the links are important.  I have patients who run marathons but can’t lose weight because their insulin levels are so high and their body is in storage mode.  We work to drive down insulin levels through their food choices.


You can’t…

  • out supplement (or medicate) a bad diet
  • out diet lack of sleep
  • out sleep too much stress
  • out exercise a bad diet
  • out supplement too much stress
  • out exercise too much stress (although it does reduce stress:)
  • out supplement (or medicate) too much stress
  • ….. you get the point! :)


For the next 90 days, challenge yourself to focus on your weakest link and set goals and work to improve it.  This could mean making the jump to a real food, low carb diet as appropriate, regular exercise, scheduling your complete physical exam and having your Vitamin D levels checked, evaluating your priorities and saying “no” to reduce stress, making an appointment with our biblical counselors, or committing to an 15-30 minute earlier bed time or a “screen free zone” in your bedroom.

We can help you discuss all of these areas and make a plan: Nutritional counseling with a nurse practitioner, evaluating common barriers and developing an exercise plan with our wellness nurse at VitalSigns, meeting with our biblical counselors to discuss areas of stress, anxiety, and depression in your life,  scheduling a complete physical exam.

Call us at 865-539-0270 to set up your appt. today!


Why Am I So Tired?

​“I’m just exhausted all the time, and I don’t know why. I used to have all kinds of energy. What do you think is wrong with me?” I get asked some version of that question several times a week. At any given time, there are just so many people who are tired or fatigued. Sorting out what’s causing it can be very tough, because there is such a huge list of possibilities. And often the cause is multifactorial – several factors working together to cause the weariness.

​Let’s at least dip our foot into how to sort out the underlying cause of this pervasive symptom. First we would spend a good bit of time on a history of the fatigue. For example, are there other symptoms that go along with the fatigue? If there is fever, or cough, or headache, or joint pains, or tearfulness than that points us in a specific direction. If the fatigue is an isolated symptom, that can be tougher, like trying to solve a crime without clues.
The timing of the fatigue is another helpful sign. Did it start abruptly a short time ago or did it sneak into life years ago? And, exactly what are they experiencing? Is it sleepiness, or weakness, or lack of motivation, or low energy? The exact description can point us in a particular direction.

​A physical exam will occasionally reveal a clue to the reason for fatigue. Are there swollen lymph nodes, or an enlarged liver, or abnormal sounds in the lungs? These kinds of findings are not terribly common in a person with general fatigue, but they’re worth taking a few minutes to have them checked.
Lab tests and other testing can be helpful if the history has given us a direction in which to explore.
Otherwise, just doing a raft of testing is usually very expensive and rather unhelpful. Some basic blood testing is the exception in that it does sometimes turn up one of the more common causes. For example, a small number of lab tests can readily screen for specific causes such as anemia (low red blood count), hypothyroidism, diabetes, or vitamin B-12 deficiency. Likewise, the blood tests will sometimes provide clues to point us in a direction, such as if the liver enzymes are substantially elevated or there are markers that indicate a lot of inflammation in the body.

When all is said and done and we’ve looked under every rock we can think of, what are we likely to find? One of the more common causes for fatigue is sleep deprivation. Either the person simply isn’t getting enough hours in bed, or the quality of their sleep is poor due to some sleep disorder such as sleep apnea, insomnia, or shift work. This is especially likely if they are tired even in the morning when they first get up. Other lifestyle factors such as lack of exercise, poor diet, obesity, or excess alcohol can also be major players in fatigue.

Another big category is in the arena of mental health. Sometimes fatigue is the way depression or chronic stress can show itself. Medication side effects can also play a roll, if a person is on sedating antihistamines or beta blockers or other meds that tend to contribute to fatigue.

Physical maladies such as those already named (anemia, diabetes and the like) and others we haven’t mentioned such as chronic arthritic diseases, heart disease, chronic lung diseases, urinary tract infection, low testosterone, adrenal insufficiency, hepatitis C, and mononucleosis, to name just a few, can also be the culprits. Devastating causes such as hidden cancers, leukemia, or lymphoma are quite rare but need to be thought about if other clues or lab results point us in that direction. If the fatigue has dragged on for months or years, the still much-debated diagnoses of chronic fatigue syndrome or fibromyalgia may be considered. In the end, even in carefully done medical studies of fatigue, after a thorough search has been completed, nearly a third have no clear, specific cause.

If you’re sick of being tired, you may want to work through things with your doctor to see if there is a definite cause that can be identified and treated. In the meantime, shoring up your habits by getting adequate sleep, good nutrition, and regular exercise can sometimes make a world of difference. At any rate, if your dragging along just keeps dragging on, it may be time to get it checked out.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835