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#5 Treatment of Chronic Insomnia
58 Plays2 years ago
Insomnia is one of the most common conditions encountered in primary care. In this episode, Drs. Scott & Robertson explore the evidence-based management of chronic insomnia, with some surprising revelations along the way!
Additionally, Episode #4 on Probiotics for the Prevention of Antibiotic-Associated Diarrhea provoked a lot of debate, and the What's the Proof team lets you in on the conversation.
Episode Outline:
- Follow-up discussion on probiotics and CDI prevention 00:53
- Cognitive Behavioral Therapy for Insomnia (CBT-I) 08:09
- Review of AASM and ACP clinical practice guidelines for insomnia medications 09:52
- Potential harms of sedative hypnotics 17:16
- How to handle the "Oh, by the way" request for sleep meds 23:00
- New data on dual-orexin receptor antagonists 25:30
Links from this episode:
- Effect of antibiotic stewardship on incidence of CDI https://pubmed.ncbi.nlm.nih.gov/28629876/
- Declining use of medications for insomnia https://pubmed.ncbi.nlm.nih.gov/35818727/
- Hypnotics’ associated with mortality or cancer https://pubmed.ncbi.nlm.nih.gov/22371848/
- SUNRISE 2 https://pubmed.ncbi.nlm.nih.gov/32585700/
- Daridorexant for insomnia https://pubmed.ncbi.nlm.nih.gov/35065036/
- AASM Insomnia Guideline https://jcsm.aasm.org/doi/10.5664/jcsm.6470#d45835e1
- ACP Insomnia Guideline https://www.acpjournals.org/doi/10.7326/m15-2175
- Simplified sleep restriction for insomnia https://pubmed.ncbi.nlm.nih.gov/26212846/
If you liked the episode, please leave a positive review and subscribe! Tell your colleagues and friends!
Comments/Questions/Suggestions? Email us at whatstheproofpodcast@gmail.com or find us on Twitter @theproofpodcast!
Credits:
- Hosts: Bobby Scott, MD, FAAFP; Sandy Robertson, PharmD; Dawn Caviness, MD, BSN
- Production & Cover Art: Bobby Scott, MD, FAAFP
- Music: Twisterium, MondayHopes, Muzaproduction, and SergeQuadrado from Pixabay
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Transcript
Introduction and Podcast Purpose
00:00:00
Speaker
You are listening to the What's the Proof podcast, where we seek to help doctors and other clinicians incorporate the best available evidence into their everyday clinical decision making. The content of this podcast is meant for educational purposes only and should not be construed as personalized medical advice. The views and opinions expressed are those of the host and guest, and no content on this podcast has been approved or sanctioned by Atrium Health.
Hosts and Absence Note
00:00:36
Speaker
Welcome everybody back to What's The Proof. I'm Bobby Scott with me is Sandy Robertson. Dawn is unfortunately not with us this month, but hopefully she'll be back next time. She has too many patients to see, right? Too many important things to do.
Probiotics for C. diff Prevention: Worth It?
00:00:50
Speaker
Unlike us. We just sit around and talk about insomnia drugs. Yeah. Yeah. So I wanted to start out, Sandy. I know we're talking about insomnia today, but what did...
00:00:59
Speaker
follow up on the last podcast where we're talking about probiotics for the prevention of C. diff and antibiotic-associated diarrhea. Bobby, I would just like to say I think you officially like to stir up trouble. Apparently so. I think so. So it really wasn't me. It was a listener, right? Okay, it was. It was. One of our faculty listeners decided to go up the chain and explore whether using
00:01:25
Speaker
Probiotics for C. diff prevention would be a good QI initiative for our hospital, and that led to some conversations with our antibiotic stewardship program. Yes. And, Sandy, I got to tell you, I was surprised at the strength of the opinions over this topic. I guess they have debated this very extensively at our hospital already. Little did we know, so we're not important enough to be included in those committees. No, we were not privy to that information.
00:01:52
Speaker
But, you know, ultimately what they came down to was that even though they've looked at it a bunch of times, looked at all the data, because our local data shows that our patients are at low risk for developing hospital acquired C. diff, therefore they didn't think they would likely benefit and it was not going to be recommended as a standard of care, which I would agree with. I would too. Our numbers, when that came out in the email, I was very pleased with that number.
Debate on Probiotics Efficacy
00:02:19
Speaker
Yeah, and they suggested focusing on risk factor modification if possible, so avoiding antibiotics, PPIs. But I guess what I was really surprised about is the strength and confidence at which it was claimed that probiotics were not helpful, and there was no data supporting it, which I think was inaccurate.
00:02:41
Speaker
I would agree with you there. I think it was a timing of when these meta-analyses were published and when the IDSA guidelines were published. And so it's just simply, unless you're really looking at all of this data, which let's face it, it's difficult to do, I think it is hard to know exactly what the latest evidence shows.
00:03:00
Speaker
Right, yeah, you mentioned the IDSA guidelines and in 2017 those were put out and they said that there was insufficient data to recommend probiotics for primary prevention of C. diff outside of clinical trials. Right. And they raised the concern that some of the studies that influenced their meta-analyses had a much higher C. diff incidence in the placebo arms than would typically be expected. Right. And that means, you know, potentially biasing the results towards benefit of probiotics.
00:03:30
Speaker
which was reasonable and that's some of the things that the Cochrane authors actually noted as well. And so they substratified their analysis based on the baseline risk for C. diff because they recognized that that potential bias was there. And so what they found out was that the benefit for C. diff prevention was seen mainly in patients with a baseline risk of greater than 5%, which I think we said in our podcast. We did, we did. And therefore if our local incidence is less than that, then obviously it is not
00:03:59
Speaker
going to be
Probiotics: Safety vs. Evidence
00:04:00
Speaker
a good intervention for a standard of care in our particular hospital. Right, right. And so you also have to look at the harm reduction model and what are the harms of doing that. Even if your numbers are lower than that, what harm could you potentially be causing in an immunocompetent? I do want to just throw that out there again. We're talking about immunocompetent patients.
00:04:21
Speaker
for the use of probiotics, even when the risk is less than 5%. We know it's low quality evidence in that situation, but I still would argue that it's a safe
00:04:32
Speaker
therapy to try. Yeah, I mean in the 32 randomized controlled trials in the Cochrane Review, the harms that were identified in immunocompetent people were minimal, so actually the adverse events were more frequent in the control groups than they were in the probiotic group. Right. At the very least, if this is becoming the standard in the U.S. to have very low numbers of C. diff during hospitalization, I think we need to have some randomized controlled trials.
00:04:58
Speaker
Yeah, absolutely. Let's answer the question. A hospital like ours would be great to do that. I think so too. I wish they would. Come find us. Grant money, come find us. Please bring us some money to help us do that study.
Shift to Insomnia Medications Discussion
00:05:11
Speaker
Not for own personal pockets, but for the study. I definitely need to chew on it a bit more. It seems that until we get more studies on this, it's probably going to be a contentious topic for sure. I think so.
00:05:24
Speaker
Yeah, and I think I just, what I didn't understand was just how strongly opposed some of the people in the conversation were against it. The IDSA guideline, for example, said that there was insufficient data to recommend the probiotics. However, it was recommended that hospitals implement an antibiotic stewardship program as a good practice recommendation.
00:05:48
Speaker
And as far as I can tell, the best evidence for antibiotic stewardship programs, specifically in C. diff prevention, is at best equivalent in strength to the evidence for probiotics, but probably more appropriately classified as lower in quality. Right. I would agree. I want to chalk that strong statement up to the fact that it was via email. Yeah. And let's just assume that it wasn't meant to be so strong. Exactly. Strongly worded. That's right.
00:06:17
Speaker
Anyway, if any of our listeners have thoughts about it, go back and listen to that episode if you haven't, but if you have thoughts and comments, please send us an email. I'd love to hear what you think about it. Absolutely, because I think with every episode, we end up learning more, don't we? We do. And speaking of learning more, Bobby, you ready for today's topic? I can't wait. Oh, it's one of my favorites. I can't wait to talk about medications for insomnia.
CBT as First-Line for Insomnia
00:06:47
Speaker
We have a large amount of evidence here, right? A whole lot. A whole lot. Well, let's start out by what brought on this topic. Not only do we talk about it all the time with our residents, and I struggle as a pharmacist to know the safe, the balance between when to recommend prescribing and not prescribing.
00:07:03
Speaker
for our faculty here. But last month, a study came out in the Journal of Clinical Sleep Medicine that found from 2013 to 2018, the use of medications for insomnia, whether on or off-label, decreased by 31%. And that, I was really pleasantly surprised by that. And in fact, the use of inpatients greater than 80 years of age dropped by 86%.
00:07:27
Speaker
That's huge. That is. Yeah. And I have to commend the prescribers for doing that. It's thought to be secondary to the recent initiatives to deprescribe medications. We know they have lots of concerning adverse effects. We know that they could potentially be efficacious, but they come with a lot of baggage. I think we would all say that anecdotally we see that in our patient population. Do you agree?
00:07:50
Speaker
Yeah, I'm not sure that any of us feel super confident and comfortable when we prescribe them. You know, we almost feel like maybe we're a little hesitant when we have to do it. Right, right. I'm right there with you in recommending. So what are, you know, what's the data out there for insomnia? Well, the most current clinical practice guidelines in the United States recommend
00:08:14
Speaker
Not surprising, cognitive behavioral therapy for insomnia. That is the first line treatment for chronic insomnia, which is, by the way, defined as insomnia symptoms lasting three months or longer. People, when they come to you after truly three months of insomnia, they're pretty desperate, which I do think makes it more difficult for us to talk about CBT.
00:08:35
Speaker
Yeah, for sure. It's probably worth noting that we're not talking about acute insomnia, which often are triggered by life events or circumstances that are often going to resolve. Usually, people like that, they're going to get better.
00:08:53
Speaker
And just know that the CBT for insomnia is traditionally offered by specialty trained providers. I mean, this is a big deal, and I've read a little bit about it. I'm very impressed. The data with it suggests that it is highly effective. It does come with a price tag. And unfortunately, in a lot of areas, those specialty trained providers are not readily available. Would you say that's correct?
00:09:18
Speaker
Yes, unfortunately, we live in the Charlotte metro area. We do have a couple of options here, but in smaller towns, it's not going
Review of Insomnia Medications
00:09:26
Speaker
to be easy. It's not going to be. So once again, this is a great benefit of having a very solid primary care base where this is going to fall on the primary care provider. We have lots of smartphone apps. There are lots of online resources. So I do think that with appropriate training, PCPs can adequately give some version of CBT. And I know that we do that. We train that pretty well here.
00:09:48
Speaker
Just one more way we provide value. I think so. But naturally, because not every patient is going to either be able to correctly perform the CBT or be even agreeable to trying it, and because not every patient will benefit,
00:10:04
Speaker
I will say that I do believe there is a role for medications for insomnia and I'd like to at least review what we have. That's okay. Yeah. All right. So let's take a look at the evidence. So Bobby, how effective are these medications in treating insomnia?
00:10:20
Speaker
Well the first point that we should make is that the evidence for benefit in medications is generally of low to moderate quality. Most of these are industry sponsored trials and they always have to be cautious with those. Study durations are most commonly four weeks or less with only a small number extending out to three to six months. So we are not talking about multi-year trials here.
00:10:47
Speaker
There are very few comparative studies, so drawing any conclusions about which medications are better is very difficult. Many trials do not report on global patient-oriented outcomes like sleep quality and quality of life, and often focus on disease-oriented outcomes such as those measured by polysomnography, which are fancy sleep studies that
00:11:13
Speaker
maybe provide some data there. And additionally, most of the trials demonstrate a very large placebo response. So relative differences in outcomes as a result of the medication compared to placebo are generally small. So you are not making me feel good about the quality of this evidence. No, not great. I said we had a lot, but it wasn't great. No, it is not. You just basically said,
Surprising Non-Recommendations for Insomnia
00:11:38
Speaker
you gave me every negative that could come from a meta-analysis or systematic review.
00:11:43
Speaker
Correct. Pretty much. Okay, well moving forward. Yeah, so there are two major guidelines that have been put out in recent years. One is by the American Academy of Sleep Medicine. That was put out in 2017. And then the American College of Physicians put out one in 2016.
00:12:02
Speaker
These are based on systematic reviews and meta-analyses conducted by those groups, and they represent the highest level of evidence that we have currently. Now, we don't have time on the podcast today to discuss these in thorough detail, but we will try to concisely summarize the data for you. Okay, I appreciate you doing that for me. Yeah, that's what I'm here for.
00:12:22
Speaker
The earlier ACP guideline only found sufficient evidence to present benefits in four total medications for use in the general population. These are esopiclone, all forms of zolpidem, suvorexin, and doxepin.
00:12:41
Speaker
Interesting. I don't know that I would have picked those for, specifically. Yeah, I mean obviously Zolpidem is very commonly used. Yes. Yeah, but yeah, it was a little surprising. A little bit. All of these were based on low quality evidence, except for the standard form of Zolpidem and Suverexant, which they graded as moderate quality.
00:13:01
Speaker
And relative to placebo, the effects were generally small. You fall asleep six to 19 minutes faster, sleep a total of 11 to 48 minutes longer, and spend five to 16 minutes less time awake after you fall asleep. And for patients older than 55, the evidence is even more limited. The outcomes are roughly in the same range as in the general population, but the evidence is lesser.
00:13:29
Speaker
Bobby, are you impressed with the minute reduction? Not particularly. I mean, you got to consider, too, that these are relative to placebo. So placebo has a pretty strong effect. So I mean, if you add it to that, I mean, you're looking up to 30, 40 minutes, even, you know.
00:13:47
Speaker
Maybe longer, even up to an hour. But, you know, if you can do that with placebo, it's not really the medicine that's doing it. So that's where it becomes hard to swallow. It does. It does. Now, the 2017 AASM guidelines also found sufficient evidence for benefit in only a limited number of medications.
00:14:08
Speaker
They broke it down by medicines to use for sleep onset and sleep maintenance insomnia. Okay, makes sense. So for sleep onset insomnia, they suggest using esopiclone, xylopodem, temazepam, and triazolam. So now we have some benzodiazepines in there. Okay. And for sleep maintenance, they recommend esopiclone again, xylopodem, doxepin, temazepam, and suvarexin.
00:14:36
Speaker
And regarding outcomes, the numbers are not really remarkably different from those that are in the ACP guidelines. They're very similar. I could go through all of them, but it'd take an hour. Okay. But the numbers are the same or similar. Yeah, relatively, roughly the same. Interesting. Okay.
Potential Harms of Sedative Hypnotics
00:14:49
Speaker
I would just like to say for the record how impressed I am at your pronunciation of these words. It took a lot of practice. I call them the Z drugs for that reason. So much easier. Or the brand names.
00:15:05
Speaker
What I find most interesting about the AASM guidelines when I was reviewing them is the list of medications that they say you should not use
00:15:16
Speaker
which I will admit to you that I have been guilty of recommending to both family, friends, and in a professional capacity. So, do you want me to list these for you? Because obviously there probably are some that were not on the list for our listeners. Yeah. Okay. I think people are going to be surprised. I know. First one is Trisadone.
00:15:39
Speaker
So data is only from one study. It's very limited. It did not show a significant improvement in insomnia scores, and it's associated with significant increase in harms compared to placebo. So most notably, it was headache and somnolence. So AASM does not recommend tracetone. Number two, wait for it, melatonin.
00:16:06
Speaker
based on three very low-quality studies showed no significant benefit.
00:16:13
Speaker
placebo effect. I know, I know, but that placebo effect really does work for a lot of patients. Yeah, and it makes so much sense because it's a natural chemical that your brain produces. It does, it does. I would like to say for the record that it is difficult to find significant harms with melatonin. Oh yeah, for sure. So again, if I have a patient or a friend or family that says melatonin works every time like a charm, I am not going to... Just keep taking that melatonin. Absolutely, absolutely.
00:16:41
Speaker
And third is diphenhydramine. That again, based on two low quality studies, showed no improvement relative to placebo. And I'm not, we all know the harms of first generation antihistamines in the elderly, but we also know that if you're younger and
00:16:57
Speaker
Diphenhydramine makes you sleepy and it works. It would be hard for me to give you strong recommendations against it, dry mouth. I mean, there are some side effects, but according to AASM, triazodone, melatonin, and diphenhydramine are on the list of drugs not to recommend for insomnia.
00:17:15
Speaker
Indeed. I know. So when it comes to potential harms, I'm always the person, right? You have to go to about all the significant adverse effects. We really do worry about the sedative hypnotics. These Z drugs, as you described earlier, we worry about in addition to things
00:17:34
Speaker
like just simple somnolence the next day. We have data that actually does show daytime impairment, cognitive impairment. We have seen some increase in falls and fractures in the elderly. It depends on the study. A lot of these are large retrospective studies, increase in injuries, increase in depression. There are some things that we really do have to be concerned about with the Z drugs, with the sedative hypnotics.
00:17:59
Speaker
And then clearly we all see this, rebound insomnia with sudden discontinuation. There's a reason why these medications were only studied for two weeks when they first came out. And it makes it really hard to get patients off of them when it's only going to be a short-term treatment.
00:18:14
Speaker
It's a taper. Yeah. Yeah. I tell patients you're going to have to taper and you're going to have to have some sleepless nights. That's the bottom line. And you have to just power through. If you, if you want to no longer take this medication, which I recommend, this is what you're going to have to quote, suffer through. Not many people can say it's very easy.
00:18:30
Speaker
Yeah, and it also makes it challenging because we know that there probably shouldn't be on these long term and their concerns for harms. And if their rebound insomnia is keeping them from being willing to try to taper off of it, it just adds an extra layer of complexity. It really does. It's hard. It's hard.
Risks of Insomnia Medications: 2012 BMJ Study
00:18:47
Speaker
Now, I do feel like I need to at least mention this, and I'm going to admit to you that this is something that I learned in preparing for this podcast. There is an association. Now, stay with me. It was published in 2012 in BMJ. It was a large retrospective cohort study, but an association with increased mortality and increased cancer risk for patients taking the sedative hypnotics that are, quote, in the Z class of medications. Did you know this?
00:19:17
Speaker
Yeah, this is a new one for me, too. And I think it also includes benzodiazepines as well. Oh, yes, it does. You're exactly right. Sorry about that. So we have to add in a couple of those as well. Just to give you a little bit of the data, there were over 10,000 patients that were – they recorded taking these medications, these classes, and then 23,000 controls, and they actually
00:19:37
Speaker
had pretty good homogeneity with regards to the patient populations. They studied them for two and a half years, and we won't go into the numbers, but there was a higher risk of mortality and cancer when they compared the groups, and any dose of the sedative hypnotics or the benzo studied was associated with an increased risk of mortality, and it went up to a five-fold increased risk, and there are all kinds of positive reasons as to why this is.
00:20:03
Speaker
And I think we can all agree with depression, suicidality, accidents, daytime impairment. A lot of that makes sense, but I think they kind of dive into other reasons as well. But then also, there was an increased risk of cancer. And it was even if you took 18 doses in a year, which that's not a lot. Yeah, not a lot at all.
00:20:24
Speaker
So again, this is a large retrospective study. It only shows correlation, not causation. But I just felt like we needed to at least tell our listeners. Yeah, I'm surprised that that's not more commonly known. That seems like a really important bit of information.
00:20:43
Speaker
Well, we do talk about correlations with our patients about other medications, and sometimes we're trying to give them all the information to maybe sway them in one way or another. But this is something that if they were to Google, you know, these medications, they might would find this association. So perhaps we need to mention it.
00:21:01
Speaker
Yeah, for sure. Unfortunately, our randomized controlled trials were short-term, so we don't have long-term data on safety. Many of the times, they did not adequately report adverse events. This is really the best we have in terms of the harms. They've always been retrospective studies that are observational, but that's all they got.
Guidelines and Emphasis on Behavioral Interventions
00:21:22
Speaker
Right. Bobby, why don't you recap these major guidelines for me?
00:21:25
Speaker
Yeah, and first thing I want to mention, though, is that even though we didn't go into detail on that study, all of the references are in the show notes, so please check them out, read them for yourself, verify what we're saying. Absolutely. Call us out on it, if we're wrong. Yeah. So to recap, the two major guidelines give weak recommendations for the use of these medications.
00:21:50
Speaker
esopoclone, zolpidem, and temazepam for both sleep onset and sleep maintenance insomnia, xyloplon and triazolam mainly for sleep onset insomnia, doxopin and suvarexant mainly for sleep maintenance insomnia,
00:22:10
Speaker
And again, do not use trazodone, melatonin, or diphenhydramine. And there are a few others that were listed in there, but those are the three that are most commonly used that I think people may want to stop recommending. Right, right. And not that we have to say it again, but maybe. You know, this is weak evidence. The demonstrated results are only modestly better than placebo, so remember that. When they also come with significant concerns of harm and
00:22:38
Speaker
When we're prescribing and then we have to deprescribe, it becomes a problem. These are the reasons why in general, I would say this recent study shows less and less prescribing of these medications for insomnia. We don't have time in this podcast, but the cognitive behavioral therapy, it really works. It just takes a little bit of time and effort. Would you agree? Yeah, I would definitely agree.
00:23:00
Speaker
I'm going to editorialize a little bit here. So I think our residents often struggle with this because they ask me about this. And, you know, unfortunately, insomnia medications, those are often an oh, by the way request from patients. You get that as you're walking out the door. And I think it's really imperative that we avoid making decisions on using these medications based on a two or three minute conversation while you're leaving the room.
00:23:25
Speaker
We are just not doing right by patients if we aren't talking about the potential benefits and harms, and likely the majority of patients can improve with behavioral interventions. Sleep hygiene is a good place to start for most people, but if you are treating insomnia, I would really encourage you to read about other behavioral techniques that are out there, such as sleep restriction, stimulus control,
00:23:51
Speaker
For example, one simple sleep restriction intervention has been shown to improve insomnia with a number needed to treat of only four. That's right. And there's evolving evidence for meditation, mindfulness. Yeah. You know, these are things that, again, it's not completely easy to do on the first day. But if you, and we have so many apps and so many resources that I do think that if we spend some time with our patients, and it can't be, oh, by the way, as you're leaving, can I just get my Zolpadim?
00:24:20
Speaker
Yeah, so here's a little thing that I usually do. Because it's really helpful in following up on these patients is when it's an O by the way request. I usually listen to what they have to say a little bit. And I explain, we really need to spend a whole visit on this because this is really important. There's a lot of things we need to talk about. And then I give them a sleep diary to complete on the way out. Oh, that's good. And so that gives them something helpful to bring back to the next visit that will really
00:24:49
Speaker
be very useful when you're trying to implement these behavioral techniques. Is that pretty well received?
00:24:54
Speaker
Yeah, actually does pretty well. Sometimes people don't come back. But hopefully that's because their insomnia got better and it was just an acute thing. But when they do, like I had one recently and I'm able to make some really good behavioral interventions and hopefully she'll get better. But yeah, so if you're interested in that sleep restriction intervention, you can find a link to the study in the show notes. So take a look at it. Oh yeah, I've tried it before. It is effective. You just have to be patient with it.
00:25:24
Speaker
So, just to summarize again, the two guidelines that you reviewed, those are at least five years old now. So, let's just briefly go over any new data that's out there, okay? So, I don't know if you have any experience with the dual orexin receptor antagonists or the orexin medications. Do you have much experience with that? I have not prescribed any yet of my own, but I have seen patients that have
00:25:50
Speaker
been prescribed them by other providers. Right, right. They are FDA approved. There's three of them on the market now. And so, suberexcent, of course, was included in the guidelines. That's the first one. But now we have limberexcent, which in an industry-sponsored Sunrise II trial, so just remember that it is a small trial and it's industry-sponsored.
00:26:13
Speaker
It did show improvements in the onset of sleep by about 25 minutes to 74 minutes of total sleep time compared to placebo. And these benefits were seen over 12 months. So it wasn't just a four-week study, so I have to hand it to them for going out a year. Yeah, these newer studies, I think, are doing better. They're improving in how they're conducting their studies. I think so. We're getting better at it.
00:26:36
Speaker
And the latest direct sent antagonist is Dare Direct Sent approved earlier this year. Efficacy is based on two industry sponsored trials which showed sleep improvement compared to placebo, about 30 minutes in sleep latency, and an hour in total sleep time.
00:26:53
Speaker
This medication is interesting because it was designed to work quickly, but also to have a half-life that would lead to an 80% reduction in the medication by morning. So it's a little bit more of a designer drug. The hope is that it would reduce daytime impairment.
00:27:11
Speaker
from residual medication effects. The studies did show statistically significant improvement in the scores on daytime functioning questionnaire. However, they're small changes and they may not be clinically relevant. It is worth noting that it seemed to be very well tolerated. There were more adverse effects that led to discontinuation in the placebo group and the most common
00:27:31
Speaker
Adverse event which is you know we say this with a lot of really safe medication is nasopharyngitis and headache I think you can say that safely with any medication. Yes, so I don't know maybe we've landed on something here again I'm not promoting it, but it could potentially be promising. I'm always open to newer safer medications these come with a price tag I looked at one of the websites yesterday for cash only and it's over $500 a month. Oh, yeah
00:28:00
Speaker
the sleep will cost you.
00:28:03
Speaker
Yeah, I'm intrigued by these medicines. I think hopefully we'll see some more data to come out to corroborate some of these industry-sponsored trials. I hope so. Yeah, they look pretty interesting. I'm going to leave it at that. Interesting. Yeah. I don't want to say anything too positive or too negative. Right. Yeah, totally on that. Yeah. And with that note, that's the end of the episode today. We don't have any additional segments because we just had so much to talk about today. Maybe tonight, the listeners can put this podcast.
00:28:33
Speaker
on while they're listening. Yeah, they can help them go right to sleep. Yeah, nice soothing voices and I don't know, really dull data. I think so. I think so. Thank you for listening. Yeah. Thank you to all listeners. Please let us know. Keep in touch. I'd love to hear your thoughts on the podcast. And again, all the show notes have our references, so feel free to check them out. We'll see you next time. Good night.