The Problem of Sleep

The first patient I am going to see today wrote on his Kite: “I need something to help me sleep.” Over the course of my career in correctional medicine, I have seen literally hundreds of such requests. I have empathy for the patient who submitted this kite. There is no question that it is hard to sleep in a jail. 

First, there are the physical impediments to sleep.  They never turn the lights all the way off!  If you are someone who likes it to be really dark when you go to bed, too bad for you. And it is loud!  Most inmates are housed in large dorms with 40-60 (or more) inmates who are talking, snoring, yelling.  There are no carpets or drapes to absorb noise, which bounces and echoes in the cavernous concrete space. The large metal doors clang loudly when they close. Even footsteps on the concrete floor are surprisingly loud.

The mattresses and pillows are not designed to be comfortable.  They are designed to be secure, i.e. hard to hide contraband in. That means the mattresses and pillows are thin with little padding. Jails are cold, even in the summer, but the blankets are also often thin and may itch to boot. Inmates are not issued two blankets.

Finally (and most importantly for many inmates), there is the mental anguish that prevents sleep.  This is an alien and frightening environment.  You are sleeping in the same room with 50 other inmates, some of whom can be quite scary.  You worry about being away from your family, what will your family and neighbors think, will you lose your job, how will you make bail, what about court, what if I get convicted?

For all of these reasons and more, complaints of insomnia are common in a jail. Jail medical providers need to have a policy or guideline on how to deal with complaints of insomnia. But before I see my first patient who wants a sleeping aid, I need to review the following guiding principles in my mind:

The Principle of Fairness.

The Principle of Fairness is the single most important consideration when dealing with requests for sleeping aids in the jail (I have written about this before, but it bears repeating). Whatever you do for one inmate who says they cannot sleep, you must do for all inmates with the same complaint, otherwise you playing favorites and being unfair.

If I prescribe, say, Benadryl to my patient requesting a sleeping aid, then according to the principle of fairness, I have to give Benadryl to every inmate with the same complaint. And since all clinical encounters are discussed back in the dorms. Tomorrow, I will have ten requests for Benadryl from that patient’s dorm, with more coming later as word spreads throughout the jail.

I am not saying that you should never prescribe sleeping aids. In fact, many patients need to be treated for their insomnia. What I am saying that whatever you decide to do about one particular patient’s complaint, you have to do fairly, for all inmates with the same complaint.

There are a wide variety of sleeping medications available commercially, from prescription drugs like Ambien and Halcyon to over-the-counter sleep aids containing (usually) diphenhydramine. There are also many drugs not marketed as sleeping aids but, because of their sedating properties, are used off-label as sleep aids. The two that I see most commonly used this way are Seroquel (quetiapine) and Trazodone. I will discuss these in detail in a future post.

The Principle of Verifying Subjective Complaints

Many inmates who request a sleeping pill are actually sleeping just fine. I have lost count of the number of patients requesting a sleep aid who show up at my mid-morning medical clinics with a pillow crease on their face, tousled hair and bleary eyes because they had to be awakened from deep sleep to come to my clinic. The problem in many of these patients is not that they can’t sleep but rather that their sleep schedule is disordered. If you sleep every morning until lunchtime (as many do), you are not going to be able to fall asleep easily at 10:00 PM the next night.

Jail clinics have a big advantage over outside clinics in their ability to verify sleep patterns. There is no way, for example, for my personal primary care doctor to come to my house and watch me sleep. But jail inmates are observed all day and all night by detention staff. If I want to know whether a particular patient is really awake all night and day (as the patient told me), I simply need to ask the detention staff to monitor that patient and record a sleep log for a couple of shifts. If the detention officers tell me that a particular patient truly has not slept for two nights, I am going to have a much different treatment plan than if the patient actually does sleep, but during the day.

Before writing a prescription for a sleeping aid based on a subjective complaint of insomnia (as is almost universally done on the outside), jail practitioners should verify clinically significant sleeplessness before prescribing medications.

The Principle of Weighing Potential Benefits against Potential Harms

Like all medications, sleeping aids have potential benefits but also potential harms. Practitioners often tend to think only of benefits and ignore potential harms when they prescribe. It is especially important not to do this with sleeping aids.

First, patients may become dependent on them. Sleep aids work best when they are used sparingly, once in a while, but this is not how most patients use sleeping aids (in my experience). Most take the sleeping pill every night. This is, of course, generally not a good thing. Patients who are asking for a sleeping pill in a jail are usually not requesting something to use once in a while, but rather something to take each and every night. They are not going to be happy with a short-term prescription. So know this: saying yes to a request to a sleeping pill is a long term commitment.

Second, patients can be come dependent or even addicted to many sleeping pills. Since many of our jail patients are already battling addiction to a variety of substances, we practitioners need to be careful not to enable addictive behavior by prescribing alternative psychoactive substances.

Sleeping pills may be abused in a jail. Many can cause a euphoric high when snorted or saved up and overdosed. Also, any sedating medication is a high-value commodity in the jail black market. A patient receiving sleeping pills will inevitably be pressured to share or sell that prescription.

In many patients who request a sleeping aid, these cumulative potential harms easily outweigh any potential benefit a patient may get from a sleeping pill.

Of course, I am not saying never to prescribe a sleeping aid in a jail–there are circumstances and patients who should be helped to fall asleep. More about them next.

As always, what I have written here is my opinion, based on my training, experience and research. I could be wrong! If you think I am wrong, please say why in comments.

What is your policy for the prescription of sleeping aids? Please comment.

5 thoughts on “The Problem of Sleep

  1. We have had considerable success using Pamelor or Elavil for night time pain that also works to help patient’s sleep. As expected – if this gives patient’s some quality sleep – the discussion about controlling daytime pain is simply so much easier. Plus- there doesn’t seem to be as much secondary gain (pill cheeking) with these meds.

  2. A thought – anticipated outcome. Should vital signs be obtained for a patient sitting calmly in the exam room and found to be meaningfully elevated the examiner would be surprised. Had the patient just been brought in from recreation and a spirited game of basket ball – no surprise. Truth – many of those in jail are (as described) in a stressful situation – as well as missing their favorite recreational chemicals. Difficulty sleeping is no surprise. Additionally, the ‘sleep debt’ is seriously reduced in jail. A brief history of pre-jail activity and sleep pattern often reveals 12+ hours of activity (include meals, work, TV, commute, etc.) and 6 – 7 hours of sleep. When asked nearly all say they should be getting 8 hours of sleep – but when their previous life experience is reviewed many [not all] realize that they are OK and do not need a ‘sleeper’. Those that do not often become belligerent demanding ______. After about 28 years working in corrections there were 2 – 3 who had clear sleep deprivation symptoms and verified lack of necessary sleep. Each of those also had serious (family health) problems unrelated to their incarceration. After 72 hours of medication and appropriate sleep they were resolved.

  3. One other quirky note – our state allows inmates to purchase electronic media devices they can download songs from a kiosk that is run by the DOC. I have spoke to a number of inmates that download sleeping background white noise – rainfall, fans, relaxation sounds and exercises. Not sure how many other states have this ability but it is a nice little modality to help.

  4. Do you think the standard operating procedure in the community is wrong?

    One could, presumably, use actigraphy to corroborate the subjective complaint of insomnia in the free world (although insurance probably wouldn’t pay). I suppose a Fitbit or similar device would serve a similar purpose in a rudimentary manner, if the patient could access one.

    Anyway, I’m wondering if this could be one of those cases where jail inmates might get better care than people in the community because the facility will pay for a “test” where insurance companies won’t pay for a non-jail equivalent.

  5. I would like to know why Melatonin was removed from being ordered in quarterly packages? Melatonin used to be allowed in California prisons but has been removed for a while. However, my understanding from speaking with a national vendor is that it is allowed in other state prisons.

    The FDA notes melatonin as a dietary supplement and should be allowed to be ordered as it benefits to aid sleep has a long established history.

    Again, why can’t inmates order Melatonin in California prisons?

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