The answer is yes- if done thoughtfully, after talking with your doctor
Melatonin is
- Low cost
- Over the counter
- Generally well tolerated
- Does not produce dependence
- Is often-but not always- effective in producing restorative sleep
William Conway, MD, FACP, FASAM
Internal Medicine, Diabetes and Metabolic Health, Longevity
Nashville, Tennessee
Why Melatonin May Be a Safer Choice
Melatonin-in general- is safer than your other choices.
Suboxone patients in Nashville often take many medications- prescribed and over the counter- for many reasons
At the medical cafeteria, this is the common menu used by persons with insomnia.
Xanax, Klonopin, valium– the benzodiazepines-are commonly used for a multitude of reasons, ranging from calming your anxiety to managing your withdrawal. These drugs do cause physical dependence. Some patients develop benzodiazepine addiction. In my experience, getting off benzodiazepines is difficult.
Benzodiazepines are dangerous in many ways. They usually stop working with long-term use. As months turn into years, the person finds less benefit. Anxiety may worsen: Gait may become tentative: Your friends quietly whisper to each other that “She is aging badly, losing her memory and wits.”
The long-term use of benzodiazepines is a story which often, if not usually, turns out badly.
The best medical decisions include the perspective of how they are likely to play out over decades. Is this decision likely to promote or hurt your vitality years to decades ahead?
The Z-Drugs (Ambien) are also used by persons with insomnia. Next-day grogginess is common. More dangerous is driving if you are chemically impaired. Sleepwalking has been reported. Z- drugs are not a great choice either for long-term sleeplessness.
Neurontin (Gabapentin) is interesting and dicey in the complicated fashion that the real world often is. In my solitary diabetes practice, Neurontin consistently produces relief- to various extents- for the painful feet of diabetic neuropathy. Suboxone complicates the picture with Neurontin.
Only a fool ignores the advice of the FDA: The FDA warns that the use of gabapentin can produce breathing problems when combined with opioids. Suboxone is an opioid. Neurontin is not the automatic go-to drug for sleeplessness for persons on suboxone.
However, rational medical decision-making includes the FDA but places the guidance of the FDA in greater context of an individual patient.
What does the evidence show about the risk of gabapentin in suboxone patients? Forgive the following sentence. Precision of decision-making requires precision of language
Ellis et al. in a buprenorphine specific study did not find a statistically significant association for hospitalization or risk of drug-related poisoning with gabapentin, after adjusting for confounding.
In my limited experience, gabapentin provides relief to persons with chronic pain. In my limited experience, I have not seen toxicity from gabapentin
Sedating antihistamines, including diphenhydramine, can cause drowsiness. I rarely use sedating antihistamines, so I can only give you the literature.
Compared with commonly used alternatives, Melatonin appears safer.
Marie Nyswanger MD
Let me introduce you to Marie Nyswanger, MD. I could not control myself. In a future blog, I will share Dr. Nyswanger’s writing and thinking, compiled from her prestigious scientific publications and her out-of-print book. Her out-of-print book is the most expensive book I have ever purchased. Dr. Nyswanger has a fascinating biography.
Dr. Nyswanger is the addiction psychiatrist who invented methadone maintenance with Dr. Vincent Dole at Rockefeller Institute.
In their pioneering program published in 1967, they stated that patients with disabling addiction to barbiturates or alcohol were excluded.
The caution about co-occurring sedative dependence remains with me. The advice of Marie Nyswanger is advice I take.
Indications for Benzodiazepines in Medical Practice
A balanced presentation of benzodiazepines must be given to offset my previously expressed views.
There are indications in medical practice for benzodiazepines. Physicians routinely supervise, in benzodiazepine use disorder or dependence, the gradual processes of discontinuance. Psychiatrists use benzodiazepines for selected patients who, in their judgment, would benefit. Benzodiazepines are extraordinarily valuable drugs in the operating room or the intensive care unit. Benzodiazepines have an important role in medical practice in Nashville.
How Effective is Melatonin
Well, you cannot have everything.
Melatonin is not Lantus insulin. With Lantus Insulin, virtually all of the patients I have ever had benefited. Their blood sugars go down, and they feel better. Lantus can also be exceptionally dangerous. Using too much Lantus alone can produce miserable lows, which can be life-threatening. Commonly effective drugs are often commonly very toxic if used in dangerous ways.
The problem with Melatonin is that it does not work predictably or reliably for everyone.
There is not a vast medical literature supporting melatonin’s effectiveness. The American Academy of Sleep Medicine suggests against routinely prescribing melatonin for chronic insomnia.
Caveat Emptor. Let the buyer beware.
On a positive note, melatonin benefits many patients. I personally have found that long-acting melatonin helped restore my sleep. Melatonin does work in some patients,
A Practical Approach to Insomnia in Suboxone Patients
Not sleeping well is common with suboxone patients. Opioid Use Disorder may be an orphan; More commonly, Opioid Use Disorder exists in a family of related illnesses- and the other unrelated, chronic illnesses commonly seen in America.
Every person is a mosaic of health and chronic illnesses. In suboxone patients, the number of chronic illnesses ranges from none to several. Depression, ADHD, anxiety, and chronic pain are underlying reasons patients begin opioids.
In patients with comorbid depression, anxiety, adult ADHD in Nashville, or chronic pain, the most effective approach is the use of standard effective treatments. Insomnia may reduce if ADHD or depression are placed in remission. Managing chronic pain safely may improve sleep.
There is a place for the unusual causes of insomnia. A rare cause of insomnia is not rare for you if you have it. Be open to seeing the sleep specialist. In general, I firmly believe that being open to a wide range of subspecialty physicians will benefit you. We have excellent physicians in Nashville.
In my opinion, suboxone patients do better when their treatable illnesses are treated with treatments that work.
Oh well, that is our creed in internal medicine. We love finding and treating all treatable illnesses within the scope of our practice.
Frequently Asked Questions About Melatonin with Suboxone
Can I take melatonin with Suboxone?
It may be reasonable for some patients; discuss it with your prescriber, especially if you take other sedating medications.
Does it interfere with buprenorphine treatment?
No established interference with treatment effectiveness has been demonstrated, but direct studies of the combination are limited.
What if it does not work?
Persistent insomnia deserves evaluation; cognitive behavioral therapy for insomnia (CBT-I) is an evidence-based first-line option.
Endnotes
1. Dole VP, Nyswander M. A Medical Treatment for Diacetylmorphine (Heroin) Addiction: A Clinical Trial With Methadone Hydrochloride. JAMA. 1965;193(8):646–650. doi:10.1001/jama.1965.03090080008002. https://doi.org/10.1001/jama.1965.03090080008002
2. Dole VP, Nyswander ME. Heroin Addiction—A Metabolic Disease. Arch Intern Med. 1967;120(1):19–24. doi:10.1001/archinte.1967.00300010021004. https://doi.org/10.1001/archinte.1967.003000100210
3. National Center for Complementary and Integrative Health. Melatonin: What You Need To Know. NIH. https://www.nccih.nih.gov/health/melatonin-what-you-need-to-know
4. U.S. Food and Drug Administration. FDA Urges Caution About Withholding Opioid Addiction Medications From Patients Taking Benzodiazepines or CNS Depressants. 2017. https://www.fda.gov/media/127688/download
5. U.S. Food and Drug Administration. Certain Prescription Insomnia Medicines: New Boxed Warning Due to Risk of Serious Injuries Caused by Complex Sleep Behaviors. 2019.
6. U.S. Food and Drug Administration. FDA Warns About Serious Breathing Problems With Gabapentin and Pregabalin. 2019.
7.Ellis MS, Xu KY, Tardelli VS, et al. Gabapentin use among individuals initiating buprenorphine treatment for opioid use disorder. JAMA Psychiatry. 2023;80(12):1269–1276. doi:10.1001/jamapsychiatry.2023.3145
8. American Geriatrics Society Beers Criteria Update Expert Panel. 2023 updated AGS Beers Criteria. J Am Geriatr Soc. 2023;71(7):2052–2081. doi:10.1111/jgs.18372
9.. Goyal P, Kattula D, Rao R, et al. Trazodone for sleep disturbance in opioid dependent patients maintained on buprenorphine. Drug Alcohol Depend. 2023;250:110891. doi:10.1016/j.drugalcdep.2023.110891
10.Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical practice guideline for pharmacologic treatment of chronic insomnia in adults. J Clin Sleep Med. 2017;13(2):307–349. doi:10.5664/jcsm.6470
11. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults. J Clin Sleep Med. 2021;17(2):255–262. doi:10.5664/jcsm.8986
12. Cohen PA, Avula B, Wang Y, Katragunta K, Khan I. Quantity of melatonin and CBD in melatonin gummies sold in the US. JAMA. 2023;329(16):1401–1402. doi:10.1001/jama.2023.2296
