In this article you will learn: • the various sleep remedies available to buy in the pharmacy when their use is appropriate and when to refer• what additional lifestyle advice to give to encourage a good sleep routine• over the counter medications that may cause sleep problems as a side effect.
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Sleep problems affect many people and can occur at different stages throughout our lives. Here's how you can help your customers to get a good night's sleep
Scenario 1 Frequent flyers
It's been a busy morning but when things quieten down a bit, your colleague mentions that she saw you serving a regular customer. She asks you what he wanted, and you remember that he asked for a packet of Nytol, which you sold him after asking him all the appropriate questions. "I thought so," your colleague says. "I sold him a pack a few days ago and I'm sure he's been in for them quite a few times before."
You realise that this medication should not be taken regularly and can be subject to abuse. You have a chat with your pharmacist and decide on a strategy to deal with this customer should he return to the pharmacy again for the same product.
You need to deal with this sensitively, as you certainly do not wish to make any embarrassing allegations. A possible tactic would be to ask the customer if the tablets are for his own use and politely mention that you have noticed him buying them more and more frequently. You can remind the customer that they can only be used safely on a temporary basis, and if he is finding he needs to use them every night or in a higher dosage than recommended, he should really visit his GP. He may need an alternative medicine on prescription.
Scenario 2 Early morning waking
A man in his 20s is looking at the herbal sleep remedies and explains that he is looking for something to help him sleep longer – although he has no trouble getting to sleep, he often wakes very early in the morning and can't then nod back off. He ends up lying in bed wide awake worrying about things until it is time to get up for work. Because of this he is feeling extremely tired during the day, but that's about it; there are no other symptoms.
You explain to him that the sleep aids available over the counter are generally only designed to help a person drift off to sleep.
In an otherwise happy person, early morning waking is usually due to going to bed too early and can be remedied by moving the bedtime later. It also can be age-related – when people get older they tend to need less sleep overall, often take naps in the day and then struggle to sleep in.
However, because this man admits to having worries, it could be that his early morning waking is a sign of depression.
In depression it often takes longer to get to sleep, sufferers often sleep for shorter periods, and there can be little or no periods of the deep sleep that are important for the body's restorative processes.
This customer needs to resolve the root cause of his sleep problem rather than try to treat himself with the inappropriate use of sleeping tablets. After chatting with the pharmacist, he decides the best course of action is to make an appointment with his GP to discuss how he is feeling.
Scenario 3 Temporary sleep problems
A woman approaches the counter and asks for some advice. "Is there anything you can give me to help me sleep? Over the last week or so I have had a lot on my mind and am struggling to nod off. I feel so tired in the day that it's beginning to affect my work," she says.
You ask the customer the usual WWHAM questions.
She tells you that she does not take any regular medication and has no underlying medical conditions, such as asthma, glaucoma, bladder or certain stomach conditions. You can see she is over 16, so you go ahead and recommend one of the sleep aids available to buy over the counter.
The two main drugs used are diphenhydramine (Nytol) and promethazine (Sominex). These are antihistamines and are used for their sedative properties. It is important to tell the lady she shouldn't drive or drink alcohol after taking any sleep aids, and if she is still having problems after two weeks she should be advised to see her GP.
She tells you she isn't too sure about taking a traditional OTC sleeping tablet, so you remind her that natural remedies are also available, containing ingredients such as valerian, lettuce, passion flower and hops.
However, you also take the opportunity to offer her some lifestyle advice which could help. Even though she says that she feels tired during the day, you tell her to avoid napping, and to only go to bed in the evening when she actually feels sleepy. She should also try and avoid a lie-in – however, tempting this may seem – as a good sleep pattern involves getting up at the same time every day. You also suggest the customer follows the 30 minute rule. This says that if it takes longer than 30 minutes to get to sleep, the person should get up, go to a different room, do something distracting such as reading and only return to bed when they feel sleepy. This should be repeated until sleep is achieved.
Scenario 4 Sleep problems in pregnancy
Insomnia is very common during pregnancy even though pregnant women will commonly tell you they are extremely tired. Anxiety, fear, worry or excitement about the future can all help to make it difficult to switch off. Physical symptoms such as nasal congestion, restless leg syndrome and leg cramps, and pregnancy-related symptoms such as increased size, indigestion, backache and a restless baby – as well as needing the loo during the night – certainly won't help either.
It is often said that these problems are all nature's way of preparing you for motherhood, and your pharmaceutical options are limited in pregnancy:
• Sedative antihistamines are not licensed for use during pregnancy or breastfeeding and it is probably wise to avoid herbal products• Homeopathic remedies are available, but are best prescribed by a homeopath• Hop pillows may help, but hops should never be taken during pregnancy
Essential oils such as lavender, camomile or ylang-ylang can help, but only two to three drops should be used. Lavender should be used with caution in the first trimester, but is safe if used occasionally at a maximum of three drops each time.
It can be put in a bath or onto a tissue next to the bed for 15-20 minutes only; any longer can cause nausea and headache.
Instead, you tell the lady about lifestyle measures that can help (see box, right) and the merits of an extra pillow or two for added comfort and support. She says she has a live-in partner, so you suggest he might like to help with a relaxing neck and shoulder or foot massage before bedtime.
Scenario 5 Sleep side-effects
Some medicines in the pharmacy can affect sleep as a side-effect. Older antihistamines such as chlorphenamine, which reduce the symptoms of hayfever and allergies, are known to cause drowsiness. In fact, the active ingredient in these hayfever remedies are also used in sleeping aids because of the sleep-inducing properties of the key ingredient. Fortunately, for those people for whom this might be a problem – people who drive for a living or students with exams throughout the hayfever season, for example – other non-drowsy preparations are available. These include acrivastine, loratadine and cetirizine. A number of other drugs available over the counter also have side effects that can affect sleep, and these should always be pointed out to customers as they could adversely affect their lifestyle. The decongestant pseudoephedrine is a stimulant, so customers should be advised not to take it too close to bedtime. Other drugs that can result in drowsiness include the painkillers codeine and dihydrocodeine.
• OTC sleep remedies are for temporary use only – for a maximum of two weeks• Always remember to act discreetly and with sensitivity when discussing a customer's sleep problems• Remember lifestyle advice.
Do:• Get a regular bedtime routine – with a set bed time, bath and a milky drink• Take regular exercise – but not within two hours of bedtime• Create an environment that encourages sleep – try to achieve a quiet, dark, cool and tidy bedroom, with a comfortable bed.
Do not:• Drink caffeine, nicotine or alcohol, or eat a heavy meal before bedtime Take daytime naps or have lie-ins.
• Take a look at your sleep aids. Do you know which ingredients they contain?• Do any of the ingredients in the common sleep aids appear in any other OTC products?• Share with your colleagues any tips and hints on dealing with customers who may be abusing or misusing sleep aids. How will you deal with them when they next come in?