Treating Patients With Insomnia
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Show notes:
By the time the patient with insomnia makes it to primary care, they have probably been struggling with sleep for a while, and have probably tried some things on their own – without luck. And now they’re hoping YOU can fix it, preferably…tonight?
Insomnia is a murky clinical topic; it’s not always as simple as not getting enough sleep. There are other conditions that can impact sleep. There are common lifestyle factors that can impact sleep. And sometimes it IS as simple as not getting enough sleep. (Confused yet?)
Insomnia Treatment in Primary Care
If you aren’t sure where to start with the patient with insomnia, let’s get you sure. This week, we’ll talk about:
✅ Sleep hygiene – what it is and why it’s important in patients with insomnia
✅ The role of substances (alcohol, caffeine, nicotine) in sleep issues
✅ Getting an insomnia/sleep history
✅ Pharmacological approach to treating insomnia
✅ Non-pharmacological approach to treating insomnia
✅ Patient education strategies
There aren’t any tests or labs for diagnosing insomnia. Digging deep and getting a very good history is the biggest part of understanding what is going on and developing the best plan to get your patient the relief they need.
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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the right place.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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In this week's episode, we're going to be talking about insomnia, both the approach
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to assessment and diagnosis, as well as management principles.
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So I just want to validate that this can be a tricky chief complaint to address in
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primary care for a few reasons.
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So the first reason that I find in primary care is that a lot of patients who come
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in for a chief complaint of insomnia, and that's their primary reason for their
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visit, is because they're frustrated, they've been dealing with this for a while, and
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they've already tried medications to help them.
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And so they're coming in and they're like, you know what, just fix me, give me this
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medication and let me go home.
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That's like a lot of the attitude that I see.
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And so it can be tricky because it's our job to assess what's going on and not
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just hand out medications, right?
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And I think that sometimes people who are not in healthcare forget that, that there's
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more to our job than simply writing a prescription, right?
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So we just have to be careful with the assessment of insomnia, right?
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So first, I just want to say that most of my visits with patients who have insomnia,
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I start by connecting with them.
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I do this with all patients, but especially for this chief complaint, connecting with
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how they're feeling and really validating what's going on for them.
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Because until I meet patients where they're at, they may or may not be interested in
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hearing what my assessment and my management suggestions are.
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This applies for everything, but I think especially with this chief complaint.
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So I do validate that.
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You know, it sounds like it's been very frustrating for you.
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I'm here to help you.
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Let me, you know what?
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I have some questions I need to ask you first, and then we can get into what the treatment
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options are.
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And so I usually start with something along those lines and just kind of validate what's
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going on with them.
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And then I get into the history.
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So let's start with the history questions.
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So when it comes to any chief complaint, symptom-based chief complaint, we always
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start with some sort of framework, right?
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I use old cart, which you've heard of before, if you've been following for awhile.
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So starting with old card for any chief complaint.
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But what are the questions to ask in addition?
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So for insomnia, we want to ask about a couple of different things.
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One centers around sleep hygiene.
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So let me just start by describing sleep hygiene, and then you can kind of work
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backwards what the questions are, right?
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So sleep hygiene is kind of like this thing that I think maybe providers and patients
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alike are kind of like, oh my goodness, like, why are you talking to me about this?
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But in fact, they really do make a difference.
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So it's really important to stress that with patients, assessing those things before
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we're like, oh, hey, just go do these things.
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Because like I said, they've probably done all the things already and they're coming
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to see you to help them, right?
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So let's talk about you and I, let's talk about sleep hygiene, and then we'll
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translate that into the patient question.
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So sleep hygiene is going to bed at the same time and waking up at the same
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time every day, no matter it's a weekday or a weekend.
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It also includes having a cool, dark place to sleep, low noise or silent,
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preferably would be great.
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The other thing is that we want to avoid screens two hours before bed, at least.
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And so we know that the blue lights that come out of televisions or phones or
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tablets or anything like that can reduce the melatonin production in the brain,
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which leads to difficulty with sleep.
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So the other pieces we want to think about with sleep hygiene are caffeine
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use, tobacco and alcohol use.
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So caffeine use, we really want to limit the amounts that we have, especially
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keeping them early or like way before anywhere near they're going to bed.
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If a person goes to bed, for example, like 10 PM and wakes up at like seven or
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eight AM, we want to avoid caffeine after say about noon time.
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I should probably be taking that to myself.
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And then with alcohol and caffeine, alcohol and tobacco rather tobacco, I
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mean, anytime, but especially if they're doing, if they're consuming it
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before bed, alcohol, the same thing.
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So the, one of the metabolites of alcohol is actually a stimulant and that can wake
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them up in the middle of the night and be disruptive.
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The last thing about sleep hygiene is naps.
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And so what we try to do is avoid naps during the day.
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If we must snap for adults, we're talking about less than 30 minutes of
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sleep again, well before it's time for bed, whatever bedtime they have,
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if possible.
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So yeah, so that's, those are the main components of sleep hygiene.
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And so if we understand those components, our history questions are just
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eliciting those pieces of information.
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Again, one of the pitfalls is that we kind of launch into here's all the
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things you should do instead of like, okay, when are you going to bed?
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When are you waking up?
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Is it the same every day?
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Does it vary?
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Do you do shift work?
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Right?
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Do you sleep, do you work all night and sleep during the day?
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Does it switch back and forth?
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Do you keep that schedule all the time?
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Right.
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And then we get into those questions of how much caffeine are using,
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what types, right?
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When I was a new grad, I'd be like, oh, you have caffeine.
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That's great.
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Moving on to the next question, but like, let's pull it back for a second.
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And we talk about venti Starbucks multiple times a day, right before bed.
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I can have caffeine at any time.
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It doesn't affect me kind of thing.
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Yeah.
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And then just asking about all those other things.
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Like do they, do they have a cool dark room at night?
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Is it noisy?
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Is it hot?
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Are there other people?
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Things like that.
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Right.
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So that's, that's one of the history places that I start is about
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Eliciting those sleep hygiene questions initially before we launch into the,
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you know, management counseling around that.
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The next pieces though, there's a couple other pieces we want to
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assess when it comes to insomnia.
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We want to start in addition to assessing those questions about sleep
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hygiene, we want to ask about if it's an acute or if it's chronic.
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Is this the last couple of days, maybe weeks, or has this
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been for like 30 years, right?
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What are the medications?
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Have they tried with their supplements?
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Are they trying things like that?
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That's the next part.
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Another kind of diagnostic tool question is asking about like the,
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like what does it look like for them?
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And so these, there are three questions.
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Is it difficult to fall asleep, stay asleep, or is it just that you feel
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tired when you wake up in the morning or is it all three?
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So those three things are three different categories.
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One is sleep latency and that's difficulty falling asleep.
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One is sleep maintenance, which is staying asleep.
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And then the third one is sleep quality.
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They just feel like garbage, even though they slept all the
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hours that they should have.
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Right.
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And that is important for the management principles as well.
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Last pieces.
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The last pieces are getting into what I alluded to at the beginning of this
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episode is that our job is to really make sure like what else is going on
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here and be skeptics, right?
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Is this primary insomnia, meaning it's only insomnia, nothing else is
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going on with this person, or is there some underlying medical condition that
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is contributing to this insomnia, difficulty falling asleep, staying asleep,
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or they just feel like garbage in the mornings.
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So some of the things to think about.
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So we want to think about psychiatric mental health illnesses, anxiety,
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depression, PTSD, et cetera, acute grief, like what else is going on with the
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context, especially if it's more acute.
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Another thing we want to think about is like, why are they, again, if it's a
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sleep maintenance issue, they're working, waking up in the middle of the night.
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Why is that happening?
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Is it, um, they're having a difficult time catching their breath, right?
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Are we looking at paroxysmal nocturnal dyspnea is actually the
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diagnosis, not insomnia, um, or is it, um, nocturia they're avoiding
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multiple times a night or they're snoring.
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So that's another big one.
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I really want to touch on is, um, I think this is really under diagnosed.
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I don't have any stats in front of me, but generally speaking,
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anecdotally speaking, every time I assess for sleep apnea, I feel like I find it.
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So, um, we really want to assess for snoring as well as, um, do they have
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like restless movements at night?
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So do they know if they snore is somebody else in the house or where
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they live can verify if they're snoring, are they waking up gasping
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in the middle of the night?
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Those are usually the questions that I'm asking.
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And then the restlessness pretty much people can tell you that, right?
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Is there underlying like a restless leg syndrome or something like that?
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And then the last piece is it relates to those kind of underlying comorbidities
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is what medications are they taking?
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Not just for like treatment so far, but like, what are they taking
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overall and can we do some digging into those medications and see if those
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could potentially be contributing, right?
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I don't necessarily have like a list for that right now, but that's
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my general approach is when I'm talking with patients, I look at their med
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list and then I kind of like, okay, is this a potential contributor?
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You know, like looking up whatever resources that you use to verify that.
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So management.
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The management depends on what you found in your history, right?
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There's no real other diagnostic thing involved with insomnia, aside from
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the history that you've gathered from this person and you're, you're
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sleuthing for underlying medical conditions, right?
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So everything is really individualized.
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We want to, you know, again, just as a recap, we want to talk about,
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we want to assess their sleep hygiene behaviors at baseline.
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We want to assess for underlying medical conditions, medications they're
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taking, especially psychiatric mental health concerns.
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We want to ask about things like sleep apnea and restless leg, potentially
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some restless leg syndrome there.
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And once we've gotten there, we can do our management, right?
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So pretty much everybody, unless they have like clearly like, well, you
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actually have heart failure and so let's deal with that.
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Pretty much everybody can use sleep hygiene counseling, right?
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When I kind of already went over that.
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And so reinforcing that with patients, going slow, going through
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the things, brainstorming with them, really encouraging them that these
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things do make a difference.
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And I know it's not a medication, but they really do make an
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impact, so it's important to try.
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Another part of that is obtaining a sleep diary.
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I think, especially if it's not really clear, if this is a primary
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insomnia thing versus a related to an underlying condition, keeping
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a sleep diary of when they go to sleep, what time, what time they
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wake up, when they woke up, what was the context around what was
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going on, similar to headache diaries, right?
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If we can keep a sleep diary for the next week or two weeks, that would
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be really helpful for us to understanding what potentially could be going on.
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Okay, let's talk about if it is primary insomnia, what are those
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management principles?
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So fortunately or unfortunately, the research supports that CBT for
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insomnia, cognitive behavioral therapy specific to insomnia, CBT-I,
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is widely studied and is very effective for primary insomnia.
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That is first line.
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Not medication.
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So a lot of patients don't really want to hear that, but we do have
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conversations about what they can do, empower them in their own lives
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with sleep hygiene, plus if they have access to that mental health
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resource, pursuing that, that is really effective.
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That is the most, those are the most effective options
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that we have for insomnia.
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Next step though, if we don't have access to cognitive
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behavioral therapy for insomnia, someone is not willing to do that.
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We can consider pharmacologic management.
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So when it comes to pharmacologic management, the choices that we make
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are dependent on whether somebody has sleep latency challenges, meaning
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it's difficult to fall asleep, versus if they have sleep maintenance
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challenges, which is staying asleep, or if it's both, if it's sleep,
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it's a combination of mixed, because with the principles of management
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are that we try to avoid pharmacology in the first place, but
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if we do, we want to choose this lowest dose for the shortest period
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of time at the shortest half-life, right?
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And so if we have a sleep latency problem, we're going to succeed more
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often with the lower half-life options, right?
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Because it doesn't have to last the whole night.
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We just have to help people stay asleep, right?
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And we try to do it short-term, right?
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Because the most effective treatment, especially for chronic
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insomnia is CBT for insomnia.
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So what are those options?
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I'm going to give like a general approach to pharmacology here
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because things change so much.
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And this is the most kind of up-to-date thought as of May 2022
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is when I'm recording this.
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So, um, when it comes to the first line options, PS, I'm really
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good at reading things and I'm not great at pronouncing them.
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So apologies if I'm butchering these words, but, um, Ramelteon is
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the generic version of the melatonin receptor agonists.
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Um, you may know by another name, but I don't want to use
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brand names on this, uh, uh, channel.
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So that is like the first line, like in terms of on label.
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All of these are basically the same in terms of first line.
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There isn't like one, two, three, four in the same way that
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diabetes medications are.
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There's not a ton of evidence for like any of it, but in terms of
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it being on label for insomnia, that is a kind of quote unquote
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first line option because it's on label.
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Most of the other options are off label, right?
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And so it doesn't mean you have to choose the on label versus
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off label first, but just this, just for your knowledge sake,
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any of these options are appropriate.
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The next one is, um, melatonin.
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Um, and again, it doesn't have to go one, two, three, four.
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These are all options.
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Melatonin is a supplement over the counter and the thing with
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supplements versus medications, which you probably learned in
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pharmacology, but just as a refresher, they are not
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regulated in the same way.
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So one of the recommendations when we're having any patients
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take supplements is that there is a label called USP verified
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where those are more, just more monitored to make sure that
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they actually are what they say they are.
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And you can have patients ask a pharmacist for help for those
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over-the-counter medication options because melatonin is
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over the counter.
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Other ones that are off label, but they're as well first line,
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they're off label for insomnia, but they're first line options
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are sedating antidepressants.
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So those in those categories are things like amitriptyline,
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trazidone, um, mirtazapine.
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Those are all potential options.
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And the choice to use one over the other is dependent on what
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else is going on with the patient, right?
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Do they also have comorbid, um, depression?
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Then you can choose a sedating medication for depression to take
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at night to help with the insomnia, right?
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So the next kind of category is sleep maintenance.
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So basically it's all the same options, except we have the
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another additional option of those orexin receptor antagonists.
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So those, I'm going to, I'm reading them on my notes, so I
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don't butcher the names, limberexant and suvorexant.
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I typically in my regular life refer to them by the brand
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names, but on this channel, I prefer to use generics.
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So those are the generic names.
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Those, um, have a longer half-life.
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They're safer to use than the sedative hypnotics, those Z
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medications, like Zolpidem, et cetera, as well as benzodiazepines.
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Those are not really recommended anymore.
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It's a little bit of a contentious thing because some people
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are still prescribing them.
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It's not officially contraindicated, but it's really good to, it's
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really wise to avoid sedative hypnotics as well as benzodiazepines.
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But those Dora, that orexin receptor antagonists, those other newer agents,
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those have a much safer profile than those other options.
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And so you can use those, especially for those sleep maintenance people where
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they're having trouble staying asleep or it's mixed staying asleep and falling asleep.
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The problem is the cost.
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Um, most patients have a cost issue for those.
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So what are some of the other options?
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Low dose doxepin specifically can be used for sleep maintenance.
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Those are kind of like neck and neck when it comes to like those Dora
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medications as well as, as that.
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And then we try to avoid the sedative hypnotics as
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well as the benzodiazepines.
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You can also use the, all the other medications that I mentioned already.
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So the sedating antidepressants, amitriptyline, trazodone, mirtazapine,
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um, as well as if the sleep maintenance issue, your hypothesizing is
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related to restless legs.
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You can consider off-label use of gabapentin for insomnia.
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It's well, it's also off-label for a restless legs, but
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that's a potential option.
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Those are majority of the print management principles.
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And I definitely recommend you utilize the resources that you have in
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terms of the dosing options and the choices that you make, keeping in mind
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the comorbidities and what you've assessed already for that patient.
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I think one thing I just want to be extra mindful, like if you can
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take one thing away from this, two things, one is that cognitive
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behavioral therapy is first line and sleep and sleep hygiene.
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So the non-pharmacologic options are first line.
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And the second thing I want you to take away from this episode is
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that, um, we really just have to do our due diligence to make sure
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we're not missing anything medically.
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So sleep apnea, do we need a sleep study for this patient?
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Do they have underlying urologic concerns, cardiology concerns, right?
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Et cetera, et cetera.
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And I don't have a full list of all the differentials in there
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for medical reasons, cause it's very broad, but you just have to
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do kind of like your, your due diligence and digging and sleuthing
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when it comes to that history taking.
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So hopefully this episode was helpful for you.
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If you haven't grabbed the ultimate resource guide for the new NP,
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head over to realworldnp.com slash guide.
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You'll get these episodes and straight to your inbox every week
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00:17:26.920 --> 00:17:28.460
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Thank you so much for tuning in.
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Talk to you soon.
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That's our episode for today.
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Thank you so much for listening.
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Make sure you subscribe, leave a review and tell all your NP friends.
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So together we can help as many nurse practitioners as possible,
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00:17:48.510 --> 00:17:51.330
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00:18:05.930 --> 00:18:07.450
Thank you so much again for listening.
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Take care and talk soon.
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