the-matt-walker-podcast — Ask Me Anything Part 22: Latitude, Pain Gating, Temperature &

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Hi there, it's Matt here, and welcome back to the podcast, and welcome back

to another of our AMA episodes, Ask Me Anything episodes.

We've got a long list of questions, so we're just going to dive straight

in.

But as always, I am joined by the unparalleled, the unmatched brilliance

that is Dr.

E.T.

Ben-Simon.

Eti, welcome back.

Great to be here, Matt.

Okay, Eti, so with all of that said, why don't we just jump in

and start with the first question?

The first question is a very intriguing one.

Someone is saying, since moving to Finland for work, my sleep has completely changed.

Does latitude really affect sleep that dramatically?

Yes, for some period of time until which your system will

acclimate at least.

So there's, I guess there's 2 things.

The first is the initial move there, and that's all the jet lag and

the circadian disruption.

But that's not, I think, what this person is talking about.

Latitude can significantly influence sleep due to differences in

the amount of daylight exposure, the timing of the sun, and the seasonality

of that light, all of which basically impacts both your circadian rhythms and in

part by way through melatonin signaling.

There has been some work done looking at Nordic countries, including Finland, that showed

that during midnight sun or polar twilight periods,

individuals often report later sleep onsets, lower sleep efficiency, and

an increased phase delay, essentially in the summer months.

So not really a big surprise there, but if you are at the equator,

you're getting really nice, usually very consistent sinusoidal waves of light

and dark, light and dark.

And that happens day after day, month after month, irrespective of the month of

the year with some minor modifications.

But once you get in the high latitude areas, then all of a sudden,

if you're in Finland during the summer, you're going to have light at almost

all times of day.

So no wonder your brain gets confused.

And that's why you really have to be so careful to ensconce yourself in

as much darkness at night, even though it's still light outside.

Otherwise, you'll suffer those issues.

And people, they were these sort of more national representative samples, when you are

in the summer phase and there's constant light outside, you go to bed later,

the efficiency of your sleep is not as good, and you end up sort

of wanting to wake up later, but you still have to get to work,

all of which leads to a reduced total sleep time.

Why is that?

It's in part because your circadian rhythm that you have, and everyone has a

circadian rhythm, this 24-hour cycle, isn't quite 24 hours if you are

left to your own devices.

Most of us run a little bit long.

We usually sort of run, let's say, 24 hours and 10 minutes.

So our internal 24-hour clock is not of a precision that

any Swiss court— Not even close.

Yeah.

But thankfully we have lots of little fingers, like on a wristwatch sort of

situation, that will come along and each day they will reset us to precisely

24 hours.

The most powerful resetting set of fingers that we have is light.

And that is the principal, what we call Zeitgeber or time giver, to reset

our circadian rhythm.

But in high latitude summers, it offers extended daylight that will prevent

the accurate sort of resetting, as it were.

It will keep melatonin suppressed.

And that melatonin, which signals darkness, is delayed many hours later than it would

otherwise.

And then if that weren't bad enough, you have the reverse problem in the

winter where you get too much winter darkness and not enough daylight.

And as a consequence, that leads to the opposite, which is instead of excessive

amounts of wakefulness, you get excessive amounts of drowsiness.

And you can also get, as a consequence of that circadian disruption and sleep

disruption, things such as seasonal depressive symptoms or SAD, which

is seasonal affective disorder.

Some of this, by the way, the subtle twists here, your chronotype, if you

are a late-to-bed type, a night owl, that may actually intensify

the adaptation challenges.

What can you do about it?

Well, a lot of these countries will implement the use of bright artificial light

that tries to mimic natural light.

And they usually do that in the winter months where you have this big

light box.

And as you're getting ready or you're having your breakfast or you're sitting there

in the first hours of work, you get bright light exposure in the winter

to try to increase artificially the amount of natural light that you're getting.

And then in the summer, you reverse engineer that.

You get home and by 7 or 8 o'clock in the evening, even though

it's bright sunlight outside, blackout curtains, sleep mask at night, block

the ambient summer light.

What do you have thoughts on that?

Just a personal experience.

The other side of Finland, Patagonia.

I was there in the summer months, 10 p.m., bright light, and I

was so tired because I was hiking.

I was really amazed at the effect.

I just felt like I can't go to sleep.

It's too early.

I can't go to sleep.

And it really did take a couple of hours to fall asleep, even though

I was really tired.

The effect is so dramatic.

It's impressive.

And I remember being in Sweden, ironically, for a sleep conference

on June 23rd, 2 days after the summer solstice.

So it was at peak sleep disruption, and it was the strangest feeling.

You're absolutely right that there is this complete paradoxical mismatch between your internal

state of fatigue and tiredness and the external world around you screaming at

you, go out, it's time to be awake, it's morning.

You're thinking, I don't know what's going on.

It is a very surreal psychological versus physiological mismatch.

And we forget how contextual sleep is as a process psychologically, not

just physiologically.

Yeah, it's almost like a type of jet lag that's not related to planes.

Correct.

It's a perennial jet lag for several summer months in the northern latitudes.

We should call it lat lag.

I said it first.

Trademark.

All right, next question.

Before we move on, you said something that it might be worse for night

owls, and as a night owl, I was intrigued.

Would it be worse just for one season or just all across the board?

It seems to be all across the board that night owls, if anything, because

the way society is structured, et cetera, you need to almost artificially ensconce yourself

in darkness earlier in the night because you're already someone who wants to be

sleeping later, going to bed later, and waking up later.

So to try to be complicit with society's Type A early bird catches the

worm mentality, you have to use darkness even more so at night to try

to help you.

And therefore, that light at night is pushing you as the night owl even

further into the future, which is already your problem to begin with, even if

it's the middle of autumn.

So that's why it can be more problematic.

So the next question is kind of related to that.

Something I get asked a lot, is sleep before midnight better?

The listener is saying, every so often I hear that sleep before midnight is

of better quality.

Than the one after, and the listener is a night owl.

So what do you think about that?

This is a great sleep myth, and there is no really good evidence in

support of this in the absolute, in the binary.

I've heard sleep before midnight is twice as valuable as sleep after midnight.

There is nothing about the sleep that you get at 12:01 AM that is

any worse than the sleep that you were getting at 11:59 PM.

It's not like you turn into a sleep peach or an apple or a

pumpkin, whatever it is, at midnight and all things go to hell in a

handbasket.

The common belief that's held, or misbelief, stems from social

convention.

But scientifically, sleep quality actually much more strongly hinges on alignment

with your internal circadian rhythm, not with what time it says on the clock

face.

In other words, sleep that is aligned with your chronotype, morning type, evening type,

or somewhere in between, and therefore your melatonin biological onset, is much

more predictive of how high the restorative value of your sleep is relative

to where it simply occurs before or after the strike of midnight.

So No, there is nothing so special about that.

Now, I would say that the sleep that you get in the first half

of the night is more dominated by deep sleep, and the sleep that you

get in the second half of the night is more dominated by REM sleep,

such that if I naturally would go to sleep at, let's say, 11:00 PM,

and I wake up at 7:00 AM, but this time I go to sleep

now at not 11:00 PM, but I go to bed at 4:00 AM, am

I going to get the same amount of deep sleep?

And let's say that I sleep from 4:00 AM and I sleep the full

8 hours starting at 4:00 AM.

Am I going to get the same amount of deep sleep?

No, I'm not, because my brain doesn't feel as hungry for deep sleep by

4:00 AM because there is some degree of circadian rhythmic dependency.

Not entirely.

Slow-wave sleep is actually strongly related to the amount of sleep pressure, but still

there is some circadian modulation of it.

All of which is to say, a very long-winded way of saying there is

no universal magic hour before midnight.

Sleep quality depends primarily on how well your sleep aligns with your own innate

biological timing, your morningness versus eveningness, and how consistent

also you are in maintaining that rhythm.

Worry about those 2 things.

Don't worry about the clock face.

Yeah, absolutely agree.

Regularity is the most important part when it comes to getting all of your

stages and all of your good quality sleep.

Hands down.

Right amount of sleep opportunity, time in bed, right amount of regularity, and then

keep an eye out for quality.

And I think that it kind of relates to the mentality we were talking

about before.

Early bird catches the worm.

And so it kind of comes into this sphere of everything that is getting

to bed too late is just as bad as not getting up early in

the morning.

Yeah, it's funny that there is this still stigma against night owls.

People say, well, the night owls, why do you wake up so late in

the morning?

You're so lazy.

Well, why can't we turn the tables and say for the morning types, You

go to bed so early, you're lazy.

You know, and I often joke that people say the early bird catches the

worm, and that may be true, but the second mouse gets the cheese.

Anyway, moving on.

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Next question.

What part of the brain allows us to shut off pain while we sleep,

if this happens at all?

And if this is a mechanism in our brain, can we somehow identify it

and manipulate it to help with pain management when we're awake?

It's a good idea.

Yeah, it's a very good question, and it brings us on to a broader

issue, which is sensory perception writ large.

So I would say to the listener, the answer is yes and no.

Yes, you will be able to suppress a certain amount of pain during sleep,

but the same is true for almost any other of the 5 senses.

And there is a mechanism that is known in the brain that allows you

to essentially dislocate yourself from a sensory perspective from the outside world.

And with pain, to a degree, your internal world.

And the way it works is that there's a structure deep inside the brain

called the thalamus.

And the thalamus is essentially like the sensory gate of the brain.

So sound, taste, touch, smell, and signals of nociception,

of pain, they will typically pass through from all of their respective channels,

and they'll all feed into this central structure.

The thalamus.

And then the thalamus acts like this sensory gate, and it will determine what

of all of those sensory perceptual signals are sent up to your cortex at

the top of your brain.

And when your cortex starts to process them, only then do you become consciously

aware of them.

Why is this relevant for sleep?

Well, as we start to fall asleep, the sensory gate of the thalamus starts

to close shut.

And therefore, technically, your eyes are still seeing, your ears are still hearing.

That burn on the back of my hand, because I'm a terrible cook, is

still signaling pain to my brain, but it's never passed up through

the thalamus up to my cortex because the gate of the thalamus has closed

shut.

And therefore, I have stopped perceiving those sensory perceptual signals.

Which is simply another way of saying I've stopped perceiving the outside and my

own internal environmental awareness, which is just another way of saying I've fallen

asleep.

Now, it turns out that if you get a bang in your environment that's

loud enough, or the pain from the broken leg that you just got is

significant enough, they will always break through that barrier, that

gate of the thalamus, And they will still go up to the cortex.

So if there is something that is sensorially significant enough, it still has the

ability to break through the gate of the thalamus and get perceived by the

cortex.

At that point, you wake up.

So that's the reason that we can shut off pain and we can shut

off most all other sensory perceptions during sleep.

But it's not to say that it is an irreversible process.

It is a reversible process, and it can be reversed if those things are

too substantive as we're sleeping.

Or finally, once we're done with sleep, the gate of the sensory thalamus starts

to open back up again, and we get the world flitting back into our

conscious perception.

Yes, and also meaningful stimuli.

For instance, if someone says your name, it's more likely to wake you up

than other voices at the same threshold.

Yeah, there's a great study back in 2001.

I'm dating myself here by Chiara Portis at UCL, University

College London.

And they did an even more clever twist on this.

They had people inside of an MRI scanner.

They had them fall asleep.

And once they were asleep, they started playing specific tones and specific

words.

And auditory sensory stimuli to the brain at the same decibel level.

But in some of those conditions, they were presenting very salient words to

the individuals, such as their own name or the name of their child or

the sound of their crying child.

And even though all of the auditory stimuli were normalized to have the

same decibel level and the same duration of time, The things that

were most salient to the individual ended up being processed in the brain

in a very different way.

Now, it turned out that for the most part, none of these people woke

up because they didn't play them quite loud enough to wake them up.

And that was a clever part of the study.

It says that even when we're asleep, things that are salient to us will

break through the brain barrier and still be processed in a subconscious way

relative to things that are not salient.

So your brain is still clever and smart and wanting to process things that

are probably very relevant to you, even though you're still asleep.

Cool study, right?

Sleep is such an amazing state because you are on the border of

being part of the world and then kind of being engulfed in your own

internal world.

And that ability to reverse it and play with it is just, it's so

magnificent.

It's really unique.

And it's adapted to so many different things along the way.

There are so many ways that sleep has had to contort itself to remain

present across the evolutionary path.

This is one very subtle one.

Another one that's dramatic is amphibious mammals.

So things like otters or dolphins, what they have to do, they have to

keep surfacing and they have to do that 24/7.

So when do they sleep?

Because if you sleep, you're going to be submerged and you'll drown.

So nature found a way to figure this out and it's called unihemispheric sleep.

And they will sleep with one half of their brain and the other half

will be awake to allow them to resurface and breathe.

It would've been so much easier, you think, if sleep wasn't absolutely essential, non-negotiable

biological necessity.

If it wasn't, if it was somewhat debatable in the way that we sometimes

think of sleep as negotiable each night, then you would've just said, well, forget

all of this rewiring of the brain and creating half a brain sleeping and

the other half awake.

Let's just do away with sleep.

It's just a much easier problem to solve than trying to— no, sleep is

so important that it has been contorted in all sorts of ways so that

every single species still is able to obtain it.

Sleep is bloody remarkable.

All right, next question.

Do we want to touch a bit on how can we try to use

it while awake?

Is there something we can do to kind of hijack this mechanism to help

regulate pain?

I don't think there is necessarily.

I mean, the way that most of our analgesics work, some of them will

work at the level of the thalamus.

Things like anesthesia, for example, is a state where you really are going into

sort of a decorticalized state, as it were.

But then there are lots of different ways that you can modulate pain.

You can do it locally by trying to numb it.

So for example, You can be at the dentist and I'm not going to

insert anything into your brain and knock out the thalamus.

I'm simply going to locally numb you in the area where the branch of

nerves is going to be in pain.

And therefore the signal is never transmitted up to the brain to begin with.

So you can cut off the pain signal much earlier in the pathway, or

you can cut it off at any moment during the pathway all the way

up to the thalamus and then to the cortex.

So yeah, I don't think there's a way that you can use sleep to

modulate pain though.

Not that I'm aware of.

Yeah.

I think that for us to be able to use this mechanism would be

quite invasive.

So we don't know how to do that non-invasively yet, but I just like

that this question touches on something that I don't think we've tapped enough into

as sleep scientists, which is really to use the wonderful spectrum of the sleeping

brain to take things that we can use during wakefulness.

Learning mechanisms, pain management, things like that.

We know that sleep is really good at doing that, and we can use

a lot of these techniques during wakeful hours.

So I think it's just a really interesting, fascinating direction to take.

Yeah, sleep is bloody remarkable.

Next question.

Next question.

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Okay, back to the show.

So this is about lowering core body temperature.

So the listener is saying, I found the sleep advice around lowering the core

temperature at night very interesting, but I'm still not sure on the details.

Warm socks or not?

Warm blankets or not?

Warm PJs or not?

The colder the room, the warmer I tend to dress and prepare the bedclothes

at night.

So I have difficulties falling asleep with cold feet.

So in short, how do I regulate my core body temperature in practice when

in bed?

Is there more to know about how the body regulates temperature and what counts

as core and what periphery?

Very good question.

Very good question too.

So really what we're talking about here is the central trunk of the body

versus the arms, particularly the hands, and then the legs, particularly the feet, and

then the head, including the face.

Now, of course, no one wants to be dangling their arms and their feet

out of the bed to regulate the temperature, but I'm getting ahead of myself.

Let's go through the steps.

Firstly, cool ambient temperature, somewhere between about 65 to 68 degrees.

And that's usually so cold that people feel uncomfortable if they were to go

to bed as they normally would in a bedroom temperature of, let's say, 72

degrees.

So what to do about it?

The place where many people suffer this sort of sense of mild hypothermia

is in their feet indeed.

And in fact, if you have very cold feet, it's very difficult to fall

asleep.

You need to get the feet to swell with blood and the hands to

swell with blood to evacuate all of the heat that is trapped in the

core of your body.

And one way that you can do that, or you can do it in

one of two ways.

The first is don't overdress, don't dress the core of your body too much,

but you can go to bed with thick socks.

What I like to do, geriatric-like, is have a hot water bottle and I

put that at the end of my bed and I can warm my feet.

I'm actually fortunate enough now where I don't have to do that because I

have a temperature-controlled mattress.

Full disclosure, it's an Eight Sleep mattress and I'm part of the scientific board

to help develop some of that technology.

But that helps me regulate it.

But not everyone has that luxury.

So I would say hot water bottle, thick socks, that's great.

Keep the dressing of the rest of you, of the trunk of you minimal,

Bedroom temperature, 65 to 68 degrees Celsius.

Also, you can artificially evacuate heat before bed by having a warm bath or

a hot shower.

And what that does is that it will bring all of the blood that

is trapped in your core out to the surface.

And when you get out of the bath or the shower, you think the

reason you fall asleep more easily is because you're all warm and toasty.

It's the opposite.

It's that all of the blood is now at the surface of your skin.

You get out the bath, you get this huge emission of hot heat that's

trapped in the core of your body out, and it radiates out through the

outer surface, and your core body temperature plummets.

And that's the reason that you fall asleep.

So that would be the general best prescription.

Keep the bedroom cool.

Socks are absolutely fine.

Hot water bottle, temperature-controlled mattress if you can do it.

If not, just use the trick of a hot bath or a shower.

15 or 20 minutes before bed, or even 45 minutes before bed.

That works too.

And I'll just add that when you are starting to get sleepy, try to

notice the temperature of your extremities, your feet and your hands.

It is quite amazing, but about half an hour, an hour before bed, you

already start to feel that they are getting warmer than the rest of your

body.

And this is a sign that your body is trying to release heat.

So often for me, when I go into bed and my feet are already

cold, I feel like I've kind of missed a window because usually when I

go into bed, they're already warm enough because they're radiating heat out.

So that's another thing you can pay attention to.

And I know it's a bit confusing because some parts of the body are

getting cold, some parts of the body are getting hot, but the notion, like

you said, Matt, is really to try to send the heat trapped in in

the body, outside.

And the way we do it is through our hands and our feet.

So that's kind of the point of contact to pay attention to.

Yeah.

And just to note 2 things.

Firstly, why do we lie down to sleep?

Why can't we sleep as well in a chair at 45 degrees versus lying

down?

One of the theories is that when we lie down, it is a far

more efficient way of the body to radiate heat out of its core.

It turns out, number one, sleep is bloody remarkable.

Number two, if we bring you into the laboratory and you have no time

cues, you've just got 4 walls, no light, no watches, no nothing.

And we have delightfully, prior to starting the study, inserted a rectal probe

so we can measure your core body temperature.

And we've got sensors on the outside of your body, on the extremities too,

at the moment where your core body temperature starts to decrease rapidly

and the extremities of your hands and feet start to warm up most rapidly,

the point at which those 2 things are happening at the greatest, steepest point

of the curve is the point at which we keep asking you, when do

you feel sleepy?

When do you feel sleepy?

When do you feel sleepy?

And you'll say, I don't feel sleepy.

I don't feel sleepy.

And then you'll say, oof, it just hit me.

I feel sleepy.

We already knew you were going to tell us that a little bit before

because we could see the transition of your core body temperature plummeting and your

extremities starting to swell with blood and start to warm up.

And the moment where those 2 things cross over is the moment where you

subjectively say, I feel sleepy.

Sleep is bloody remarkable number 2.

I know the Oura Ring has a temperature sensor.

Do you see a spike sometimes in your hands?

Have you looked at that?

There's some possibility, but what you really want is the measurement of it in

2 locations to be most accurate.

You want the core and then you want the periphery.

So it's a little bit more tricky.

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All right, next question.

This is a question about shift work, which is fascinating.

The listener says, I'm 37 years old.

I work as an anesthetic resident in the UK.

The older I get, the harder I find shift work.

Getting sleep during inactive periods on night shift is hard because it's after a

lot of stress.

And some people can just seem to go to sleep and wake up like

it's an on-off button and not me.

Following night shifts, my sleep is affected for days to almost a week with

lack of sleep pressure at night and often increased sleep pressure in the day.

And it feels like a real hangover effect.

I have no doubt shift work has terrible consequences on health.

And I would like some advice for the shifties to make tricky sleep situation

better managed.

It's a great question.

Yeah.

Well, yeah, first, thank you for doing what you do and being there for

all of us in society when we need you most.

We're immensely grateful.

And your schedule does pose some significant circadian disruption, sleep debt challenges,

but there are a variety of evidence-based strategies that can help mitigate some of

this impact.

And I think there was a great meta-analysis of all of the different clinical

and experimental interventions.

And the size of the impact of these was really quite statistically significant.

What they found was that structured interventions that included light exposure,

napping, cognitive behavioral therapy for insomnia, and melatonin among shift workers carried

the greatest vote on the election day in terms of helping you mitigate

these effects.

So what does that mean?

The key recommendations were bright light exposure early in the night shift, and

we're talking about somewhere between 2,500 to 10,000 lux.

So again, you can just download a lux meter, L-U-X, on your phone, and

you can make sure that you're getting that type of intensity of light.

So early bright light exposure during your shift.

And that will help push your circadian phase later, meaning that you're going to

be more alert for longer periods of time.

And then you have to reverse that when you come off the night shift,

use blackout glasses or sort of really thick shades for limiting daylight

exposure as you're en route going back home to sleep wherever you're going to

sleep.

The other thing that you can try to do is pre-shift naps of about

10 to 13 minutes.

This work was done by David Dinges and Mark Rosekind, some great studies in

long-haul flight pilots and saying, if you get a chance to nap throughout the

entire long-haul flight, when should you do it to be able to maintain maximum

alertness?

And you would think, well, you could have these prophylactic naps.

You would put them right at the end when you're feeling sleepiest.

They found the opposite, that if you try to nap for 10 to 30

minutes right before the start of the shift, so sort of in the last

2 hours before you go to work, try to see if you can just

get a little bit of a 10 to 30 minute nap.

It markedly reduced the cumulative sleep debt and sleep pressure that you developed

by the end of the shift where you are really, really dragging.

I would say that probably once you get home, your biggest problem hormonally is

that it's light out and your circadian rhythm has stamped the brakes on melatonin

and there's no signaling to your brain that it's darkness because it's not, it's

daylight.

But you want the signal of pretend darkness because you are going to try

to get to sleep.

So try to use somewhere between about 1 to 3 milligrams of melatonin.

On your way home, or essentially about an hour before you expect to go

to sleep.

You shouldn't use it on the way home if you're driving.

That can make you drowsy and that's very dangerous.

So get home first and then 45 minutes to an hour before bed, take

your 1 to 3 milligrams of melatonin.

I know the military has sort of controversially used drugs like modafinil or armodafinil,

which is a wake-promoting chemical.

You have to do that under medical supervision and it may improve alertness and

performance.

But that is not a substitute for sleep.

And then the last 2 things I would say to administrators is try to

limit consecutive night shifts to 2 to 3 in a row, and

then either intersperse recovery days or try to do a rotating shift

where you kind of work, let's say, an afternoon into evening shift, and then

you rotate forward.

Rotating back is miserable.

Rotate people forward in shift work.

So start to have them do the afternoon to evening shift, then the nighttime

to morning shift, then the morning to late afternoon shift.

If you're going to rotate them on a roster, make sure you're rotating them

in forward in time in that way.

So those are things that can certainly help.

So combining circadian alignment, get your light in the first half of the shift,

use strategic napping, before you start your shift.

Make sure your sleep hygiene when you get home is good.

Keep your room dark, cool, and black.

Blackout curtains, earplugs, eye mask are great.

And then try to see if administrators will listen to people like me saying,

don't do too many shifts all in continuously in one phase without any recovery

days.

You need those recovery days.

And then if you're going to rotate shift, do it forward in time on

the clock.

And doing it forward is about how it is easier for us to postpone

sleep than it is to go to sleep earlier?

Yes, and we spoke a little bit about the circadian rhythm and how without

these sort of light synchronizers, we all typically start to run a little bit

later into the day, sort of our clock runs further.

So it's easier for us to run forward in time because that's what our

innate circadian rhythm would like to do.

And the fact that it's harder for you to force yourself to sleep than

it is to force yourself to stay awake.

That's why it's easier traveling west than east.

Correct.

West is best.

East is tough.

We need a rhyme for that.

Let's go to the last question.

The last question of today.

I have a question about the use of gabapentin.

Gabapentin, sorry.

Gabapentin for sleep.

They would like to know more about that.

Yeah, it's interesting.

Gabapentin in the context of sleep is principally used for something called restless leg

syndrome.

And I've done an entire episode about this sleep disorder.

It's a wicked vicious sleep disorder.

And there it's used to try to modulate and block the annoying, very frustrating,

infuriating sensations of restless leg where you want to move your legs and you

kind of need to move them and jerk them and sort of massage them.

And it tries to to settle down that motor cortical signaling.

But gabapentin has shown, I would say, mild to moderate benefits for

sleep symptoms associated with other things like neuropathic pain or menopause-related

hot flashes.

And then in healthy individuals, there's a little bit of data that it says

that it may reduce the time for which it takes you to fall asleep

and may keep you asleep in a bit more of a continuous fashion.

And because of those 2 things, it can increase your total sleep time.

That's what some of the meta-analyses have demonstrated.

That said though, if you look at people who are struggling with sleep and

are probably looking to things like gabapentin to help them, randomized controlled trials in

individuals with primary insomnia, not caused by pain, but just primary insomnia,

you just don't seem to get much of a robust efficacy benefit from gabapentin

compared to placebo.

So I think folks like the American Academy of Sleep Medicine and other organizations

like them, they do not recommend gabapentin as a first-line insomnia treatment due

to the limited effect size.

And also there's some potential concerns.

You've got to be careful.

You get some daytime sedation, some dizziness.

There's a bit of a dependency risk.

How is it doing it, by the way, if it is sort of helping

with some of those motor symptoms and a little bit of sedation.

It seems to act by modulating what's called the GABA system in the brain,

G-A-B-A, which stands for gamma-aminobutyric acid.

Say that after a couple of good drinks on a Friday quickly.

And it also modulates something called voltage-gated calcium channels, all of which essentially

are going to result in reducing the excitability of brain cells.

And here it's the excitability of the brain and particularly the cortex.

So if your insomnia is caused not by primary insomnia, but is caused by

secondary pain or sensory motor disturbances or things like hot

flashes, then gabapentin may improve sleep.

But for primary insomnia, it's just not going to really be moving the needle.

Things like cognitive behavioral therapy for insomnia or certain hypnotic medications remain

preferable.

So gabapentin may benefit sleep in select medical contexts, but it's just not effective

in insomnia as a primary therapy.

Alternative, better approaches exist.

Yeah, we, we talked about pain management in one of our AMAs, how sleep

is able to disconnect the brain from peripheral signals.

And when that doesn't happen, then gabapentin can help.

Exactly.

You're just trying to block out that sensory, not external sensory, like a noise

or a disruptive flash of light.

But here it's the internal signal of nociception.

So, wow, we got through those questions pretty well.

We covered a lot more than we normally do.

I love your questions.

Keep sending them in.

They are so unique and wonderful.

Yeah, we were talking about this a little bit before we started recording.

It's not just that they're great questions and they're so unique, but they really

make us happy.

It's so nice to think We're not just talking into microphones here together and

it's not reaching people, but we love the fact that you are just as

excited and curious about sleep as we are.

So if for no other reason than our own hedonic pleasure of realizing that

you love sleep and you have questions, but we are here to serve you.

Send us your questions, social media, email, shout at us on both and all

of those channels.

Etty, where can people find you out in the digital sphere just so that

they know?

On Twitter, @etosh, E-T-O-O-S-H, and also on my Gmail, etosh@gmail.com.

I would love to hear from you.

I really would.

Folks, I'm sure, can probably find me, unfortunately, but stick with Eti.

Okay.

With all of that being said, thank you, Eti, once again for being so

wonderful, so insightful, keeping me on the straight and narrow, being much more additive

than I ever am.

Any last words?

Thank you, Matt.

I think you're doing so well in covering so many topics and helping people

get better sleep.

It's only because of such a wonderful sidekick, folks.

Thank you.

Take care, sleep well, and we will see you in the next episode.

From the two of us, bye for now.