Concierge Medicine

Concierge physicians care for fewer patients than in a conventional practice, ranging from 100 patients per doctor to 1,000, instead of the 3,000 to 4,000 that the average physician now sees every year. All generally claim to be accessible via cell phone or email at any time of day or night or offer some other "special" service above and beyond the "normal" care provided. The annual fees vary widely, from $600 to $5,000 per year for an individual, with the lower annual fees being in addition to the usual fees for each service and the higher annual fees including most services.

Community Reinforcement Approach

The Community Reinforcement Approach Plus Vouchers is an intensive 24-week outpatient therapy for treatment of cocaine and alcohol addiction. The treatment goals are twofold: To maintain abstinence long enough for patients to learn new life skills to help sustain it and to reduce alcohol consumption for patients whose drinking is associated with cocaine use. Patients attend one or two individual counseling sessions each week, with the focus being on improving family relations, learning a variety of skills to minimize drug use, receiving vocational counseling and developing new recreational activities and social networks. People who also abuse alcohol receive monitored dosages of disulfiram Antabuse therapy. Patients submit urine samples two or three times each week and receive vouchers for samples that are without cocaine. The value of the vouchers increases with consecutive clean samples. Patients may exchange vouchers for retail goods that are consistent with a lifestyle without cocaine use. This approach facilitates engagement in treatment and systematically aids patients in acquiring substantial periods of cocaine abstinence. The approach is effective in urban and rural areas during outpatient treatment of adults addicted to opioids and with inner city methadone maintenance patients who have high rates of intravenous cocaine abuse.

Common Sleep Disorders

A number of sleep disorders can disrupt sleep quality and result in excessive daytime sleepiness, even if a person spends enough restful time in bed. (See "Common Signs of a Sleep Disorder"). More than 70 sleep disorders affect at least 40 million Americans and account for an estimated $16 billion in medical costs each year, not counting costs due to lost work time and other factors. The four most common sleep disorders are: insomnia; obstructive sleep apnea (sleep-disordered breathing); restless legs syndrome (RLS); and narcolepsy. Additional sleep problems include sleepwalking; sleep paralysis; night terrors; and other "parasomnias" that cause abnormal arousals.

Insomnia

Insomnia happens when a person has trouble falling asleep or staying asleep or has un-refreshing sleep despite having ample oppor­tunity to sleep. Life events occasionally cause insomnia for a short time. Such temporary insomnia is common and occurs simultaneously with stressful situations such as work, family pressures or a traumatic event. A National Sleep Foundation poll of adults in the United States found that close to half of the respondents reported temporary insomnia in the nights immediately having symptoms at least three nights per week for more than one month. Most cases of chronic insomnia are secondary or caused by another disorder or medications. Primary chronic insomnia is a distinct sleep disorder; doctors do not fully understand what brings insomnia about. About 30 to 40 percent of adults have some symptoms of insomnia within any given year and about 10 to 15 percent of adults have chronic insomnia. Chronic insomnia becomes more prevalent with age and women are more likely than men to report having insomnia.
Insomnia often causes problems during the day, such as excessive sleepiness, fatigue, a lack of energy, difficulty concentrating, depressed mood and irritability. Due to all of these potential consequences, untreated insomnia can impair quality of life as much as or more than, other chronic medical problems.
One or more of the following brings on chronic insomnia:
Another disease or mood disorder. The most common causes of insomnia are depression and or anxiety disorders. Neurological disorders such as Alzheimer's or Parkinson's disease may also result in insomnia as a symptom. Chronic insomnia can result from arthritis, asthma or other medical conditions in which symptoms become more troublesome at night, making it difficult to fall asleep or stay asleep.
Various prescribed and over-the-counter medications that can disrupt sleep, such as decongestants, certain pain relievers and steroids.
Sleep-disrupting behavior are: drinking alcohol; exercising shortly before bedtime; ingesting caffeine late in the day; watching TV or reading while in bed or irregular sleep schedules due to shift work or other causes.
Some people, however, have primary chronic insomnia. This condi­tion pertains to a tendency of being more "revved up" than normal (hyper arousal). Some people may have a heightened secretion of certain hormones, higher body temperatures, faster heart rates and a different pattern of brain waves while sleeping.
Doctors diagnose insomnia based mainly on sleep history, often by reviewing a sleep diary. An overnight sleep recording helps with diagnosis. Doctors also will try to diagnose and treat any other underlying medical or psycholog­ical problems as well as identify behaviors that might cause insomnia.
Often, people who have insomnia enter into a vicious sleep cycle. Because of having trouble sleeping in previous nights, insomniacs become anxious at the slightest sign that of not being able to fall asleep right away. This anxiety can make it more difficult to fall asleep. The more time spent in bed not sleeping and watching the clock, the more the anxiety--and sleeplessness--increases.
To break this cycle of anxiety and negative conditioning, experts recommend going to bed only when the insomniac is sleepy. If the person cannot fall asleep (or fall back to sleep) within 20 minutes, doctors recommend getting out of bed and going into another room to pursue a relaxing activity until sleepiness occurs again. Then return to bed. This reconditioning therapy is an effective way to treat insomnia.
Another effective behavioral strategy for some people is relaxation therapy. The technique involves progressively tensing and then relaxing each of the muscle groups in the body before sleep. Another method focuses on breathing deeply. Relaxation therapy can provide the needed slowing down period sleep so that the body and mind are indeed sleepy when bedtime arrives.
Sleep restriction therapy also works for some people who have insomnia. First, limit nightly sleep to four or five hours and then gradually add more sleep time each night until a normal night of sleep occurs. People should avoid daytime naps during this sleep restriction therapy because napping may prolong insomnia by making it harder to fall asleep at night. In addition, during sleep restriction therapy, avoid driving a car or operating dangerous machinery.
All these changes in behavior are part of "cognitive behavioral therapy." Cognitive behavioral therapy replaces negative thinking related to sleep with more realistic, positive thinking. Cognitive behavioral therapy is effective in most people who have chronic insomnia.
Some people who have chronic insomnia not corrected by behavioral therapy or treatment of an underlying condition may need prescription medication. These people should talk to a doctor before trying to treat insomnia with alcohol, over-the-counter or prescribed short-acting sedatives or sedating antihistamines that induce drowsiness. There are limited benefits of these treatments and there are associated risks. Some may help induce sleep but result in an un-refreshed feeling in the morning. Others drugs have longer-lasting effects and result in a tired or groggy feeling in the morning. Some treatments also may lose effectiveness over time. Doctors may prescribe sedat­ing antidepressants for insomnia, but the effectiveness of these medi­cines in people who do not have depression is unknown and there are significant side effects.
To treat insomnia, some people pursue natural remedies, such as melatonin supplements or valerian teas or extracts. These remedies are available over the counter. There is little evidence that melatonin can help relieve insomnia. Studies with valerian have also been inconclusive and the actual dose and purity of various supplements, extracts or teas that contain valerian may vary from product to product. In addition, because the Food and Drug Administration does not regulate melatonin, valerian and other natural remedies, the safety of these treatments is unknown.