From alcohol to opioids, most addictive substances can induce sleep disturbances that persist despite abstinence and may increase the risk for relapse. Nearly all FDA-approved hypnotics are Schedule IV controlled substances that although safe and effective for most populations - are prone to abuse by patients with substance use disorders.
You’re not alone if you hesitate to prescribe hypnotics to these patients; a study of 311 addiction medicine physicians found that they prescribed sleep-promoting medication to only 30% of their alcohol-dependent patients with insomnia.
This article presents evidence on how alcohol and other substances disturb sleep in patients with addictions. We discuss the usefulness of hypnotics, off-label sedatives, and cognitive-behavioral therapy (CBT). Our goal is to help you reduce your patients’ risk of relapse by addressing their sleep complaints.
Insomnia is multifactorial. Don’t assume that substance abuse is the only cause of prominent insomnia complaints. Insomnia in patients with substance use disorders may be a manifestation of protracted withdrawal or a primary sleep disorder. Evaluate your patient’s:
- other illnesses (psychiatric, medical, and other sleep disorders)
- sleep-impairing medications (such as activating antidepressants and theophylline)
- inadequate sleep hygiene
- dysfunctional beliefs about sleep.
Nevertheless, assume that substances are part of the problem, even if not necessarily the only cause of insomnia. Substance-induced sleep problems usually improve with abstinence but may persist because of enduring effects of chronic drug exposure on the brain’s sleep centers.
Insomnia is a clinical diagnosis that does not require an overnight sleep laboratory study (polysomnography [PSG]). Diagnose insomnia when a patient meets DSM-IV-TR criteria (has difficulty falling asleep or staying asleep or feels that sleep is not refreshing for at least 1 month; and the sleep problem impairs daytime functioning and/or causes clinically significant distress). In addition, consider:
- PSG if you suspect other sleep disorders, particularly obstructive sleep apnea (OSA) and periodic limb movement disorder (PLMD)
- an overnight sleep study for treatment-resistant insomnia, when you have adequately treated other causes.
A primary sleep disorder - such as OSA, restless legs syndrome (RLS), or PLMD - typically requires referral to a sleep specialist.
Sleep logs are useful. Ask patients to keep a sleep log for 2 weeks during early recovery, after acute withdrawal subsides. These diaries help assess sleep patterns over time, document improvement with abstinence, and engage the patient in treatment.
Alcohol and sleep disturbances
Insomnia is extremely common in active drinkers and in those who are in treatment after having stopped drinking. Across 7 studies of 1,577 alcohol-dependent patients undergoing treatment, more than one-half reported insomnia symptoms (mean 58%, range 36% to 91%) substantially higher than the rate in the general population (33%). Nicotine, marijuana, cocaine and other stimulants, and opioids also can disrupt sleep .
Which came first? Sleep problems may be a pathway by which problematic substance use develops. In 1 study, sleep problems reported by mothers in boys ages 3 to 5 predicted onset of alcohol and drug use by ages 12 to 14. This relationship was not mediated by attention problems, anxiety/depression, or aggression. Thus, insomnia may increase the risk for early substance use.
In an epidemiologic study of >10,000 adults, the incidence of new alcohol use disorders after 1 year in those without psychiatric disorders at baseline was twice as high in persons with persistent insomnia as in those without insomnia.
Patients with sleep disturbances may use alcohol to self-medicate, and tolerance to alcohol’s sedating effects develops quickly. As patients consume larger quantities with greater frequency to produce sleep, the risk for dependence may increase.
Comorbid sleep disorders. Alcohol-dependent patients with difficulty falling asleep may have abnormal circadian rhythms, as suggested by delayed onset of nocturnal melatonin secretion. They also may have low homeostatic sleep drive, another factor required to promote sleep.
Habitual alcohol consumption before bedtime (1 to 3 standard drinks) is associated with mild sleep-disordered breathing (SDB) in men but not in women. SDB also may be more prevalent in alcohol-dependent men age >60.
Consuming >2 drinks/day has been associated with restless legs and increased periodic limb movements during sleep. Twice as many women reporting high alcohol use were diagnosed with PLMD, compared with women reporting normal alcohol consumption. Recovering alcohol-dependent patients have significantly more periodic limb movements associated with arousals (PLMA) from sleep than controls. Moreover, PLMA can predict 80% of abstainers and 44% of relapsers after 6 months of abstinence.
Sleep disruptions caused by substances of abuse
Nicotine
Difficulty falling asleep, sleep fragmentation, less restful sleep compared with nonsmokers, increased risk for OSA and SDB
Marijuana
Short-term difficulty falling asleep and decreased slow-wave sleep percentage during withdrawal
Cocaine
Prolonged sleep latency, decreased sleep efficiency, and decreased REM sleep with intranasal self-administration; hypersomnia during withdrawal
Other stimulants (amphetamine, methamphetamine, methylphenidate)
Sleep complaints similar to those reported with cocaine use disorders
Opioids
Decreased slow-wave sleep, increased stage-2 sleep, but minimal impact on sleep continuity; dreams and nightmares; central sleep apnea
OSA: obstructive sleep apnea; SDB: sleep-disordered breathing; REM: rapid eye movement
Multifaceted treatment
A thorough history is essential to evaluate sleep and guide treatment decisions. Refer patients to an accredited sleep disorders center if their history shows:
- loud snoring
- cessation of breathing
- frequent kicking during sleep
- excessive daytime sleepiness.
Short-term insomnia. Judicious use of medications with appropriate follow-up can be effective for short-term insomnia. Keep in mind, however, that treating insomnia without addiction treatment may improve sleep but worsen addiction. Tailor medications’ pharmacokinetic characteristics to patients’ sleep complaints. For example, a medication with rapid onset may be indicated for sleep-onset insomnia but not for sleep-maintenance insomnia.
Chronic insomnia. Patients who report chronic insomnia and behaviors incompatible with sleep may be good candidates for cognitive-behavioral therapy for insomnia (CBT-I). Patient education can change maladaptive behaviors, such as staying in bed for long periods of time to compensate for sleep loss, using the bed for activities other than sleep, or worrying excessively about sleep.
Pharmacotherapy may be preferred:
- for patients with unstable physical or mental illness
- when CBT-I could exacerbate a comorbid condition (such as restricting sleep in a patient with bipolar disorder)
- for patients with low motivation for behavior change
- when trained CBT-I providers or resources to pay for CBT-I are limited.
Patient preferences are critical to successful insomnia treatment. Some cannot or will not make the commitment required for CBT-I, and some do not wish to use medications. Combining medication and CBT-I to capitalize on medications’ immediate relief and CBT-I’s durability may be effective for patients who do not respond to either approach alone.
Stimulus control: 7 steps to a better night’s sleep
Step 1. Get into bed to go to sleep only when you are sleepy
Step 2. Avoid using the bed for activities other than sleep; for example, do not read, watch TV, eat, or worry in bed. Sexual activity is the only exception; on these occasions, follow the next steps when you intend to go to sleep
Step 3. If you are unable to fall asleep within 15 to 20 minutes, get out of bed and go into another room. Remember, the goal is to associate your bed with falling asleep quickly. Return to bed intending to go to sleep only when you are very sleepy
Step 4. While out of bed during the night, engage in activities that are quiet but of interest to you. Do not exercise, eat, smoke, or take warm showers or baths. Do not lie down or fall asleep when not in bed
Step 5. If you return to bed and still cannot fall asleep within 15 to 20 minutes, repeat Step 3. Do this as often as necessary throughout the night
Step 6. Set your alarm and get up at the same time every morning, regardless of how much sleep you got during the night. This will help your body acquire a sleep-wake rhythm
Step 7. Do not nap during the day
Source. Adapted from Bootzin R, Nicassio P. Behavioral treatments for insomnia. In: Hersen M, Eissler R, Miller P, eds. Progress in behavior modification, vol. 6. New York, NY: Academic Press; 1978:30
Deirdre Conroy, PhD;
Clinical assistant professor of psychiatry, University of Michigan, Ann Arbor
J. Todd Arnedt, PhD;
Clinical assistant professor of psychiatry and neurology, University of Michigan, Ann Arbor
Kirk J. Brower, MD
Associate professor of psychiatry, University of Michigan, Ann Arbor
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