Insomnia in patients with addictions: A safer way to break the cycle Fight relapse by improving sleep with nonaddictive agents and behavior therapy ® Dowden Health Media rom alcohol to opioids, most addictive substances can induce sleep disturbances that persist despite Fabstinence and mayCopyright increase theFor risk forpersonal relapse. use only 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 hypnot- BISSELL ics to these patients; a study of 311 addiction medicine physicians found that they prescribed sleep-promoting medication to only 30% of their alcohol-dependent pa- tients with insomnia.1 IMAGES/CHRISTOPHER This article presents evidence on how alcohol and GETTY other substances disturb sleep in patients with addic- 2008 © tions. We discuss the usefulness of hypnotics, off-label sedatives, and cognitive-behavioral therapy (CBT). Our Deirdre Conroy, PhD Clinical assistant professor of psychiatry goal is to help you reduce your patients’ risk of relapse by addressing their sleep complaints. J. Todd Arnedt, PhD Clinical assistant professor of psychiatry and neurology Kirk J. Brower, MD Workup: 3 principles Associate professor of psychiatry Insomnia is multifactorial. Don’t assume that sub- stance abuse is the only cause of prominent insomnia University of Michigan Ann Arbor complaints. Insomnia in patients with substance use dis- orders 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 Current Psychiatry antidepressants and theophylline) Vol. 7, No. 5 97 continued For mass reproduction, content licensing and permissions contact Dowden Health Media. 097_CPSY0508 097 4/16/08 9:50:41 AM Table 1 Sleep disruptions caused by substances of abuse Substance Effect on sleep Nicotine Diffi culty falling asleep, sleep fragmentation, less restful sleep compared with nonsmokers, increased risk for OSA and SDBa-e Marijuana Short-term diffi culty falling asleep and decreased slow-wave sleep percentage Insomnia during withdrawalf-j and addictions Cocaine Prolonged sleep latency, decreased sleep effi ciency, and decreased REM sleep with intranasal self-administration; hypersomnia during withdrawalk-m Other stimulants Sleep complaints similar to those reported with cocaine use disordersn (amphetamine, methamphetamine, methylphenidate) Opioids Decreased slow-wave sleep, increased stage-2 sleep, but minimal impact on o-t Clinical Point sleep continuity; dreams and nightmares; central sleep apnea OSA: obstructive sleep apnea; SDB: sleep-disordered breathing; REM: rapid eye movement Insomnia is a clinical Source: For reference citations, see this article at CurrentPsychiatry.com diagnosis that does not require • inadequate sleep hygiene Sleep logs are useful. Ask patients to keep overnight sleep • dysfunctional beliefs about sleep. a sleep log for 2 weeks during early recov- laboratory studies Nevertheless, assume that substances ery, after acute withdrawal subsides. These are part of the problem, even if not nec- diaries help assess sleep patterns over time, essarily the only cause of insomnia. Sub- document improvement with abstinence, stance-induced sleep problems usually and engage the patient in treatment. The improve with abstinence but may persist National Sleep Foundation can provide ex- because of enduring effects of chronic drug amples (see Related Resources, page 109). exposure on the brain’s sleep centers. Insomnia is a clinical diagnosis that does Alcohol and sleep disturbances not require an overnight sleep laboratory Insomnia is extremely common in active study (polysomnography [PSG]). Diagnose drinkers and in those who are in treatment insomnia when a patient meets DSM-IV- after having stopped drinking. Across 7 TR criteria (has diffi culty falling asleep or studies of 1,577 alcohol-dependent patients staying asleep or feels that sleep is not re- undergoing treatment, more than one-half freshing for at least 1 month; and the sleep reported insomnia symptoms (mean 58%, problem impairs daytime functioning and/ range 36% to 91%),2,3 substantially higher or causes clinically signifi cant distress). In than the rate in the general population addition, consider: (33%). Nicotine, marijuana, cocaine and • PSG if you suspect other sleep disor- other stimulants, and opioids also can dis- ders, particularly obstructive sleep apnea rupt sleep (Table 1). (OSA) and periodic limb movement disor- der (PLMD) Which came first? Sleep problems may • an overnight sleep study for treat- be a pathway by which problematic sub- ment-resistant insomnia, when you have stance use develops. In 1 study, sleep adequately treated other causes. problems reported by mothers in boys A primary sleep disorder—such as OSA, ages 3 to 5 predicted onset of alcohol and restless legs syndrome (RLS), or PLMD— drug use by ages 12 to 14.4 This relation- typically requires referral to a sleep spe- ship was not mediated by attention prob- cialist. For more information about sleep lems, anxiety/depression, or aggression. disorders—including OSA or RLS—see Re- Thus, insomnia may increase the risk for Current Psychiatry 98 May 2008 lated Resources, page 109. early substance use. 098_CPSY0508 098 4/16/08 9:50:50 AM In an epidemiologic study of >10,000 Box 1 adults, the incidence of new alcohol use Stimulus control: 7 steps disorders after 1 year in those without psy- chiatric disorders at baseline was twice as to a better night’s sleep high in persons with persistent insomnia 5 as in those without insomnia. Step 1. Get into bed to go to sleep only Patients with sleep disturbances may use when you are sleepy alcohol to self-medicate,6 and tolerance to alcohol’s sedating effects develops quickly. As patients consume larger quantities with Step 2. Avoid using the bed for activities other than sleep; for example, do not greater frequency to produce sleep, the risk read, watch TV, eat, or worry in bed. for dependence may increase. Sexual activity is the only exception; on these occasions, follow the next steps Comorbid sleep disorders. Alcohol- when you intend to go to sleep dependent patients with diffi culty fall- ing asleep may have abnormal circadian Step 3. If you are unable to fall asleep rhythms, as suggested by delayed onset of Clinical Point within 15 to 20 minutes, get out of bed 7 nocturnal melatonin secretion. They also and go into another room. Remember, Treating insomnia may have low homeostatic sleep drive, an- the goal is to associate your bed with without treating other factor required to promote sleep.8 falling asleep quickly. Return to bed Habitual alcohol consumption before intending to go to sleep only when you addiction may are very sleepy bedtime (1 to 3 standard drinks) is associ- improve sleep ated with mild sleep-disordered breathing but worsen addiction (SDB) in men but not in women.9 SDB also Step 4. While out of bed during the may be more prevalent in alcohol-depen- night, engage in activities that are quiet dent men age >60.10 but of interest to you. Do not exercise, eat, smoke, or take warm showers or Consuming >2 drinks/day has been as- baths. Do not lie down or fall asleep sociated with restless legs and increased when not in bed periodic limb movements during sleep. Twice as many women reporting high alcohol use were diagnosed with PLMD, Step 5. If you return to bed and still compared with women reporting normal cannot fall asleep within 15 to 20 alcohol consumption.10-11 Recovering alco- minutes, repeat Step 3. Do this as often as necessary throughout the night hol-dependent patients have signifi cantly more periodic limb movements associated with arousals (PLMA) from sleep than Step 6. Set your alarm and get up controls. Moreover, PLMA can predict at the same time every morning, 80% of abstainers and 44% of relapsers af- regardless of how much sleep you got ter 6 months of abstinence.12 during the night. This will help your body acquire a sleep-wake rhythm Multifaceted treatment Step 7. Do not nap during the day A thorough history is essential to evaluate sleep and guide treatment decisions. Refer Source. Adapted from Bootzin R, Nicassio P. Behavioral patients to an accredited sleep disorders treatments for insomnia. In: Hersen M, Eissler R, Miller P, eds. Progress in behavior modifi cation, vol. 6. New York, NY: center if their history shows: Academic Press; 1978:30 • loud snoring • cessation of breathing can be effective for short-term insomnia. • frequent kicking during sleep Keep in mind, however, that treating in- • excessive daytime sleepiness. somnia without addiction treatment may improve sleep but worsen addiction. Tai- Short-term insomnia. Judicious use of lor medications’ pharmacokinetic charac- Current Psychiatry medications with appropriate follow-up teristics to patients’ sleep complaints. For Vol. 7, No. 5 99 099_CPSY0508 099 4/17/08 11:52:09 AM Box 2 Cognitive-behavioral therapy for insomnia (CBT-I): 4 components Stimulus control (SC). Patients with that may help or hinder sleep. Patients chronic insomnia may watch television, with addiction may benefi t from learning talk on the telephone, or worry about not how drug use and withdrawal affects sleeping while lying in bed. The goal of SC sleep or how substance use for sleep Insomnia is to alter this association by reestablishing may exacerbate sleep problems. Other and addictions the bed and bedroom with the pleasant SH recommendations include avoiding experience of falling asleep and staying caffeine, nicotine, and exercise in close asleep.13 Instructions for SC (Box 1, page proximity to bedtime. 99) are commonly provided with sleep Cognitive therapy. Goals are to: restriction. • identify and explore dysfunctional Sleep restriction (SR) addresses the beliefs that cause patients anxiety excessive time that patients with insomnia about sleep problems spend in bed not sleeping.