<p> Sleep Problems and Alcohol Use Disorders</p><p>Fauzia Mahr, MD (Slide 1)</p><p>Dept. of Psychiatry</p><p>Penn State Milton S. Hershey Medical center</p><p>Alcohol Medical Scholars Program</p><p>I. Introduction</p><p>A. Scope of Problem ( Slides 2 & 3)</p><p>1. 10% Population: chronic insomnia²⁰ </p><p>2. 30% Population: temp. sleep disruption²⁰</p><p>3. Costs > US $100 billion¹⁵</p><p>4. Alcohol related insomnia= $18.5 billion¹´¹¹</p><p> a. 7% US population→Alc. Abuse²⁶</p><p> b. 10%US population→Alc. Dependence²⁶</p><p>B. Consequences of insomnia¹´¹⁵ (Slide 4)</p><p>1. Decreased function</p><p> a. 2.5  Motor vehicle accidents</p><p> b.  Quality of life</p><p> c.  Job Satisfaction/productivity</p><p>2. Other (Slide 5)</p><p> a.  Risk depressive/anxiety symptoms</p><p> b.  Natural killer cell activity</p><p> i.  Immunity</p><p> ii.  Infections</p><p>1 3. Sleep and substances (Slide 6)</p><p> a. Alcohol, cocaine, caffeine  poor sleep</p><p> b. Poor sleep  risk substance use disorders (SUD’s)²</p><p> c. Most common causes insomnia</p><p> d. Alcohol + sleep = most studied</p><p>C. This lecture Covers: (Slide 7)</p><p>1. Definitions: Sleep</p><p>2. Definitions: Substances</p><p>3. Effects of alcohol on sleep</p><p>4. Treatment of alcohol related insomnia</p><p>II. Definitions: Sleep</p><p>A. Normal sleep¹⁸ (Slides 8&9)</p><p>1. Reversible unresponsiveness to environment</p><p>2. Needed for restoration</p><p>3. Two Stages:</p><p> a. Non- rapid eye movement (NREM)</p><p> b. Rapid eye movement (REM)</p><p>B. NREM Sleep⁹´¹⁸ (Slides 10 & 11)</p><p>1. First ½ of night</p><p>2. 4 stages on EEG</p><p> a. Stage 1 (Transitional)</p><p> i. 1-7 minutes</p><p> ii. Easily arousable</p><p>2 iii. Muscle tone, activity present</p><p> iv. Occurs throughout night</p><p> b. Stage 2 (Sleep spindles, K complexes)</p><p> i. 25 minutes</p><p> ii. Depth of sleep correlates with K complex pattern</p><p> iii.  Age, disruption of pattern</p><p> c. Stage 1 & 2= easy arousal</p><p> d. Stage 3 and 4 =slow wave=deep sleep</p><p>3.  Nor epinephrine/serotonin</p><p>C. REM Sleep¹⁸´²⁰ (Slide 12)</p><p>1.  2nd ½ Night</p><p>2. Dreaming, limb paralysis</p><p>3.  Acetylcholine</p><p>4.  Dopamine, nor epinephrine, epinephrine</p><p>5.  With age</p><p>D. Latency¹⁸ (Slide 13)</p><p>1. Sleep latency</p><p> a. Time to fall asleep</p><p> b. 10-20 mins.</p><p>2. REM latency¹⁹</p><p> a. Time from sleep onset  REM</p><p> b. 90-100 min.</p><p>E. Normal Sleep Cycle¹⁸ </p><p>3 1.  8 hrs.</p><p>2. NREM/REM cycle</p><p>3. Circadian rhythm →approx. 24 hr sleep cycle</p><p>4. Cycle repeats</p><p> a. 90-120 mins</p><p> b. 3-4 X per night</p><p> c. NREM 3X REM</p><p>F. Insomnia¹⁸ (Slide 14)</p><p>1. Problem initiating sleep</p><p>2. Problem maintaining sleep</p><p>3. Non-restful sleep</p><p>4. Early morning wakening</p><p>G. DSM IV Insomnia¹⁸ (Slide 15)</p><p>1. Problem maintaining/initiating sleep 1 + month</p><p>2.  Function</p><p>3. Prob. not due to other condition</p><p>H. This lecture covers: (Slide 16)</p><p>1. Definitions: Sleep</p><p>2. Definitions: Substances</p><p>3. Effects of alcohol on sleep</p><p>4. Treatment of alcohol related insomnia</p><p>III. Definitions: Substances (Slides 17&18)</p><p>A. Categories²⁶ → based on CNS effects at usual doses</p><p>4 1. Depressants → Depression of brain tissues </p><p> a. Alcohol, benzodiazepines, barbiturates¹⁸</p><p> b.  Sleep with intoxication</p><p> c.  Sleep with withdrawal</p><p>2. Stimulants¹⁸→ Stimulation of brain tissues</p><p> a. Amphetamines, cocaine, caffeine</p><p> b.  Sleep with intoxication</p><p> c.  Sleep with withdrawal</p><p>3. Opioids</p><p> a. Morphine, methadone, oxycodone etc.</p><p> b. ↓Pain, cough , diarrhea</p><p>4. Cannabinols</p><p> a. Marijuana, hashish</p><p> b. Euphoria, altered time sense, hallucinations</p><p>5. Hallucinogens</p><p> a. Ketamine, Phencyclidine (PCP)</p><p> b. ↑Sensory perceptions</p><p> c. Hallucinations at higher doses</p><p>6. Inhalanats</p><p> a. Glues, solvents,aerosols</p><p> b. Alter state of consciousness</p><p> c. Produce lightheadedness & confusion</p><p>5 B. Alcohol (Slide 19 )</p><p>1. Acute and chronic use disrupts sleep</p><p>2. 50% alcoholics use to fall asleep</p><p>3. Alcohol use as self medication 2X gen. pop. ⁶</p><p>C. Alcohol Abuse: (1+ in same 12 mos.) (Slide 20)</p><p>1.  Fulfillment role obligations</p><p>2. Use in hazardous situations</p><p>3. Legal problems</p><p>4. Social, interpersonal problems</p><p>5. Never dependent</p><p>D. Alcohol Dependence: (3+ in same 12 mos.) (Slide 20)</p><p>1. Tolerance ( amt for  effect)</p><p>2. Withdrawal</p><p>3. Use more or longer than planned</p><p>4. Desire +inability to cut down</p><p>5.  Other activities</p><p>6. Ongoing use despite consequences</p><p>E. Alcohol Withdrawal (2+) (Slide 20)</p><p>1.  Autonomic activity (sweating, pulse rate)</p><p>2. Tremor</p><p>3. Insomnia</p><p>4. Nausea/vomiting</p><p>5. Hallucinations/illusions</p><p>6 6. Agitations</p><p>7. Anxiety</p><p>8. Seizures</p><p>9. Related to  alcohol after chronic use</p><p>F. This Lecture Covers; (Slide 21)</p><p>1. Definitions: Sleep</p><p>2. Definitions: Substances</p><p>3. Effects of alcohol on sleep</p><p>4. Treatment of alcohol related sleep problems</p><p>IV. Effects of alcohol on sleep</p><p>A. Alcohol related insomnia⁴´⁶ (Slide 22)</p><p>1. Insomnia in alcoholics 2X gen.pop.</p><p>2. Prevalence:</p><p> a.  Age</p><p> b.  Severity of alcoholism</p><p> c. 7+ years heavy drinking⁴</p><p>B. Acute Use and Sleep⁵´⁷´¹⁸ (Slides 23&24)</p><p>1. 1st ½ Night</p><p> a.  Sleep latency</p><p> b.  REM</p><p> c.  Other sleep stages</p><p>2. 2nd ½ Night</p><p> a.  Sleep quantity</p><p>7 b.  Awakenings</p><p> c.  REM</p><p>C. Chronic Use and Sleep </p><p>1.  Effect/drink</p><p>2.  Sleep latency</p><p>D. How Alcohol Disrupts Sleep¹³´⁴´⁵ (Slides 25&26)</p><p>1. Affects hypothalamic-pituitary-adrenal axis (HPA axis)</p><p>2.  Corticotropin Releasing Factors (CRF)</p><p>3.  CRF  cortisol sleepiness</p><p>4. As alcohol eliminated, HPA rebound</p><p>5. HPA rebound  Sleep disturbance</p><p>E. Alcohol and Insomnia¹´¹⁵ </p><p>1. 10% Alcohol related costs 2 insomnia</p><p>2. Both present= Risk depression/anxiety</p><p> a. Repeated intoxicationdepression²⁶</p><p> b. Withdrawal temporary anxiety</p><p>3. Both present= Memory dysfunction</p><p> a. Reversible with abstinence²⁶</p><p>4. Both present=2X mortality²¹</p><p>F. Alcohol and Sleep Apnea¹ (Slide 27)</p><p>1. Acute alcohol sedative   inspiratory resistance</p><p>2.  Risk sleep apnea</p><p> a. 2X Sleep latency</p><p>8 b. 20% Less sleep</p><p> c. 2X Premature Death in elderly</p><p>G. Alcoholism +REM changes  predict relapse²⁷ </p><p>1.  REM %</p><p>2.  REM density</p><p>3.  REM latency</p><p>H. This lecture covers (Slide 28)</p><p>1. Definitions: Sleep</p><p>2. Definitions: Substances</p><p>3. Effects of alcohol on sleep</p><p>4. Treatment</p><p>V. Treatment¹⁰´¹¹´¹²´¹⁴´²⁶ </p><p>A. Guidelines (Slide 29)</p><p>1. Assessment & treatment of Alcohol as cause</p><p>2. Education</p><p>3. Behavior therapies</p><p>4. Rhythm restoring treatments</p><p>5. Medication</p><p>B. Insomnia treatment begins with alcohol treatment (Slide 30)</p><p>1. Identify alcohol as cause</p><p> a. Obtain accurate history</p><p>9 b. Alcohol Use Disorders Identification Test (AUDIT)</p><p> i.  Reliable</p><p> ii. 10 Item instrument</p><p> iii. 4 Point scale</p><p>1'. ’Frequency of drinks</p><p>2'. ’# of drinks</p><p>3'. ’Frequency of heavy intake</p><p>4'. ’Inability to stop drinking</p><p>5'. ’Failure to meet obligations</p><p>6'. ’Frequency of AM drinking</p><p>7'. ’Frequency of feelings of guilt</p><p>8'. ’Frequency of blackouts</p><p>9'. ’Injury to self or others</p><p>10'. ’Concern of others about drinking </p><p> c. CAGE questionnaire</p><p> i. 4 Item questionnaire</p><p>1'. ’Tried to “cut down”</p><p>2'. ’Feel “annoyed” others with drinking</p><p>3'. ’Felt “guilty” about drinking</p><p>4'. ’Taken an “eye opener” in AM</p><p>2. Detoxification if necessary (Slide 31) </p><p> a. Physical exam & Lab tests</p><p> i. EKG</p><p>10 1'. ’Look for Arrythmias</p><p> ii. Gamma glutamyl transferase ( GGT)</p><p>1'. ’Normal = < 35 </p><p> iii. Carbohydrate deficient transferrin ( CDT)</p><p>1'.  20 g/l Heavy drinking </p><p> b. Vitamins</p><p> i. Thiamine</p><p> ii. Multivitamins</p><p> c. Reassurance</p><p> d. Benzodiazepines ( BZDs)</p><p>3. Rehabilitation (Slide 31)</p><p> a.  Motivation</p><p> i. Involve & educate family members</p><p> ii. Help patient own responsibility </p><p> b. Help readjust to life</p><p> i. Individual therapy</p><p> ii. Group /Family therapy</p><p> iii. Self help groups</p><p>1'. ’Alcoholics anonymous ( AA )</p><p> c. Relapse prevention</p><p> d. ± Meds</p><p> i. Naltrexone ( Revia or Trexan)</p><p> ii. Acomprosate ( Campral)</p><p>11 iii. Disulfuram (Antabuse)</p><p> iv. Selective serotonin reuptake inhibitors (SSRIs)</p><p> v. Buspirone (Buspar)</p><p>C. Education²⁶ (Slide 32) </p><p>1. Sleep problems response to use of Alcohol</p><p>2. Can persist 6 mo. or </p><p>3. Sleeping pills may worsen problem</p><p>4. Body must adjust to Ø Alcohol</p><p>D. Assessment </p><p>1. Self Report Instruments</p><p> a. Pittsburg Sleep Quality Index¹⁹ (Slide 33) </p><p> i. Sleep problems 1 mo. +</p><p> ii. 19 items</p><p>1'. ’Subjective sleep quality</p><p>2'. ’Sleep latency</p><p>3'. ’Sleep duration</p><p>4'. ’Habitual Sleep efficiency</p><p>5'. ’Sleep disturbance</p><p>6'. ’Use of sleeping medication</p><p>7'. ’Daytime dysfunction</p><p> iii. Scores 0-21</p><p> b. Sleep Diary (Slides 34&35)</p><p>12 i. Daily X 2wks.</p><p> ii. Determines sleep continuity¹⁵</p><p>1'. ’Time to bed</p><p>2'. ’Time to wake</p><p>3'. ’Minutes to fall asleep</p><p>4'. ’# + Duration wakings</p><p>5'. ’Final awakening</p><p>6'. ’Minutes awake in bed</p><p>2. Other Factors¹⁴´¹⁵´¹⁸ (Slide 36)</p><p> a. Sleep hygiene</p><p> i. Same bedtime</p><p> ii. Same wake time</p><p> iii. Use bed for sleep</p><p> iv. No strenuous exercise after 6 PM</p><p> b. Environment¹⁵´¹⁸ </p><p> i. Dark, quiet, same room</p><p> ii. Comfortable temp.</p><p> iii. Good ventilation</p><p> iv. Turn clock away</p><p>3. Assess/treat other medical causes¹⁵´²³ </p><p> a. Depression</p><p> i. Early AM awakenings</p><p>13 ii. Non-restorative sleep</p><p> b. Anxiety</p><p> i. Multiple awakenings during night</p><p> c. Bipolar d/o</p><p> i.  Need for sleep</p><p>E. Behavioral Treatment¹⁴´¹⁵</p><p>1. Stimulus Control therapy </p><p> a. 1st Line behavioral tx.</p><p> b. Limit awake time in bed (15 min.)</p><p> c. Limit activity before bed</p><p> d. Make bed a sleep cue</p><p> i. Same wake time</p><p> ii. Same room</p><p> iii. Bed for sleep only</p><p>2. Cognitive Behavioral Therapy for Insomnia (CBT-I)¹⁴´¹⁵ </p><p> a. Time limited, manualized (Slide 37)</p><p> b. Targets cognitive distortions</p><p> i. Neg thoughts re insomnia</p><p>1'. ’Hopelessness</p><p>2'. ’Catastrophic thinking</p><p>3'. ’Loss of control</p><p> ii. Neg beliefs re results insomnia</p><p>14 1'. ’Irreversibility of insomnia</p><p>2'. ’Should be challenged</p><p> c.  Anxiety, arousal</p><p> d.  Increases sleep</p><p>3. Sleep Restriction Technique </p><p> a. Fixed wake time</p><p> b. Daily sleep diaries</p><p> c. Sleep window =total sleep time +30 minutes</p><p> d. Adjust window</p><p> i. > 85% efficiency=no change</p><p> ii. <85% efficiency= 15 minutes</p><p> iii. >90%efficiency= 15 minutes</p><p>4. Relaxation Training (Slide 38)</p><p> a.  Physical, emotional arousal</p><p> b. Collaborate with patient on method</p><p> i. Progressive muscle relaxation</p><p> ii. Diaphragmatic breathing</p><p> iii. Biofeedback</p><p> iv. Meditation</p><p>F. Pharmacologic Treatment¹⁰´¹²´¹⁸</p><p>1. Melatonin¹⁸ (Slide 39)</p><p> a. Secreted by pineal gland</p><p> b. Regulates circadian rhythm</p><p>15 c. Regulated by light stimulus</p><p> d.  In alcoholism¹¹</p><p> e. Dose=6 mg nightly</p><p>2. BZDs (Slide 40)</p><p> a. Valium (Diazepam), alprazolam (Xanax), Lorazepam </p><p>(Ativan)</p><p> b.  GABA (sedating)</p><p> c. Sim. Effect to alcohol  sim. Abuse/dependence</p><p> d. Avoid if possible</p><p> e. Discourage daily use</p><p>3. Hypnotics (Slide 41)</p><p> a. Zaleplon (Sonata) ~ 10 mg b. Zolpidem (Ambien) ~ 10 mg c. Eszopiclone (Lunesta) ~ 1 mg</p><p>4. Other </p><p> a. Antidepressants</p><p> i. Trazodone (Desyrel)</p><p> ii. Amitriptyline(Elavil)</p><p> b. Antipsychotics (Off label use)</p><p> i. Olanzapine (Zyprexa)</p><p> ii. Quetiapine (Seroquel)</p><p> c. Anticonvulsants (Off label use)</p><p> i. 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