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Evidence-Based Reviews


Insomnia in patients with addictions: A safer way to break the cycle

Fight relapse by improving sleep with nonaddictive agents and behavior therapy.

Vol. 7, No. 5 / May 2008

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.1

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.

Workup: 3 principles

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. For more information about sleep disorders—including OSA or RLS—see Related Resources.

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. The National Sleep Foundation can provide examples (see Related Resources).

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%),2,3 substantially higher than the rate in the general population (33%). Nicotine, marijuana, cocaine and other stimulants, and opioids also can disrupt sleep (Table 1).

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 14.4 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.5

Patients with sleep disturbances may use alcohol to self-medicate,6 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.7 They also may have low homeostatic sleep drive, another factor required to promote sleep.8

Habitual alcohol consumption before bedtime (1 to 3 standard drinks) is associated with mild sleep-disordered breathing (SDB) in men but not in women.9 SDB also may be more prevalent in alcohol-dependent men age >60.10

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.10-11 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.12

Table 1

Sleep disruptions caused by substances of abuse

Substance

Effect on sleep

Nicotine

Difficulty falling asleep, sleep fragmentation, less restful sleep compared with nonsmokers, increased risk for OSA and SDBa-e

Marijuana

Short-term difficulty falling asleep and decreased slow-wave sleep percentage during withdrawalf-j

Cocaine

Prolonged sleep latency, decreased sleep efficiency, and decreased REM sleep with intranasal self-administration; hypersomnia during withdrawalk-m

Other stimulants (amphetamine, methamphetamine, methylphenidate)

Sleep complaints similar to those reported with cocaine use disordersn

Opioids

Decreased slow-wave sleep, increased stage-2 sleep, but minimal impact on sleep continuity; dreams and nightmares; central sleep apneao-t

OSA: obstructive sleep apnea; SDB: sleep-disordered breathing; REM: rapid eye movement

Reference Citations: click here

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 (Box 1).13

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.

Box 1

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: Academic Press; 1978:30

CBT-I is effective for primary insomnia and insomnia associated with medical conditions. Using sleep restriction, stimulus control, sleep hygiene, and cognitive therapy, it addresses maladaptive sleep behaviors and counters dysfunctional beliefs about sleep (Box 2).13,14

In older adults with insomnia but no history of addiction, CBT-I was more effective than placebo and as effective as a hypnotic alone (temazepam, 7.5 and 30 mg qhs) and a hypnotic/CBT-I combination in reducing nighttime wakefulness, increasing total sleep time, and increasing sleep efficiency. After 2 years, patients treated with CBT-I alone were most likely to maintain these initial treatment gains.15

Limited data exist on CBT-I’s effectiveness in patients with addiction. In 2 studies, alcohol-dependent patients reported improved sleep.16,17 CBT-I also improved measures of anxiety and depression, fatigue, and some quality-of-life items.16

Box 2

Cognitive-behavioral therapy for insomnia (CBT-I): 4 components

Stimulus control (SC). Patients with chronic insomnia may watch television, talk on the telephone, or worry about not sleeping while lying in bed. The goal of SC is to alter this association by reestablishing the bed and bedroom with the pleasant experience of falling asleep and staying asleep.13 Instructions for SC (Box 1) are commonly provided with sleep restriction.

Sleep restriction (SR) addresses the excessive time that patients with insomnia spend in bed not sleeping. SR temporarily restricts time spent in bed and prohibits sleep at other times. The resulting mild sleep deprivation may promote consolidated sleep, leading to improved patient-reported sleep quality.14

Sleep hygiene (SH) addresses behaviors that may help or hinder sleep. Patients with addiction may benefit from learning how drug use and withdrawal affects sleep or how substance use for sleep may exacerbate sleep problems. Other SH recommendations include avoiding caffeine, nicotine, and exercise in close proximity to bedtime.

Cognitive therapy. Goals are to:

  • identify and explore dysfunctional beliefs that cause patients anxiety about sleep problems
  • replace these beliefs with more appropriate self-statements that promote sleep-healthy behaviors.

Common themes address patients’ unrealistic sleep expectations, inability to control or predict sleep, and faulty beliefs about sleep-promoting practices.

Precautions about hypnotics. The newer alpha-1-selective benzodiazepine receptor agonists (zolpidem, zaleplon, and eszopiclone) and the older nonselective benzodiazepines (such as flurazepam, temazepam, and triazolam) share an equivalent range of abuse liability.18 Consequently, all benzodiazepine receptor agonists are classified as Schedule IV controlled substances and should be used with caution, if at all, in substance-abusing or substance-dependent patients (Table 2).

In general, most physicians who specialize in treating addictions would not recommend these drug classes as first choice in postwithdrawal, substance-dependent patients complaining of chronic insomnia. Nevertheless, you are likely to encounter patients with a history of substance abuse/dependence who are taking legally prescribed benzodiazepine receptor agonists for insomnia, and they may be very reluctant to discontinue these medications.

Weigh and discuss with the patient the risks and benefits of taking vs discontinuing the hypnotic, as well as alternatives. Because chronic hypnotic use may interfere with addiction recovery, it is important to discuss the patient’s recovery plan.

If you decide to prescribe a hypnotic with abuse liability, the newer alpha-1-selective benzodiazepine receptor agonists are preferable—as they would be for non-addicted patients—because they are less likely to disrupt sleep architecture. They are also less likely than the long-acting benzodiazepines (such as flurazepam) to accumulate over time and result in daytime impairment.

Patient contracts. A written agreement can be useful whenever you prescribe a controlled substance for a patient with an addiction history. Include these issues:

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