Insomnia in Patients with Addictions: A Safer Way to Break the Cycle; Fight Relapse by Improving Sleep with Nonaddictive Agents and Behavior Therapy

Article excerpt

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.

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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, page 109.

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, page 109).

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. …