The term insomnia refers to a condition where a person has difficulty sleeping. This can occur in a number of different manners, including:
- Problems with initiating sleep or falling asleep
- Waking up at night and not being able to get back to sleep
- Waking up too early in the morning and being unable to get back to sleep
- Significant fatigue, lethargy, and sleepiness after waking up
The Academy of Sleep Medicine has a number of specifications that classify issues with insomnia.
- It occurs in people who do not have some other type of psychological disorder or physical condition. This is referred to as primary insomnia.
- Insomnia resulting from some other condition, such a psychological disorder, some specific medical condition, and/or as a result of medication or drug use is referred to as secondary insomnia.
- Insomnia that continues for at least three nights a week over at least a month in duration is recognized as being chronic insomnia.
- Insomnia that occurs for any less duration less than three times a week is referred to as acute insomnia.
According to Epidemiology of Sleep, a number of risk factors have been identified that increase the probability that individuals may develop issues with insomnia. These risk factors include:
- Age: Older individuals are more likely to display higher rates of insomnia.
- Gender: Women have overall higher prevalence rates of insomnia than men.
- Medical or psychological disorders: Certain medical conditions (e.g., arthritis or chronic pain) and psychological disorders (e.g., major depressive disorder) are associated with higher rates of insomnia than the general population.
- Drug use or abuse: Insomnia is often a side effect of many different medications and of drug abuse, including alcohol abuse.
Insomnia and Alcohol Use Disorders
The relationship between insomnia and alcohol abuse or alcohol use disorder (the current clinical designation for alcohol abuse or alcoholism) is bidirectional. People with sleep disorders are significantly more likely to be diagnosed with any substance use disorder than individuals who do not have sleep disorders. In addition, individuals with mental health disorders are far more likely to have alcohol use disorders than individuals without these conditions.
Likewise, individuals who suffer from alcoholism often experience issues with insomnia as a complication of their alcohol abuse, as alcohol intake disrupts the quality of an individual sleep; alcohol interferes with REM sleep. Individuals who have alcohol use disorders and have attempted to remain abstinent will experience issues with insomnia as a result of the withdrawal process.
Finally, a number of medical conditions, such as chronic back pain, are strongly associated with the development of depression; the development of a substance use disorder; such as alcohol use disorder; or both. Thus, the relationship between insomnia and substance use disorders like alcoholism is very complicated and occurs over a number of different contexts. It is virtually impossible to make a determination regarding any type of causal relationship between alcohol abuse and issues with sleep because these variables are so interconnected. Several important relationships are known:
People who are diagnosed with sleep disorders are also diagnosed with substance use disorders at rates of 5-10 times greater than individuals without sleep disorders. Most often, these substance use disorders are associated with abuse of central nervous system depressants, such as sleeping aids and alcohol.
Individuals diagnosed with depression have significant rates of substance use disorders and issues with sleep; one of the diagnostic criteria for major depressive disorder is difficulty sleeping. It is estimated that at least 30 percent of individuals diagnosed with major depressive disorder also have a co-occurring substance use disorder. The most common substance use disorder in these cases is alcohol use disorder.
Individuals with medical conditions, such as arthritis, chronic back pain, etc., have elevated rates of substance abuse and clinical depression. One study found that over half of individuals with chronic back pain suffer from insomnia compared to only 3 percent of individuals in the sample without chronic back pain.
An early study looking at the relationships between back pain, depression, and substance abuse found that the symptoms of depression and substance abuse preceded the back pain in over 75 percent of the samples in the studies investigated.
Individuals who suffer from alcoholism will experience insomnia as part of the withdrawal symptom associated with recovery and have difficulties with sleep as a result of long-term alcohol use.
Based on these findings, it is important to consider issues that may occur with sleep difficulties, co-occurring psychological disorders, and co-occurring physical issues when someone is being treated for alcohol use disorder.
The Treatment of Co-Occurring Insomnia and Alcoholism
Individuals with moderate to severe alcohol use disorders will often have a number of co-occurring issues like mental health disorders, such as major depressive disorder, and a number of other health issues. Insomnia will be a common symptom of all of these conditions and should be addressed in conjunction with other issues in order for an individual to experience a smoother transition to recovery. Using an integrated treatment approach, where a multidisciplinary team of treatment providers work together at helping the individual reach their goals, would be the preferred approach in such a case.
The outline of the treatment approach would include the following elements:
Assessment: A thorough assessment of the individual that covers multiple levels, including a physical evaluation, a psychological evaluation, and a cognitive evaluation, should take place at the onset of treatment. This evaluation is designed to identify all problem areas as well as strengths and weaknesses that the individual brings with them to the treatment program. The assessment should also attempt to identify any other potential substances of abuse being taken by the person. The evaluation will help to set the overall approach to treatment and outline goals for the individual.
Medical detox: During the assessment process, the individual should be enrolled in a physician-assisted withdrawal management program, also known as medical detox. Managing withdrawal symptoms from alcohol is best accomplished in an inpatient unit where the individual can be monitored closely. Physicians will typically use benzodiazepines to control the symptoms of alcohol withdrawal and add other medications as needed in the specific case. Over time, the benzodiazepine will be slowly tapered down as the individual’s system adjusts to lowered doses of the drug. This will allow the individual to safely withdrawal from alcohol and avoid any potentially serious complications (e.g., seizures or the development of delirium tremens).
Medical care: Medical management of the individual’s symptoms and medical conditions should continue throughout the treatment process. This includes medical management of the symptoms of insomnia when appropriate.
Therapy: At the very beginning of the treatment program, the individual should be enrolled in a formal substance use disorder therapy program that can either consist of individual therapy, group therapy, or both. Substance use disorder therapy will assist the individual in understanding their motivations for abusing alcohol, recognizing triggers that can lead to relapse, and developing a solid foundation for long-term recovery. The treatment will assist the individual in developing the skills necessary to be successful in remaining abstinent from alcohol as well as provide them with resources they can utilize in difficult situations.
Cognitive Behavioral Therapy: Cognitive Behavioral Therapy (CBT) for insomnia can also be implemented. An individual can be put on a sleep hygiene schedule, and the use of CBT techniques can help the individual to relax and sleep more soundly in conjunction with any medical management for insomnia. CBT for insomnia is an appropriate long-term treatment approach for this issue. The use of medications to treat insomnia is suggested as a short-term solution, and these can be used where appropriate. However, many of the medications that are used to treat insomnia are themselves potential drugs of abuse, and individuals who already have existing substance use disorders should not be expected to safely use these without close supervision over time. Thus, the use of therapy to help the individual develop sound sleep habits and to relax is considered to be the long-term solution in most cases.
Social support: Individuals in recovery for alcoholism should become involved in social support groups, such as Alcoholics Anonymous. Meetings can be solid sources of ongoing support for sustained recovery from alcoholism.