Narcolepsy & Substance Abuse

Symptoms of Narcolepsy

People with narcolepsy experience issues with daytime and nighttime sleeping that are associated with disturbances in REM sleep (rapid eye movement). The most common symptoms of narcolepsy include:

• Excessive daytime sleepiness (EDS): Individuals with narcolepsy experience daytime sleepiness in excess of what would be described as just being tired or fatigued. This is often is accompanied by issues with concentration, issues with memory, severe fatigue or lack of energy, extreme exhaustion, and depression. They may experience involuntary sleep episodes, which are periods of very brief sleeps (usually no more than a few seconds). During these involuntary episodes of sleep, nearly half of the people who suffer from them continue to engage in habitual activities, such as typing, writing, walking, and even driving. These individuals are alerted to these short periods of sleep by the results of their behavior during these involuntary sleep episodes, such as short periods of illegible scribble during handwriting, going off the road during driving, etc.
• Cataplexy: Sometimes referred to as “drop attacks” when they are severe, cataplexy involves a sudden loss of muscle tone while the person is awake, leading to some periods of weakness and/or a temporary loss of voluntary muscle control. Severe cataplexy results in a complete loss of muscle tone in all voluntary muscles, leading to a total physical collapse where individuals are unable to speak, move, or even keep their eyes open (drop attacks). Typically, individuals are still conscious during these episodes. These episodes are often misdiagnosed as seizures. Cataplexy appears to be associated with the activity of neurons in the brainstem that, when activated, are responsible for inhibiting any muscle movement during REM sleep. In animal models, it appears that these neurons become activated during cataplexy contacts.
• Disrupted sleep at night: People with narcolepsy often have difficulty staying asleep at night. These difficulties may include waking up and being unable to go to sleep (middle insomnia or terminal insomnia), vivid dreams that result in the person acting out the aspects of dreams, talking during the sleep, and/or involuntary movements of the legs that wake them up.
• Sleep paralysis: This is the sensation of total paralysis that some individuals experience when they are slowly drifting off into sleep or waking up, but still conscious. Some people who experience sleep paralysis also experience hypnagogic hallucinations (hallucinations that occur as one is falling asleep) or hynopompic hallucinations that occur when they slowly begin to wake up. Most often, the hallucinations are primarily visual in nature and can be quite disturbing to individuals who experience them.

It is not unusual for individuals with narcolepsy to experience weight gain once the disorder develops.

Causes of Narcolepsy

The prevalence of narcolepsy is relatively low, about one in 2,000. There are no identified causes of narcolepsy. Several different associations have been drawn between narcolepsy and low levels of a neurotransmitter known as orexin or hypocretin, which may be involved in wakefulness.

Some genetic associations have been made; however, it appears that the majority of cases of narcolepsy have little or no family history, which would suggest that genetic associations do not play a major role in the development of these cases. There have been cases where brain injuries have resulted in the development of narcolepsy in some individuals; however, most cases of narcolepsy do not have a history of traumatic brain injury.

Diagnosing Narcolepsy

Narcolepsy can only be diagnosed by a physician. None of the above major symptoms are diagnostic of narcolepsy, although cataplexy is often used to diagnose narcolepsy or at least to warrant further investigation. Typically, the diagnostic process consists of:

• A full physical examination
• A polysomnogram, which is a test done while the individual is asleep: The test records numerous physiological functions, such as brain activity, nerve activity in the muscles, heart rate, respiratory rate, etc. This test can reveal issues with REM sleep and rule out other potential conditions that may be contributing to the person’s symptoms.
• Multiple sleep latency tests: These are performed when the person is awake to measure their tendency to fall asleep and to measure whether the individual is experiencing intrusive REM sleep episodes. This test also measures a number of physiological activities, such as heart rate, respiratory rate, nerve function, etc.
• Hypocretin test: This test is done to measure levels of hypocretin in the spinal fluid.While this test is not conclusive, it can help determine if someone has narcolepsy or some other issue. Unfortunately, it often involves a spinal tap, which can be quite uncomfortable.

Narcolepsy Treatment & Medications

Although narcolepsy is considered a neurological disorder, it is also assessed and treated by psychiatrists, and it has numerous psychological features associated with it. There is no cure for narcolepsy, but the United States Food and Drug Administration has approved several medications for the treatment of narcolepsy:

• Provigil (modafinil) is a mild stimulant medication that can be used to decrease excessive daytime sleepiness associated with narcolepsy.
• Nuvigil (armodafinil) is also stimulant that can be used to treat excessive daytime sleepiness and cataplexy.
• Methylphenidate (brand names: Ritalin, Concerta, etc.) is a stimulant that has been useful in the treatment of narcolepsy.
• Other amphetamines are used to treat narcolepsy.
• Xyrem (sodium oxybate {GHB}) is a sedative that promotes sleep and used for the treatment of narcolepsy to help people sleep better at night and to reduce excessive daytime sleepiness and cataplexy. Xyrem is available through a restricted access program, and it is classified as a Schedule III controlled substance.

Certain antidepressant medications also appear to be effective in controlling excessive daytime sleepiness and cataplexy, particularly tricyclic antidepressants (e.g., desipramine) and certain selective serotonin reuptake inhibitors (e.g., Prozac and Effexor). Antidepressants often have less severe side effects than stimulants; however, they do have their own side effect profile that can include weight gain, issues with sexuality, and high blood pressure. Certain behavioral interventions can also be helpful, such as avoiding caffeine or alcohol, maintaining a regular sleep schedule, and engaging in stress reduction and relaxation techniques. Of course, there are ongoing clinical trials investigating the uses of other medications in the treatment of narcolepsy.

Because of the severe stress that individuals with narcolepsy experience, there is also the potential for development of other psychological issues, such as depression, anxiety, issues of adjustment, etc. In addition, individuals with sleep disorders do appear at risk to develop substance use disorders.

Narcolepsy and Substance Abuse

There has been quite a bit of research that has investigated the association between sleep disorders such as narcolepsy and substance abuse. A number of studies have looked at different associations between symptoms of narcolepsy and impulsiveness, which suggest an increased probability to engage in risk-taking behavior, such as substance abuse.

For instance, one study published in the Journal of Clinical Sleep Medicine found that individuals who are diagnosed with narcolepsy and had cataplexy were significantly more impulsive than individuals who did not have cataplexy. A study reported in the journal Psychiatry found that a significant number of a small sample of individuals with sleep disorders also reported having substance use disorders, particularly alcohol use disorders, polysubstance abuse, and narcotic use disorders. About half of the sample reported using drugs to induce sleep or to assist with sleep issues.

A few of the drugs used to treat narcolepsy, such as Provigil, antidepressant medications, and Nuvigil, are considered to be low-risk drugs for abuse; however, other amphetamines, methylphenidate, and sodium oxybate are known to have higher potentials for abuse. Nonetheless, individuals who take these medications under the supervision of a physician and within the confines of a prescription appear to avoid developing significant issues with substance abuse; however, individuals who get them illegally or doctor shop for more medications are more prone to develop issues with substance use disorders.

At this time, there does not appear to be a large body of reliable research specifically investigating the rates of co-occurring narcolepsy in substance use disorders despite the connection between sleep disorders and substance abuse; however, it is certain that individuals who are not formally involved in treatment for narcolepsy are at risk to develop a substance use disorder based on the aforementioned studies.

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