Millions of people struggle with some form of a sleep and wake disorder – either getting too little sleep, too much sleep, or experiencing some other kind of disruption that prevents them from experiencing proper sleep patterns – and many of them turn to drugs and alcohol to mitigate the problem. Treatment for sleep and wake disorders, alongside a co-occurring substance abuse problem, is designed to help people find healthier ways of putting their mind and body in the right place to rest easy.
What are sleep and/or wake disorders? The American Psychiatric Association defines them as a spectrum of problems “with the quality, timing and amount of sleep.” This not only means that patients get less than the recommended number of hours of sleep a night, but also that they experience fatigue, mental and emotional distress, and difficulty functioning during the day. Insomnia is an example of one of the most common types of sleep and wake disorders; others that are well-known include narcolepsy (extreme sleepiness during the day and unintentionally falling asleep during the day), restless leg syndrome (a sleep movement disorder that creates an uncomfortable compulsion to move the legs while falling asleep), and obstructive sleep apnea (experiencing abnormal breathing patterns during sleep, to the point where it wakes the patient up).
The causes behind the development of sleep disorders have been linked to physical and emotional difficulties in patients’ lives. They can be a symptom of mental health conditions, and they can contribute to the development of mental health conditions on their own. In a primary care setting, anywhere between 10 percent and 20 percent of patients complain that they do not get enough sleep; as many as 33 percent of adults report recurring symptoms of insomnia (difficulty falling and staying asleep, not feeling rested upon waking up, fatigue during the day); and 6–10 percent of patients met the criteria for insomnia so severe that it is considered to be its own disorder (insomnia disorder).
Many other people also suffer from various degrees of sleep and wake disorders. Most healthy adults require between seven and nine hours of sleep every night in order to function at normal capacity during the following days. However, research conducted by the Centers for Disease Control and Prevention reveal that as many as 30 percent of American adults regularly sleep for under six hours, and only 30 percent of high school students get the necessary eight hours of sleep on a school night. Upwards of 35 percent of the American population rate their sleep quality as being “poor” or barely “fair.”
Ultimately, notes the American Psychiatric Association, over 50 million Americans would meet the criteria for a form of chronic sleep disorder.
Chronically insufficient sleep leads to more than simply feeling drowsy and cranky the following day. Sleep is necessary to help the brain operate at peak levels; habitually depriving the brain of that opportunity does lead to fatigue and decreased energy, but it can also cause ongoing problems with thinking, memory, and concentration. The decision-making and mood-regulation centers of the brain will be especially harmed by the lack of sleep, and drowsy drivers caused 72,000 crashes and 800 deaths in 2013.
Additionally, sleep and wake disorders also take their toll on the body. The physical benefits of sleep are numerous: healing and repairing the heart and blood vessels, boosting the immune system, improving stamina, and even helping people live longer. However, consistently getting bad sleep can lead to conditions such as diabetes and heart disease. Doctors will also look for medical and neurological problems that cause sleep disorders, such as Parkinson’s disease, congestive heart failure, and osteoarthritis.
As sleep proves elusive and the problems mount, many people turn to different ways to induce sleep, cope with the stress, or both. Pouring a nightcap has long been a home remedy for sleeplessness, and a dose of alcohol (specifically, the depressant effects of the central nervous system) has been praised for helping along the gradual onset of sleep.
While there are benefits to moderate alcohol consumption before bed, especially as a way of bringing about sleep, this can be a double-edged sword. Coming to associate alcohol with a good night’s rest creates an unhealthy dependence on alcohol to the point that not having a drink before bed will serve as a mild form of withdrawal.
Furthermore, while alcohol can help bring about sleep, it is not a sleep aid and should not be used as such. The Alcoholism: Clinical and Experimental Research journal noted that alcohol shortens the amount of time it takes for people to sleep, but it reduces the amount of time people spend in rapid eye movement (REM) sleep, the deepest and most beneficial part of the normal sleep cycle. People who get the full REM sleep experience feel fully refreshed and relaxed for the following day; insufficient REM sleep can make patients feel tired and anxious upon waking. However, if patients are unaware of this, they might continue drinking alcohol to try and “sleep better.” They can fall asleep sooner, but the ongoing use of alcohol will be ineffective at best and outright harmful at worst.
On a related note, people who take different kinds of drugs will also likely experience changes to their sleep patterns. Some drugs, like stimulants, boost brain activity beyond normal levels. This can be useful and have legitimate medical applications, but it can also keep brain functions running at such a high level that the patient never gets a chance to slow down and relax, let alone sleep. Examples of such stimulant drugs include:
One notable stimulant is coffee, which is a mild stimulant of the central nervous system. Caffeine is useful for increasing alertness and concentration, but drinking too much of it and drinking it late in the day will likely keep a person “too wired” to sleep. This might induce other forms of substance use and abuse, as the person desperately tries to induce sleep.
In Sleep Medicine Reviews, researchers theorized that substance abuse and sleep and wake disorders go both ways; drug addiction can cause disruptions to sleep, but a persistent sleep disorder can similarly contribute to the development of a substance abuse problem. If this continues, the two become linked as co-occurring disorders, one feeding into the other. When people try to discontinue their drug use, they may struggle to find the right sleep balance, which leads to a relapse; when they stay on their drugs, their sleep becomes more broken, causing the stress and dysfunction that often precipitate drug use.
Some studies have suggested that people who have sleep and wake disorders alongside a co-occurring drug problem might never have possessed the ability to sleep well, possibly as a result of genetic and/or environmental factors. In Alcoholism: Clinical and Experimental Research, researchers noted that children who had sleep problems as early as 3 to 5 years old were more likely to experience early onset alcohol abuse, as well as abuse of marijuana and other substances, than children who had no such trouble. The enduring fight for sleep leads many in this situation to resort to substance abuse at an early age in a desperate attempt to cope with the anxiety and frustration that chronic sleep deprivation causes.
Regardless of how early the co-occurring sleep and wake disorders and substance abuse begin, the right kind of therapy can transform patients’ lives. Treating sleep disorders involves creating a home environment that is conducive to healthy sleep patterns; this might involve:
Psychiatric Times looked at some of the many treatment options for patients who suffer from sleep and wake disorders with co-occurring drug abuse. As far back as 2001, research had suggested that if problems with sleep cause issues with drug use, then treating the underlying causes of the sleep disorder should improve rates of drug use.
The main approaches for treating a sleep and wake disorder that presents with substance abuse largely fall into two categories: behavioral interventions and prescription medications. Over-the-counter (OTC) medications are popular and easy choices for people looking for sleep remedies; however, if there are co-occurring substance abuse issues present, these products should not be taken without consulting a doctor.
When it comes to behavioral techniques, there is no single form of psychotherapy that has proven more successful than others in resolving both sleep disorders and addiction. One study found that “progressive relaxation training” helped insomnia in patients who were alcoholics; however, other studies that discovered that there is no significant difference between behavioral methods and medication therapy.
Prescription medications for better sleep are commonly found in the benzodiazepine class of drugs. There is debate on the safety of using benzodiazepines for patients who struggle with substance use, especially if that substance is alcohol. This is due, in part, to the neurotransmitters that benzodiazepine affects since alcohol’s initial stimulation effects target these same neurotransmitters. The concern among some doctors is that benzodiazepine drugs have “a high liability for misuse, abuse and dependence” in patients who are prone to alcoholism. The ideal treatment for this group of patients would be a drug that sedates them, that does not last in their system for a long period of time, that does not interact with other prescription medications, and should not induce feelings of pleasure and reward, which is a risk factor with general benzodiazepine intake.
One class of medication that might fit all the criteria for safe prescription for patients who have sleep and wake disorders and substance abuse problems is gabapentin, sold under the brand name Neurontin. The drug is primarily prescribed for treating epileptic seizures and pain as the result of nerve damage.
Chemically, gabapentin is structured similar to the GABA neurotransmitter, the same neurotransmitters targeted by benzodiazepines and alcohol. GABA is important in this context because its purpose is to reduce any unusual electrical activity in the central nervous system. People who have brains that cannot produce the necessary amount of the GABA neurotransmitter will likely struggle with chronic levels of anxiety and stress, which can contribute both to sleep disorders and substance abuse problems.
The British Journal of General Practice explains that Neurontin’s function of boosting production of the GABA neurotransmitter “assumes the effect of sedation.” Users feel very relaxed and at peace. Crucially for patients who are at risk for substance abuse, there is a relatively low risk of becoming dependent on gabapentin if the drug is taken at therapeutic levels.
For reasons such as these, the researchers in Psychiatric Times suggest that gabapentin with long-term therapy is the best treatment option for patients who have sleep and wake disorders with co-occurring substance abuse. To test this, a study was conducted with a group of alcoholic patients who had symptoms of insomnia up to a month after their last drink. Between gabapentin and a placebo control, gabapentin outdid the placebo on sleep improvement, “but it also had a direct positive effect on preventing relapse to heavy drinking,” even when separating the effect of the gabapentin on sleep alone.
Other encouraging medications include antidepressant drugs like mirtazapine (Remeron) or nefazodone (Serzone). Such drugs have the effect of “improving sleep architecture,” and also shorten the time needed to fall asleep in patients who have depression. This results in not only an improvement in the total sleep time, but also significantly better quality of sleep.
Gabapentin or other medication alone will not address the full scope of the causes and problems of sleep and wake disorders alongside a co-occurring drug abuse problem; this will come through short-term counseling and long-term therapy, which might involve group and family meetings, peer-led support networks like Alcoholics Anonymous, and many years of careful and healthy living. When all these elements are put together, people can look forward to refreshing and consistent sleep without the shadow of substance abuse keeping them up at night.