Treatment for Sleep-Wake Disorders alongside Co-Occurring Drug Abuse

Integrated treatment approaches for sleep-wake disorders occurring alongside a co-occurring substance abuse problem are designed to help people find healthier ways of putting their mind and body in the right place to rest easy.

Sleep-Wake Disorders

The somewhat broad concept of disordered sleep applies to a spectrum of problems that interfere with the timing, quantity, and quality of sleep that someone experiences, with an additional defining feature of sleep-wake disorders being that they result in significant daytime impairment or distress.^[1] 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-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 characterized by an uncomfortable compulsion to move the legs while falling asleep), and obstructive sleep apnea (experiencing an intermittently blocked airway, often resulting in frequent interruptions to normal sleep).^[2]

The causes behind the development of some sleep disorders have been linked to physical and emotional difficulties in patients’ lives. They can be associated with other mental health conditions, and they may contribute to the development or worsening of mental health conditions themselves. In a primary care setting, as many as 33% of adults report recurring symptoms of insomnia (difficulty falling and staying asleep, not feeling rested upon waking up, fatigue during the day); and 10-15% of patients indicate that their insomnia is severe and/or chronic.^[3]

A Sleeplessness Epidemic

Many people 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, as part of what the Centers for Disease Control and Prevention (CDC) has labeled a public health epidemic, as many as 30% of American adults regularly get less than 6 hours of sleep, and only 30% of high school students get the necessary eight hours of sleep on a school night. Upwards of 35% of the American population rate their sleep quality as being “poor” or barely “fair.”^[4]

The American Psychiatric Association has indicated that more than 50 million Americans would meet the criteria for a form of chronic sleep disorder. Chronically insufficient sleep may lead 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.^[5]

Additionally, sleep and wake disorders also take their toll on the body. The physical benefits of sleep are numerous—promoting healing and repair of the heart and blood vessels, boosting the immune system, improving stamina, and even helping people live longer. However, consistently getting bad sleep may contribute to conditions such as diabetes and heart disease.

Alcohol and Insomnia

As sleep proves elusive and health problems mount, many people turn to different ways to induce sleep, cope with the stress, or both. Pouring a nightcap has long been a folk remedy for sleeplessness, with many praising alcohol for helping along the gradual onset of sleep.^[6]

While alcohol may at times help bring about sleep, it is not a sleep aid and should not be used as such. The journal Alcoholism: Clinical and Experimental Research notes that though alcohol shortens the amount of time it takes for people to sleep, it reduces the amount of time people spend in rapid eye movement (REM) sleep—an important, restorative stage of the normal sleep cycle. People who get the full REM sleep experience feel more 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 may fall asleep sooner in the short-term, but the ongoing use of alcohol will be ultimately ineffective and could be outright harmful.^[7]

Drugs and Sleep Deprivation

On a related note, people who take different kinds of drugs could also experience changes to their sleep patterns. Some drugs, like stimulants, boost certain types of brain activity beyond normal levels. Though there may be legitimate medical applications for stimulant therapy, sleep disturbances are common, especially initiation of stimulant use. Common illicitly used stimulant drugs include cocaine, methamphetamine, and MDMA. Prescription stimulants that may initially disrupt sleep patterns include:

• Dextroamphetamine (Adderall, Dexedrine).
• Lisdexamfetamine (Vyvanse).
• Methylphenidate (Ritalin).

One notable non-amphetamine 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 compel other forms of substance use and misuse, as the person desperately tries to induce sleep.

Sleep-Wake Disorders and Substance Abuse

In one journal review (Sleep Medicine Reviews), researchers point to a bidirectional association between substance use and sleep—substance use may itself result in disruptions to sleep, but a persistent sleep disorder can conversely contribute to the development of a substance use problem or a relapse to problematic substance use.^[8] Over time, the two may 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 continued drug use.

Some studies have suggested that people who have significantly disordered sleep in addition to a 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 use, as well as the use of marijuana and other substances, than children who had no such trouble.^[9] The persistent fight for sleep could lead many in this situation to substance use at an early age in a desperate attempt to cope with the anxiety and frustration that chronic sleep deprivation causes.

Regardless of how early co-occurring sleep 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:

• Creating a consistent sleeping and waking schedule.
• Setting aside time to relax and unwind before bed.
• Coming up with a plan to deal with inevitable sleep problems without having to use drugs or alcohol.

Treating Sleep-Wake Disorders and Co-Occurring Drug Abuse

A review in Psychiatric Times looked at some of the many treatment options for patients who suffer from sleep and wake disorders with co-occurring drug abuse. Some of the reviewed literature suggested that if problems with sleep spur issues with drug use, then treating the underlying causes of the sleep disorder should improve rates of drug use.^[10]

The main approaches for treating a sleep-wake disorder that is associated with substance abuse largely fall into two categories: behavioral interventions and medications.

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.^[11][12]

Though their use has been largely supplanted by the so-called z-drug class of sleeping medications (e.g., zaleplon, zolpidem, eszopiclone), some people continue to look to prescription benzodiazepines for help with insomnia and other sleeping issues. An important concern among some doctors in prescribing benzodiazepine drugs lies in their potential for misuse, abuse, and dependence in a patient population already struggling with alcoholism or substance use issues. Even the aforementioned z-drugs may have similar abuse potential of their own. Several over-the-counter (OTC) medications are popular and easy choices for people looking for sleep remedies; however, it would be wise to discuss the appropriateness of any of these option with a doctor.

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—the latter being a risk that seems hard to tease out from the other therapeutic effects, especially should these medications be used in excess.

Other Medications and Long-Term Treatment

Like the aforementioned z-drugs (also known as non-benzodiazepine sedative hypnotics), another pharmacotherapeutic option once thought to be devoid of abuse liability of its own is gabapentin—marketed under the brand name Neurontin, among others. The drug is approved for use in managing partial seizures, restless leg syndrome, and post-herpetic neuralgia (pain in association with shingles), however it has a number of off-label uses, and some people may inquire about its potential efficacy as a sleep-aid. Though there may be a relatively lower likelihood of becoming dependent on gabapentin if the drug is taken at therapeutic levels, the risk remains.^[13]

One 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 certain sleep improvement measures (and also seemed to delayed relapse to heavy drinking); however, its effects may be limited in terms of the quality of sleep experienced by the experimental subjects, as measured by more objective measures.^[14] Certainly, more investigation in this field is needed before gabapentin is embraced as a definitive treatment for people in recovery who are experiencing sleep disturbances.

Other encouraging medications include antidepressant drugs like mirtazapine (Remeron) or nefazodone (previously branded as 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.^[15]

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.