Evidence-Based Reviews

Insomnia in patients with addictions: A safer way to break the cycle

Current Psychiatry. 2008 May;7(5):97-109

References

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8. Irwin M, Gillin JC, Dang J, et al. Sleep deprivation as a probe of homeostatic sleep regulation in primary alcoholics. Biol Psychiatry 2002;51(8):632-41.

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Substance	Effect on sleep
Nicotine	Difficulty falling asleep, sleep fragmentation, less restful sleep compared with nonsmokers, increased risk for OSA and SDB^a-e
Marijuana	Short-term difficulty falling asleep and decreased slow-wave sleep percentage during withdrawal^f-j
Cocaine	Prolonged sleep latency, decreased sleep efficiency, and decreased REM sleep with intranasal self-administration; hypersomnia during withdrawal^k-m
Other stimulants (amphetamine, methamphetamine, methylphenidate)	Sleep complaints similar to those reported with cocaine use disordersⁿ
Opioids	Decreased slow-wave sleep, increased stage-2 sleep, but minimal impact on sleep continuity; dreams and nightmares; central sleep apnea^o-t
OSA: obstructive sleep apnea; SDB: sleep-disordered breathing; REM: rapid eye movement
Reference Citations: click here

Multifaceted treatment

A thorough history is essential to evaluate sleep and guide treatment decisions. Refer patients to an accredited sleep disorders center if their history shows:

loud snoring
cessation of breathing
frequent kicking during sleep
excessive daytime sleepiness.

Short-term insomnia. Judicious use of medications with appropriate follow-up can be effective for short-term insomnia. Keep in mind, however, that treating insomnia without addiction treatment may improve sleep but worsen addiction. Tailor medications’ pharmacokinetic characteristics to patients’ sleep complaints. For example, a medication with rapid onset may be indicated for sleep-onset insomnia but not for sleep-maintenance insomnia.

Chronic insomnia. Patients who report chronic insomnia and behaviors incompatible with sleep may be good candidates for cognitive-behavioral therapy for insomnia (CBT-I). Patient education can change maladaptive behaviors, such as staying in bed for long periods of time to compensate for sleep loss, using the bed for activities other than sleep, or worrying excessively about sleep (Box 1).¹³

Pharmacotherapy may be preferred:

for patients with unstable physical or mental illness
when CBT-I could exacerbate a comorbid condition (such as restricting sleep in a patient with bipolar disorder)
for patients with low motivation for behavior change
when trained CBT-I providers or resources to pay for CBT-I are limited.

Patient preferences are critical to successful insomnia treatment. Some cannot or will not make the commitment required for CBT-I, and some do not wish to use medications. Combining medication and CBT-I to capitalize on medications’ immediate relief and CBT-I’s durability may be effective for patients who do not respond to either approach alone.

Box 1

Stimulus control: 7 steps to a better night’s sleep

Step 1. Get into bed to go to sleep only when you are sleepy
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Step 2. Avoid using the bed for activities other than sleep; for example, do not read, watch TV, eat, or worry in bed. Sexual activity is the only exception; on these occasions, follow the next steps when you intend to go to sleep
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Step 3. If you are unable to fall asleep within 15 to 20 minutes, get out of bed and go into another room. Remember, the goal is to associate your bed with falling asleep quickly. Return to bed intending to go to sleep only when you are very sleepy
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Step 4. While out of bed during the night, engage in activities that are quiet but of interest to you. Do not exercise, eat, smoke, or take warm showers or baths. Do not lie down or fall asleep when not in bed
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Step 5. If you return to bed and still cannot fall asleep within 15 to 20 minutes, repeat Step 3. Do this as often as necessary throughout the night
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Step 6. Set your alarm and get up at the same time every morning, regardless of how much sleep you got during the night. This will help your body acquire a sleep-wake rhythm
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Step 7. Do not nap during the day
Source. Adapted from Bootzin R, Nicassio P. Behavioral treatments for insomnia. In: Hersen M, Eissler R, Miller P, eds. Progress in behavior modification, vol. 6. New York: Academic Press; 1978:30

CBT-I is effective for primary insomnia and insomnia associated with medical conditions. Using sleep restriction, stimulus control, sleep hygiene, and cognitive therapy, it addresses maladaptive sleep behaviors and counters dysfunctional beliefs about sleep (Box 2).^13,14

In older adults with insomnia but no history of addiction, CBT-I was more effective than placebo and as effective as a hypnotic alone (temazepam, 7.5 and 30 mg qhs) and a hypnotic/CBT-I combination in reducing nighttime wakefulness, increasing total sleep time, and increasing sleep efficiency. After 2 years, patients treated with CBT-I alone were most likely to maintain these initial treatment gains.¹⁵

Limited data exist on CBT-I’s effectiveness in patients with addiction. In 2 studies, alcohol-dependent patients reported improved sleep.^16,17 CBT-I also improved measures of anxiety and depression, fatigue, and some quality-of-life items.¹⁶

Box 2

Cognitive-behavioral therapy for insomnia (CBT-I): 4 components

Stimulus control (SC). Patients with chronic insomnia may watch television, talk on the telephone, or worry about not sleeping while lying in bed. The goal of SC is to alter this association by reestablishing the bed and bedroom with the pleasant experience of falling asleep and staying asleep.¹³ Instructions for SC (Box 1) are commonly provided with sleep restriction.

Sleep restriction (SR) addresses the excessive time that patients with insomnia spend in bed not sleeping. SR temporarily restricts time spent in bed and prohibits sleep at other times. The resulting mild sleep deprivation may promote consolidated sleep, leading to improved patient-reported sleep quality.¹⁴

Sleep hygiene (SH) addresses behaviors that may help or hinder sleep. Patients with addiction may benefit from learning how drug use and withdrawal affects sleep or how substance use for sleep may exacerbate sleep problems. Other SH recommendations include avoiding caffeine, nicotine, and exercise in close proximity to bedtime.

Cognitive therapy. Goals are to:

identify and explore dysfunctional beliefs that cause patients anxiety about sleep problems
replace these beliefs with more appropriate self-statements that promote sleep-healthy behaviors.

Common themes address patients’ unrealistic sleep expectations, inability to control or predict sleep, and faulty beliefs about sleep-promoting practices.