Sleep problems in addicts: a behavioral approach Ahmed Eid el-Aghoury MBChB MScMed, Board-certified ATP Director
Why? A strong hypothesis: “persons who are recovering from an addiction to any psychoactive substance and have a sleep disturbance are at an increased risk of relapse compared to those without a sleep disturbance” Brower KJ, Perron BE. Sleep disturbance as a universal risk factor for relapse in addictions to psychoactive ubstances. Med Hypotheses. 2010 May;74(5):928-33. Epub 2009 Nov 11. PubMed PMID: 19910125; PubMed Central PMCID: PMC2850945. The treatment of sleep disturbance is a potential target for the management of SUD, esp in protracted withdrawal.2 Abbassia Training Program, ATP Cairo, July 2011
Range of sleep problems Sleep disturbance can include both objectively measured and subjectively reported problems involved with falling asleep, staying at sleep, distressing dreams, or inability to progress through normal stages of sleep A universal withdrawal symptom3 Abbassia Training Program, ATP Cairo, July 2011
Range of sleep problems Withdrawal-related insomnia: should be ROUTINELY considered Nocturnal sleep-disturbing nicotine craving: Patients who awoke most days or daily had the lowest chance to quit smoking and the lowest compliance with the program, “special group” OSA: opioids & MDMA RLS: tramadol Brower KJ, Perron BE. Prevalence and correlates of withdrawal-related insomnia among adults with alcohol dependence: results from a national survey. Am J Addict. 2010 May-Jun;19(3):238-44. PubMed PMID: 20525030; PubMed Central PMCID: PMC2998536. Riemerth A, Kunze U, Groman E. Nocturnal sleep-disturbing nicotine craving and accomplishment with a smoking cessation program. Wien Med Wochenschr. 2009;159(1-2):47-52. PubMed PMID: 19225735. Ramar K. Reversal of sleep-disordered breathing with opioid withdrawal. Pain Pract. 2009 Sep-Oct;9(5):394-8. Epub 2009 Jun 22. PubMed PMID: 19549061.4 Abbassia Training Program, ATP Cairo, July 2011
In children and adolescents Trouble sleeping in childhood were twice as likely to have the same problem in adolescence. Childhood overtiredness predicted poor response inhibition in adolescence. Both: early onset of substance abuse Wong MM, Brower KJ, Nigg JT, Zucker RA. Childhood sleep problems, response inhibition, and alcohol and drug outcomes in adolescence and young adulthood. Alcohol Clin Exp Res. 2010 Jun;34(6):1033-44. Epub 2010 Apr 5. PubMed PMID: 20374209. Wong MM, Brower KJ, Zucker RA. Childhood sleep problems, early onset of substance use and behavioral problems in adolescence. Sleep Med. 2009 Aug;10(7):787-96. Epub 2009 Jan 12. Erratum in: Sleep Med. 2010 Jan;11(1):110-1. PubMed PMID: 19138880; PubMed Central PMCID: PMC2716423. Roane BM, Taylor DJ. Adolescent insomnia as a risk factor for early adult depression and substance abuse. Sleep. 2008 Oct;31(10):1351-6. PubMed PMID: 18853932; PubMed Central PMCID: PMC2572740.5 Abbassia Training Program, ATP Cairo, July 2011
Even prenatal ! Prenatal cocaine, opiate, marijuana, alcohol, and/or nicotine exposure: was associated with sleep problems till early adolescence!Stone KC, LaGasse LL, Lester BM, Shankaran S, Bada HS, Bauer CR, Hammond JA. Sleep problems in children with prenatal substanceexposure: the Maternal Lifestyle study. Arch Pediatr Adolesc Med. 2010 May;164(5):452-6. PubMed PMID: 20439796; PubMed CentralPMCID: PMC2917192.6 Abbassia Training Program, ATP Cairo, July 2011
College students College students with insufficient sleep: frequently use medications and alcohol as sleep aids, use stimulants as alertness aids, and fall asleep at the wheel, or have motor vehicle accidents due to sleepiness.Taylor DJ, Bramoweth AD. Patterns and consequences of inadequate sleep in college students: substance use and motorvehicle accidents. J Adolesc Health. 2010 Jun;46(6):610-2. Epub 2010 Feb 25. PubMed PMID: 20472221.7 Abbassia Training Program, ATP Cairo, July 2011
Sleep System SLEEP WAKE Thalamus GABA ACh VLPO HIST 5-HT NE8 Abbassia Training Program, ATP Cairo, July 2011 Saper CB, et al. Trends Neurosci. 2001.
The Sleep Switch9 Abbassia Training Program, ATP Cairo, July 2011 Adapted from Saper CB, et al. Trends Neurosci. 2001.
Sleep Architecture: NREM & REM Sleep10 Abbassia Training Program, ATP Cairo, July 2011 Pace-Schott EF, Hobson JA. Nat Rev Neurosci. 2002.
Nomenclature of sleep states and stages NREM Quiet sleep (infants) Orthodox sleep Synchronized sleep NREM stages 1 and 2 Light sleep NREM stages 3 and 4 Deep sleep Slow-wave sleep (SWS) Delta sleep REM sleep Active sleep (infants) Paradoxical sleep Desynchronized sleep11 Abbassia Training Program, ATP Cairo, July 2011
Patterns of sleep: somnotype & chronotype Shneerson JM, (2005): Sleep Medicine: a guide to sleep and its disorders. 2nd ed.12 Abbassia Training Program, ATP Oxford, Blackwell Publishing Ltd. Cairo, July 2011
Sleep Latency and Efficiency Sleep Latency Sleep Efficiency It takes most people Most people sleep 10-20 minutes to fall approximately 90% of asleep. the time that they are Average sleep in bed. latency Average sleep Less than this may be efficiency sign of excessive sleepiness13 Abbassia Training Program, ATP Cairo, July 2011
Non drug management of insomnia CBTi Sleep restriction Stimulus control Siebern AT, Manber R. Insomnia and its effective non-pharmacologic treatment. Med Clin North Am. 2010 May;94(3):581-91. Review. PubMed PMID: 20451034.14 Abbassia Training Program, ATP Cairo, July 2011
Sleep restriction Increases process S According to chronotype & somnotype Manage medical conditions before15 Abbassia Training Program, ATP Cairo, July 2011
Stimulus control Got to bed when sleepy & Get out of bed if unsleepy Set a regular morning wake time Avoid napping16 Abbassia Training Program, ATP Cairo, July 2011
Mindfulness meditation (MM) Useful in treating the distress and emotional reactivity associated with chronic insomnia A group program that integrates mindfulness principles with behavior therapy: 2 hrs / session × 8 wks + one all-day retreat Cognitive components: Beginners mind / non striving/ letting go / non judging / acceptance / trust / patience Behavioral components: stimulus control , sleep restriction, and sleep hygiene. Britton WB, Bootzin RR, Cousins JC, Hasler BP, Peck T, Shapiro SL. The contribution of mindfulness practice to a multicomponent behavioral sleep intervention following substance abuse treatment in adolescents: a treatment-development study. Subst Abus. 2010 Apr;31(2):86-97. PubMed PMID: 20408060.17 Abbassia Training Program, ATP Cairo, July 2011
After sunset at Abbassia Email: email@example.com Abbassia Training Program, ATP Cairo, July 2011