behavioral approach to sleep problems in addicts

Ahmed Eid el-Aghoury MBChB MScMed, Board-certified ATP Director

Sleep problems in addicts: a behavioral approach

Abbassia Training Program, ATP

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”

The treatment of sleep disturbance is a potential target for the management of SUD, esp in protracted withdrawal.

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.

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Range of sleep problemsSleep 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 symptom

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Range of sleep problemsWithdrawal-related insomnia: should be

ROUTINELY consideredNocturnal 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 & MDMARLS: 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.

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In children and adolescentsTrouble 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.

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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 substance exposure: the Maternal Lifestyle study. Arch Pediatr Adolesc Med. 2010 May;164(5):452-6. PubMed PMID: 20439796; PubMed Central PMCID: PMC2917192.

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College studentsCollege 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 motor vehicle accidents. J Adolesc Health. 2010 Jun;46(6):610-2. Epub 2010 Feb 25. PubMed PMID: 20472221.

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Sleep System

GABAVLPO

HIST

5-HT NE

ACh

ThalamusThalamus

WAKESLEEP

Saper CB, et al. Trends Neurosci. 2001.

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The Sleep Switch

Adapted from Saper CB, et al. Trends Neurosci. 2001.

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Sleep Architecture: NREM & REM Sleep

Pace-Schott EF, Hobson JA. Nat Rev Neurosci. 2002.

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Nomenclature of sleep states and stagesNREM

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 sleep

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Patterns of sleep: somnotype & chronotype

Shneerson JM, (2005): Sleep Medicine: a guide to sleep and its disorders. 2nd ed. Oxford, Blackwell Publishing Ltd. Cairo, July 201112


Sleep Latency and EfficiencySleep Latency

It takes most people 10-20 minutes to fall asleep.Average sleep latencyLess than this may be sign of excessive sleepiness

Sleep EfficiencyMost people sleep approximately 90% of the time

that they are in bed.Average sleep efficiency

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Non drug management of insomniaCBTiSleep restrictionStimulus 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.

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Sleep restrictionIncreases process SAccording to chronotype & somnotypeManage medical conditions before

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Stimulus controlGot to bed when sleepy & Get out of bed if

unsleepySet a regular morning wake timeAvoid napping

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Mindfulness meditation (MM)Useful in treating the distress and emotional

reactivity associated with chronic insomniaA 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.

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Abbassia Training Program, ATP Cairo, July 2011

After sunset at Abbassia

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Email: [email protected]

behavioral approach to sleep problems in addicts

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