Sleep Problems and Alcohol Use Disorders

Fauzia Mahr, MD   (Slide 1)

Dept. of Psychiatry

                                         Penn State  Milton S. Hershey Medical center

Alcohol Medical Scholars Program

I.      Introduction

A.   Scope of Problem                              ( Slides 2 & 3)

                                            1.    10% Population: chronic insomnia²⁰

                                            2.    30% Population: temp. sleep disruption²⁰

                                            3.    Costs > US $100 billion¹⁵

                                            4.    Alcohol related insomnia= $18.5 billion¹´¹¹

a.    7% US populationAlc. Abuse²⁶

b.    10%US populationAlc. Dependence²⁶

B.   Consequences of insomnia¹´¹⁵       (Slide 4)

                                            1.    Decreased function

a.    2.5 Ý Motor vehicle accidents

b.    ß Quality of life

c.    ß Job Satisfaction/productivity

                                            2.    Other                                  (Slide 5)

a.    Ý Risk depressive/anxiety symptoms

b.    ß Natural killer cell activity

i.          ß Immunity

ii.       Ý Infections

                                            3.    Sleep and substances     (Slide 6)

a.    Alcohol, cocaine, caffeine Þ poor sleep

b.    Poor sleep Ý risk substance use disorders (SUD’s)²

c.    Most common causes insomnia

d.    Alcohol + sleep = most studied

C.   This lecture Covers:                        (Slide 7)

                                            1.    Definitions: Sleep

                                            2.    Definitions: Substances

                                            3.    Effects of alcohol  on sleep

                                            4.    Treatment of alcohol related insomnia

II.    Definitions: Sleep

A.    Normal sleep¹⁸                                (Slides 8&9)

                                            1.    Reversible unresponsiveness to environment

                                            2.    Needed for restoration

                                            3.    Two Stages:

a.    Non- rapid eye movement (NREM)

b.    Rapid eye movement (REM)

B.   NREM Sleep⁹´¹⁸                                (Slides 10 & 11)

                                            1.    First ½ of night

                                            2.    4 stages on EEG

a.    Stage 1 (Transitional)

i.         1-7 minutes

ii.       Easily arousable

iii.     Muscle tone, activity present

iv.     Occurs throughout night

b.    Stage 2 (Sleep spindles, K complexes)

i.         25 minutes

ii.       Depth of sleep correlates with K complex pattern

iii.     Ý Age,Þ disruption of pattern

c.    Stage 1 & 2= easy arousal

d.    Stage 3 and 4 =slow wave=deep sleep

                                            3.    Ý Nor epinephrine/serotonin

C.   REM Sleep¹⁸´²⁰                                     (Slide 12)

                                            1.     Ý 2nd ½ Night

                                            2.    Dreaming, limb paralysis

                                            3.    Ý Acetylcholine

                                            4.    ß Dopamine, nor epinephrine, epinephrine

                                            5.    ß With age

D.   Latency¹⁸                                               (Slide 13)

                                            1.    Sleep latency

a.    Time to fall asleep

b.    10-20 mins.

                                            2.    REM latency¹⁹

a.    Time from sleep onset Þ REM

b.    90-100 min.

E.   Normal Sleep Cycle¹⁸                     

                                            1.    ~ 8 hrs.

                                            2.    NREM/REM cycle

                                            3.    Circadian rhythm approx. 24 hr  sleep cycle

                                            4.    Cycle repeats

a.    90-120 mins

b.    3-4 X per night

c.    NREM 3X REM

F.    Insomnia¹⁸                                   (Slide 14)

                                            1.    Problem initiating sleep

                                            2.    Problem maintaining sleep

                                            3.    Non-restful sleep

                                            4.    Early morning wakening

G.   DSM IV Insomnia¹⁸                    (Slide 15)

                                            1.    Problem maintaining/initiating sleep 1 + month

                                            2.    ß Function

                                            3.    Prob. not due to other condition

H.   This lecture covers:                    (Slide 16)

                                            1.    Definitions: Sleep

                                            2.    Definitions: Substances

                                            3.    Effects of alcohol on sleep

                                            4.    Treatment of alcohol related insomnia

III.   Definitions: Substances                         (Slides 17&18)

A.   Categories²⁶ based on CNS effects at usual doses

                                            1.    Depressants Depression of  brain tissues

a.    Alcohol, benzodiazepines, barbiturates¹⁸

b.    Ý Sleep with intoxication

c.    ß Sleep with withdrawal

                                            2.    Stimulants¹⁸ Stimulation of brain tissues

a.    Amphetamines, cocaine, caffeine

b.    ß Sleep with intoxication

c.    Ý Sleep with withdrawal

                                            3.    Opioids

a.    Morphine, methadone, oxycodone etc.

b.    Pain, cough , diarrhea

                                            4.    Cannabinols

a.    Marijuana, hashish

b.    Euphoria, altered time sense, hallucinations

                                            5.    Hallucinogens

a.    Ketamine, Phencyclidine (PCP)

b.    Sensory perceptions

c.    Hallucinations at higher doses

                                            6.    Inhalanats

a.    Glues, solvents,aerosols

b.    Alter state of consciousness

c.    Produce lightheadedness & confusion


B.   Alcohol                                                              (Slide 19 )

                                            1.    Acute and chronic use disrupts sleep

                                            2.    50% alcoholics use to fall asleep

                                            3.    Alcohol use as self medication 2X gen. pop. ⁶

C.   Alcohol Abuse: (1+ in same 12 mos.)         (Slide 20)

                                            1.    ß Fulfillment role obligations

                                            2.    Use in hazardous situations

                                            3.    Legal problems

                                            4.    Social, interpersonal problems

                                            5.    Never dependent

D.   Alcohol Dependence: (3+ in same 12 mos.) (Slide 20)

                                            1.    Tolerance (Ý amt for ß effect)

                                            2.    Withdrawal

                                            3.    Use more or longer than planned

                                            4.    Desire +inability to cut down

                                            5.    ß Other activities

                                            6.    Ongoing use despite consequences

E.   Alcohol Withdrawal (2+)                                   (Slide 20)

                                            1.    Ý Autonomic activity (sweating, pulse rate)

                                            2.    Tremor

                                            3.    Insomnia

                                            4.    Nausea/vomiting

                                            5.    Hallucinations/illusions

                                            6.    Agitations

                                            7.    Anxiety

                                            8.    Seizures

                                            9.    Related to ß alcohol after chronic use

F.    This Lecture Covers;                                       (Slide 21)

                                            1.    Definitions: Sleep

                                            2.    Definitions: Substances

                                            3.    Effects of alcohol on sleep

                                            4.    Treatment of alcohol related sleep problems

IV.  Effects of alcohol on sleep

A.   Alcohol related insomnia⁴´⁶                         (Slide 22)

                                            1.    Insomnia in alcoholics 2X gen.pop.

                                            2.    ÝPrevalence:

a.    Ý Age

b.    Ý Severity of alcoholism

c.    7+ years heavy drinking⁴

B.   Acute Use and Sleep⁵´⁷´¹⁸                                 (Slides 23&24)

                                            1.    1st ½ Night

a.    ß Sleep latency

b.    ß REM

c.    Ý Other sleep stages

                                            2.    2nd ½ Night

a.    ß Sleep quantity

b.    Ý Awakenings

c.    Ý REM

C.   Chronic Use and Sleep

                                            1.    ß Effect/drink

                                            2.    Ý Sleep latency

D.   How Alcohol Disrupts Sleep¹³´⁴´⁵      (Slides 25&26)

                                            1.    Affects hypothalamic-pituitary-adrenal axis (HPA axis)

                                            2.    Ý Corticotropin Releasing Factors (CRF)

                                            3.    Ý CRFÞ Ý cortisol ÞÝsleepiness

                                            4.    As alcohol eliminated, HPA rebound

                                            5.    HPA rebound Þ Sleep disturbance

E.   Alcohol and Insomnia¹´¹⁵                      

                                            1.    10% Alcohol related costs 2° insomnia

                                            2.    Both present=Ý Risk  depression/anxiety

a.    Repeated intoxicationÞdepression²⁶

b.    WithdrawalÞ temporary anxiety

                                            3.    Both present=Ý Memory dysfunction

a.    Reversible with abstinence²⁶

                                            4.    Both present=2X mortality²¹

F.    Alcohol and Sleep Apnea¹                     (Slide 27)

                                            1.    Acute alcohol Þsedative Þ Ý inspiratory resistance

                                            2.    Ý Risk sleep apnea

a.    2X Sleep latency

b.    20% Less sleep

c.    2XÝ Premature Death in elderly


G.   Alcoholism +REM changes Þ predict relapse²⁷   

                                            1.    Ý REM %

                                            2.    Ý REM density

                                            3.    ß REM latency

H.   This lecture covers                                                           (Slide 28)

                                            1.    Definitions: Sleep

                                            2.    Definitions: Substances

                                            3.    Effects of alcohol on sleep

                                            4.    Treatment

V.   Treatment¹⁰´¹¹´¹²´¹⁴´²⁶                                                            

A.   Guidelines                                                                            (Slide  29)

                                            1.    Assessment & treatment of Alcohol as cause

                                            2.    Education

                                            3.    Behavior therapies

                                            4.    Rhythm restoring treatments

                                            5.    Medication

B.   Insomnia treatment Þbegins with alcohol treatment   (Slide 30)

                                            1.    Identify alcohol as cause


a.    Obtain accurate history

b.    Alcohol Use Disorders Identification Test (AUDIT)

i.         Ý Reliable

ii.       10 Item instrument

iii.     4 Point scale

                                                                                                                                  1'.      ’Frequency of drinks

                                                                                                                                  2'.      ’# of drinks

                                                                                                                                  3'.      ’Frequency of heavy intake

                                                                                                                                  4'.      ’Inability to stop drinking

                                                                                                                                  5'.      ’Failure to meet obligations

                                                                                                                                  6'.      ’Frequency of AM drinking

                                                                                                                                  7'.      ’Frequency of feelings of guilt

                                                                                                                                  8'.      ’Frequency of blackouts

                                                                                                                                  9'.      ’Injury to self or others

                                                                                                                              10'.      ’Concern of others about drinking 

c.    CAGE questionnaire

i.         4  Item questionnaire

                                                                                                                                  1'.      ’Tried to “cut down”

                                                                                                                                  2'.      ’Feel “annoyed” others with drinking

                                                                                                                                  3'.      ’Felt “guilty” about drinking

                                                                                                                                  4'.      ’Taken an “eye opener” in AM

                                            2.    Detoxification if necessary                           (Slide 31)          

a.    Physical exam & Lab tests

i.         EKG

                                                                                                                                  1'.      ’Look for Arrythmias

ii.       Gamma glutamyl transferase ( GGT)

                                                                                                                                  1'.      ’Normal = < 35

iii.     Carbohydrate deficient transferrin (  CDT)

                                                                                                                                  1'.      Ý 20 g/l ÞHeavy drinking

b.    Vitamins

i.         Thiamine

ii.       Multivitamins

c.    Reassurance

d.    Benzodiazepines ( BZDs)

                                            3.    Rehabilitation                                               (Slide 31)

a.    Ý Motivation

i.         Involve & educate family members

ii.       Help patient own responsibility

b.    Help readjust to life

i.         Individual therapy

ii.       Group /Family therapy

iii.     Self help groups

                                                                                                                                  1'.      ’Alcoholics anonymous ( AA )

c.    Relapse prevention

d.    ± Meds

i.         Naltrexone ( Revia or Trexan)

ii.       Acomprosate ( Campral)

iii.     Disulfuram (Antabuse)

iv.     Selective serotonin reuptake inhibitors (SSRIs)

v.       Buspirone (Buspar)


C.   Education²⁶                                                            (Slide 32)                                       

                                            1.    Sleep problems Þresponse to use of Alcohol

                                            2.    Can persist 6 mo. or Ý

                                            3.    Sleeping pills may worsen problem

                                            4.    Body must adjust to Ø Alcohol

D.   Assessment                                                      

                                            1.    Self Report Instruments

a.    Pittsburg Sleep Quality Index¹⁹      (Slide 33)                                      

i.         Sleep problems 1 mo. +

ii.       19 items

                                                                                                                                  1'.      ’Subjective sleep quality

                                                                                                                                  2'.      ’Sleep latency

                                                                                                                                  3'.      ’Sleep duration

                                                                                                                                  4'.      ’Habitual Sleep efficiency

                                                                                                                                  5'.      ’Sleep disturbance

                                                                                                                                  6'.      ’Use of sleeping medication

                                                                                                                                  7'.      ’Daytime dysfunction

iii.     Scores 0-21

b.    Sleep Diary                              (Slides 34&35)

i.         Daily X 2wks.

ii.       Determines sleep continuity¹⁵

                                                                                                                                  1'.      ’Time to bed

                                                                                                                                  2'.      ’Time to wake

                                                                                                                                  3'.      ’Minutes to fall asleep

                                                                                                                                  4'.      ’# + Duration wakings

                                                                                                                                  5'.      ’Final awakening

                                                                                                                                  6'.      ’Minutes awake in bed

                                            2.    Other Factors¹⁴´¹⁵´¹⁸                              (Slide 36)

a.    Sleep hygiene

i.         Same bedtime

ii.       Same wake time

iii.     Use bed for sleep

iv.     No strenuous exercise after 6 PM

b.    Environment¹⁵´¹⁸                             

i.         Dark, quiet, same room

ii.       Comfortable temp.

iii.     Good ventilation

iv.     Turn clock away

                                            3.    Assess/treat other medical causes¹⁵´²³


a.    Depression

i.         Early AM awakenings

ii.       Non-restorative sleep

b.    Anxiety

i.         Multiple awakenings during night

c.    Bipolar d/o

i.         ß Need for sleep


E.   Behavioral Treatment¹⁴´¹⁵

                                            1.    Stimulus Control therapy                 

a.    1st Line behavioral tx.

b.    Limit awake time in bed (15 min.)

c.    Limit activity before bed

d.    Make bed a sleep cue

i.         Same wake time

ii.       Same room

iii.     Bed for sleep only    

                                            2.    Cognitive Behavioral Therapy for Insomnia (CBT-I)¹⁴´¹⁵                                                      

a.    Time limited, manualized         (Slide 37)

b.    Targets cognitive distortions

i.         Neg thoughts re insomnia

                                                                                                                                  1'.      ’Hopelessness

                                                                                                                                  2'.      ’Catastrophic thinking

                                                                                                                                  3'.      ’Loss of control

ii.       Neg  beliefs re results insomnia

                                                                                                                                  1'.      ’Irreversibility of insomnia

                                                                                                                                  2'.      ’Should be challenged

c.    ß Anxiety, arousal

d.    Ý Increases sleep

                                            3.    Sleep Restriction Technique        

a.    Fixed wake time

b.    Daily sleep diaries

c.    Sleep window =total sleep time +30 minutes

d.    Adjust window

i.         > 85% efficiency=no change

ii.       <85% efficiency=ß 15 minutes

iii.     >90%efficiency=Ý 15 minutes

                                            4.    Relaxation Training                    (Slide 38)

a.    ß Physical, emotional arousal

b.    Collaborate with patient on method

i.         Progressive muscle relaxation

ii.       Diaphragmatic breathing

iii.     Biofeedback

iv.     Meditation

F.    Pharmacologic Treatment¹⁰´¹²´¹⁸

                                            1.    Melatonin¹⁸                                        (Slide 39)

a.    Secreted by pineal gland

b.    Regulates circadian rhythm

c.    Regulated by light stimulus

d.    ß In alcoholism¹¹

e.    Dose=6 mg nightly

                                            2.    BZDs                                                  (Slide 40)

a.    Valium (Diazepam),  alprazolam (Xanax), Lorazepam (Ativan)

b.    Ý GABA (sedating)

c.    Sim. Effect to alcohol Þ sim. Abuse/dependence

d.    Avoid if possible

e.    Discourage daily use

                                            3.    Hypnotics                                        (Slide  41)

a. Zaleplon (Sonata) ~ 10 mg

b.      Zolpidem (Ambien) ~ 10 mg

c. Eszopiclone (Lunesta) ~ 1 mg



                                            4.    Other                                                                        

a.    Antidepressants

i.         Trazodone (Desyrel)

ii.       Amitriptyline(Elavil)

b.    Antipsychotics (Off label use)

i.         Olanzapine (Zyprexa)

ii.       Quetiapine (Seroquel)

c.    Anticonvulsants (Off label use)

i.         Gabapentin (Neurontin)

ii.       Valproic acid (Depakote)

G.   This lecture covers                                   (Slide  42)

                                            1.    Definitions: Sleep

                                            2.    Definitions: Substances

                                            3.    Effects of alcohol on sleep

                                            4.    Treatment






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