Sleep And Drug Addiction: Understanding The Complex Relationship

Sleep disturbances are common among people with substance use disorders. Drugs of abuse and alcohol have disruptive effects on sleep, including interfering with the ease of falling asleep, increasing the difficulty in maintaining sleep, and altering the cycling of sleep stages from non-rapid eye movement (NREM) sleep to rapid eye movement (REM) sleep. These sleep effects then have a consequent impact on next-day function, including increasing daytime sleepiness and impairing alertness.

The specific characteristics of the sleep/alertness disturbances vary depending on the substance of abuse. For example, acute alcohol use can have a hypnotic effect, but as consumption becomes chronic, alcohol has less of a hypnotic effect. Sleep problems are commonly associated with drug and alcohol use, and nearly 70% of patients admitted for detoxification report sleep problems prior to admission, with 80% of those who report sleep problems relating them to their substance use.

Sleep disturbances can also be a consequence of withdrawal from drugs. For example, when quitting drugs, you may get insomnia or other sleep problems, including broken sleep, strange dreams, or restless legs syndrome. These sleep disturbances can take a toll on your mental and physical health, making recovery harder.

Sleep disturbances are a risk factor for substance abuse

Sleep disturbances are associated with both acute and chronic use of addictive substances. While substance use may directly cause sleep disturbances, difficulty sleeping may also be a risk factor for relapse. Sleep disturbances may also be a contributing factor in initiating and maintaining drug and alcohol abuse and as a factor that increases the risk for relapse.

Substance use can interfere with the ease of falling asleep, increase the difficulty in maintaining sleep, and alter the cycling of sleep stages from non-rapid eye movement (NREM) sleep to rapid eye movement (REM) sleep. These sleep effects can have a consequent impact on next-day function, including increasing daytime sleepiness and impairing alertness.

The specific characteristics of the sleep/alertness disturbances vary for different substances. For example, stimulants such as cocaine and amphetamine cause light, restless, and disrupted sleep. Drugs from other classes, such as depressants (e.g. benzodiazepines, alcohol) and opiates (e.g. heroin) initially produce soporific effects, including increased daytime sleepiness and reduced sleep latency, but cause sleep disruptions later in the night due to acute withdrawal effects.

Chronic use of substances can further impact sleep quality and quantity. Sleep-related outcomes of chronic substance use are broadly similar across substances and include extended sleep onset latency, reduced total sleep time, more nighttime awakenings, and decreased slow-wave sleep and REM sleep.

Withdrawing or abstaining from substance use has its own unique impact on sleep parameters, which may be dependent on the duration of abstinence. Sleep disturbance tends to be associated with acute withdrawal from any substance, as evidenced by extended sleep onset latency, reduced total sleep time, and reduced slow-wave sleep. In addition, REM sleep often shows a rebound effect during abstinence.

As the period of abstinence is extended, sleep patterns tend to return to baseline. However, some sleep characteristics (e.g. REM sleep disturbances) may persist well into abstinence.

Sleep problems increase the chances of drug abuse

Sleep problems can increase the chances of drug abuse. People with sleep issues may "self-medicate" with illegal drugs, alcohol, or medication. This can cause further sleep problems and increase the risk of drug abuse.

Sleep disturbances are a common feature of substance use disorders. Drugs of abuse and alcohol have disruptive effects on sleep, including difficulty falling and staying asleep, and reduced overall sleep time. These sleep disturbances can be seen during active substance use and discontinuation.

Substance abuse can lead to nighttime wakefulness, less "good" sleep, and stronger daytime sleepiness. Drugs like cocaine, caffeine, and nicotine are stimulants that can make people feel alert, but their use may also lead to poor sleep. Alcohol, a depressant, can make people sleepy, but its effects weaken over time as the body builds up a tolerance.

Sleep problems are also common during drug withdrawal. People quitting drugs may experience insomnia, strange dreams, or restless leg syndrome, which can negatively impact their mental and physical health and make recovery more difficult.

Treating sleep problems in people with substance use disorders can be challenging. While there are therapies and non-addictive medications available, these individuals may also need to address other issues such as anxiety or other health conditions.

Studies have found a high prevalence of sleep disturbances among those with substance abuse disorders, with a potential bidirectional relationship between sleep problems and substance use. Addressing and treating sleep disorders may help reduce the risk of substance abuse and induce remission.

Sleep disturbances can be a result of drug abuse

The specific characteristics of the sleep/alertness disturbances vary for different drugs, but the effects of chronic use on sleep are similar among both central nervous system (CNS) stimulants and depressants. Decreased sleep time, increased sleep latency, and wake time after sleep onset, and deficiency in slow-wave sleep generation appear to be common to chronic use of alcohol, cocaine, cannabis, and opioids. REM sleep is also affected by acute and chronic use, but may be more sensitive to the pattern or quantity of recent use and time from last use, as results vary more among studies.

There is also a bidirectional relationship between sleep problems and substance use disorders, with sleep problems increasing the risk for developing substance use disorders, and acute and chronic substance use leading to acute and chronic problems with sleep.

Sleep disturbances can increase the risk of relapse

The specific characteristics of the sleep/alertness disturbances for various substances of abuse have been reviewed elsewhere, but the purpose of this chapter is to discuss the modulatory role these sleep disturbances may play in substance use disorders (SUD). It has been suggested that these sleep and alertness alterations, although not the primary reinforcing mechanism, function as contributing/modulatory factors in initiating and maintaining drug and alcohol abuse and as factors that increase the risk for relapse.

The most common sleep diagnosis associated with SUD is insomnia. Insomnia is defined as difficulty initiating, maintaining sleep, and/or awakening early in the morning that occurs on three or more nights per week, endures for three months or more and causes significant impairment in daytime functioning. Importantly, the sleep disturbance is present despite an adequate opportunity and circumstance to sleep.

The sleep-specific signs during discontinuation may include REM sleep rebound or rebound insomnia, as many of the substances of abuse and alcohol alter these sleep parameters. This rebound may lead to therapy seeking, making it difficult to differentiate drug-seeking from therapy-seeking. In drug-seeking, the drug and its effects, typically its “euphorogenic” effects, are the focus of the drug use, while in therapy-seeking, the alleviation of the disease-related symptoms is the focus of the drug use. However, in the clinic, drug-seeking and therapy- seeking can become closely intertwined and what was once therapy-seeking can shift to drug-seeking.

The challenge is to differentiate the two behaviors in making diagnoses and appropriately treating patients. The defining characteristic of drug seeking is evidence that the drug is taken in excessive amounts, in non-therapeutic contexts, and is preferred over other commodities (e.g. money) and various social and occupational activities. The degree to which that the drug is chosen over other commodities or social activities provides evidence supporting its risk for abuse. The scientific literature for most drugs of abuse indicates that the drug is readily discriminated from placebo by behavioral and subjective assessments, which include ratings of the drug for it “euphorogenic” and drug-liking effects. That is, the drug's mood effects are the focus of its use.

In contrast, therapy seeking is evident if the drug has demonstrated efficacy for the disorder or condition being treated. Therapy seeking is also supported if the patient has the signs and symptoms of the appropriate diagnosis for the indicated use of the drug. The pattern of drug taking, including its dose, timing, and duration of use, should be consistent with its therapeutic effects. If the drug is no longer effective, its use is discontinued. Evidence supporting therapy seeking behavior also includes that the patient believes that the drug is effective and readily experiences its therapeutic benefits.

The drug seeking versus therapy seeking distinction becomes difficult in situations where therapy seeking shifts to drug seeking behavior. As noted earlier, while pre-sleep alcohol use may initially be effective in improving sleep onset for someone with insomnia, rapid tolerance development is likely, which may lead to dose escalation. Further, other of alcohol's reinforcing effects (i.e., its “euphorogenic” effects) may be discovered by the person, especially as dose is escalated. At that point, its use may extend beyond the therapeutic context (i.e., solely before sleep as a sleep inducer). A similar shifting pattern can be described for stimulant or opiate use. On the other hand, drug seeking may be maintained because the drug, in addition to its mood altering and “euphorogenic” effects, also has therapeutic effects (i.e., the stimulant effects of cocaine or amphetamine do in fact reverse the excessive sleepiness that is experienced during drug discontinuation). Thus, the dependence is maintained by a combination of its mood altering effects and its therapeutic effects, a circumstance that has been referred to as “self-medication”.

Sleep disturbances can be a withdrawal symptom

Sleep disturbances during withdrawal

When quitting drugs, people may experience insomnia or other sleep problems, including broken sleep, strange dreams, or restless legs syndrome. These can take a toll on mental and physical health, making recovery harder.

Sleep problems have been reported during withdrawal from:

• Prescription or non-prescription drugs
• Alcohol
• Cannabis
• Cocaine
• Opioids

Sleep disturbances during withdrawal from prescription or non-prescription drugs

Withdrawal from prescription or non-prescription drugs can cause insomnia or other sleep problems. This can be even harder if the person has been addicted to drugs or alcohol and is trying to stop.

A quarter to three-quarters of people in treatment for alcohol abuse report insomnia, sleep apnea, and other problems, and it is a common complaint in people trying to quit opioids. Poor sleep quality is typical in withdrawal from cocaine. One study found people in recovery from drug or alcohol abuse were five times more likely to have insomnia.

Sleep disturbances during alcohol withdrawal

Alcohol withdrawal can cause increased sleep latency, reduced total sleep time, and reduced slow-wave sleep. Sleep disturbances can persist for up to three years in alcoholism. Sleep remains shortened, and REM sleep pressure is elevated.

Sleep disturbances during cannabis withdrawal

Withdrawal from cannabis can cause increased sleep onset latency, reduced total sleep time, and reduced slow-wave sleep. Sleep disturbances can last several days but may continue for several weeks.

Sleep disturbances during cocaine withdrawal

Withdrawal from cocaine can cause increased sleep latency, reduced total sleep time, and reduced slow-wave sleep. Sleep disturbances can persist for several weeks.

Sleep disturbances during opioid withdrawal

Withdrawal from opioids can cause increased sleep latency, reduced total sleep time, and reduced slow-wave sleep. Sleep disturbances can persist for several days but may continue for several weeks or months.

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