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Sleep Problems May Be A Pathway To Future Substance Abuse

You are listening to ReachMD, The Channel For Medical Professionals. Sleep problems may be a pathway to future substance abuse. Substance abuse and subsequent withdrawal can lead to sleep disturbances. How do you evaluate the substance abuse that also has sleep problems? Welcome to the Clinician's Roundtable. I am Dr. Leslie Lundt, your host, and with me today is Dr. Deirdre Conroy.

Dr. Leslie Lundt.

Dr. Deirdre Conroy, Clinical Assistant Professor Of Psychiatry at the University Of Michigan.

DR. LESLIE LUNDT:

Welcome to ReachMD, Deidre.

DR. DEIRDRE CONROY:

Thank you.

DR. LESLIE LUNDT:

Is substance abuse the only cause of insomnia in these patients that have addiction?

DR. DEIRDRE CONROY:

Not necessarily, it certainly can be 1 contributing factor, but there are other factors such as preexisting medical conditions or psychiatric conditions that could predate the insomnia related to the substance abuse so it's important to kind of separate those 2 and work with your patient to understand where the substance abusecame in and how that related to the sleep problems related to the substance.

DR. LESLIE LUNDT:

So they could have any kind of flavor of insomnia just because they have addictions we can assume it's related to that.

DR. DEIRDRE CONROY:

Exactly, and it's kind of easy to make that connection while that the patients abusing alcohol then that alcohol is causing the insomnia, but if for example the patient has always had poor sleep ever since they are a child and then perhaps drink to self medicate then that person may be in a different category.

DR. LESLIE LUNDT:

Do the sleep disturbances that you see vary according to the substance that the patient abuses?

DR. DEIRDRE CONROY:

Yes they do and it depends on whether they are actively using the substance or whether they are in withdrawal from the substance. So, for example, if the patient has been addicted to stimulants they will obviously complaint of insomnia or difficulty falling or staying asleep, but any kind of sedatives they may have more sleepiness. Alcohol tend go both ways, you may have patients using alcohol to help them sleep and it might help them fall asleep, but contribute to awakenings in the second half of the night as the alcohol is metabolized. Those people widely using alcohol may actually complain of both, difficulty falling asleep without the alcohol and then even after drinking poor quality sleep.

DR. LESLIE LUNDT:

Let's focus on alcoholic since that’s the most common thing most of us see in our practice in terms of substance abuse. How commonly do you see alcoholics present with a sleep disturbance?

DR. DEIRDRE CONROY:

It's actually very common and a few studies have looked at the ranges of percentages of patients complaining of insomnia. Those alcohol dependent patients range from anywhere from 36 to even 91% and that 91% was actually the somewhat recent finding and that actually encompassed all kinds of sleep complaints not only insomnia so that night includes sleep-disordered breathing, periodic leg movements, but nonetheless is a very high percentage of people complaining of sleep problems.

DR. LESLIE LUNDT:

So as significant if not substantial proportion of alcoholics present with the sleep disturbance. How do we know though is it the chicken or the egg?

DR. DEIRDRE CONROY:

And that’s such a good question and one that we are really interested in. Our group has actually come out with some data suggesting that it may be a little bit of both. One of the studies that we did looked at children of alcoholics and the moms rated their 3 to 5-year-old children on whether they had sleep difficulties and those children who had either trouble sleeping which is very general or staying awake during the day were actually more likely to develop early onset drinking or substance use. So kind of raises a question does problem sleeping make you more likely to develop a substance abuse problem down the road or is it that you have been using a substance for so long that some of the chemicals in your brain have changed, because we know that some of the neurotransmitters affected by alcohol are also those involved in sleep. So, right know it's a bit of a mystery and we are hoping to kind of attack both ends as that was looking at young children and their sleep problems and then those who have already developed substance use problems.

DR. LESLIE LUNDT:

Interesting well and isn't it true in adults that the most common self-medication for insomnia is alcohol?

DR. DEIRDRE CONROY:

That's right, that's right. It's very easy, it's you know, over-the-counter, they have some kind of control over it initially when they are starting out and it can spiral. You can no longer feel sleepy after those 2 drinks but then you increase to 3 and then 4 and that's where the problem comes in.

DR. LESLIE LUNDT:

You had mentioned sleep-disordered breathing is that more common in alcoholics than in a non-drinking population?

DR. DEIRDRE CONROY:

It is and again it’s something that can range from if the patient is actively drinking to when they are in withdrawal or former alcohol and specifically in example of alcohol dependent patient. Alcohol is a respiratory suppressant so if you have a patient who habitually has drinks before bedtime, studies do show that the likelihood of them having greater sleep-disordered breathing is higher and secondly studies have also shown that the patients who have stopped drinking also tend to have more sleep-disordered breathing and might be different mechanisms going on, but in general the substance abusing population, or I should say alcohol specifically, do have more sleep-disordered breathing than nonalcoholic.

DR. LESLIE LUNDT:

And how about periodic limb movements disorder is that more common as well?

DR. DEIRDRE CONROY:

That has also been shown to be higher in alcohol-dependent patients who are in recovery and of course the periodic limb movement disorders assessed in the sleep laboratory and the number of periodic limb movements per hour of sleep appear to be higher in these patients who have a history of heavy drinking in their lives. The connection is there. The mechanisms of why that’s happening is a still bit of mystery that could be related to the peripheral neuropathy line of thinking, but it's still being researched.

DR. LESLIE LUNDT:

If you are just joining us, you are listening to the Clinician's Roundtable on ReachMD XM157, The Channel For Medical Professionals. I am Dr. Leslie Lundt, your host, and with me today is Dr. Deirdre Conroy from the University of Michigan. We are discussing sleep disturbances in addicted patients.

Deirdre what do we know about other drugs, say marijuana, the so commonly used. Do you know much about its connection with sleep disorders?

DR. DEIRDRE CONROY:

Marijuana is an interesting one, with bedtime use of marijuana there are surprisingly very few studies. Some of the studies have been done in the 70s so they are kind of outdated now, but those tend to suggest more ease of falling asleep. The problem becomes in the withdrawal phase of marijuana. So patients will complain of difficulty falling asleep in marijuana withdrawal and this is actually both subjectively and objectively when they are in the sleep laboratory.

DR. LESLIE LUNDT:

And what do we know about in terms of marijuana or alcohol for that matter, how often is insomnia a trigger to relapse? Where they have been claimed about their sleep disturbance lead them back to their drug of choice.

DR. DEIRDRE CONROY:

It's quite common actually and that is 1 of the observations 1 of the addiction psychiatrist that we were with here found that many of the patients that he had that had been using alcohol complained of insomnia and those particular patients who had the complaint of insomnia were more likely to relapse and again we looked at both how the patients say they slept and we look at them in a sleep laboratory and there were number of different parameters that we looked at in the sleep including rapid eye movement sleep, how long it takes them to fall asleep, those predicted relapse to alcohol so is a very important period when they stop drinking and to look at how they are sleeping to prevent, hopefully if we were to treat, prevent relapse.

DR. LESLIE LUNDT:

Now you mentioned sleep study that sounds like that was in a research setting. When would a sleep study in this population be necessary in clinical practice?

DR. DEIRDRE CONROY:

In general clinical practice, it is important to ask a few questions about how the patient functions during the day. Anybody, number one, who reports falling asleep when they don't intend to, falling asleep at the wheel, in front of the television, those kinds of complaints in combination with a history of snoring, choking, or gasping in sleep may be suggestive of obstructive sleep apnea. So obstructive sleep apnea as well as periodic limb movement disorder when the patients may say they kick their legs frequently during the night or the bed partner say they kick those are considered primary sleep disorders and that would be indication for a sleep study. Generally, difficulty falling asleep or difficulty returning back to sleep suggests more insomnia symptoms, which we don’t always need a sleep study though in some cases they do.

DR. LESLIE LUNDT:

So how should a primary care doctor go about evaluating these patients that have history of addiction either actively or in recovery when they do complaint of poor sleep.

DR. DEIRDRE CONROY:

The best that would be a very thorough history and primary care physicians and all physicians are press for time, but it is important to really ask about the sleep and its relationship to the substance, but as I was mentioning its important to get the whole picture of what the sleep was like before the substance, how the substance change, did you sleep better when you are using the substance and since you stopped is your sleeping better or worse and the few questions about sleep-disordered breathing and sleepiness during the day are important questions to address with your patient.

DR. LESLIE LUNDT:

Do you help them to have a research, may be people can look online for what a good sleep history might look like?

DR. DEIRDRE CONROY:

Ya actually there are couple of web sites; 1 of the web site is from the national sleep foundation and that web site is www.sleepfoundation.org and that has a nice description of all different types of disorders what should I look for it gives example of sleep diaries which is a very valuable tool for clinicians like myself who monitor insomnia symptoms overtime. So it provides a lot of those different questionnaires and tools that a clinician can use. Second one is the American academy of sleep medicine web site and that's www.aasmnet.org.

DR. LESLIE LUNDT:

Okay great. Any last tips for how to manage these patients?

DR. DEIRDRE CONROY:

Well I think, in addition to getting the sleep study, a patient with insomnia can also respond well to any kind of behavioral, cognitive behavioral therapy that can be quite effective for these patients.

DR. LESLIE LUNDT:

Fantastic. Well thank you so much for being on this show today.

DR. DEIRDRE CONROY:

Thank you for having me.

We have been speaking with University of Michigan psychologist Dr. Deirdre Conroy about diagnosing insomnia and other sleep disorders in substance abusing patients. I am Dr. Leslie Lundt, you are listening ReachMD XM157, The Channel For Medical Professionals. For a complete program guide and downloadable of podcasts, visit our website at www.reachmd.com. For comments and questions or if you have ideas for future topics, please call us toll free at 888-MD.

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