1. Sleep Problems and Alcohol Use Disorders Fauzia Mahr, MD Penn State Milton S. Hershey Medical Center 1 © AMSP 2011

2. Scope of Problem 2 © AMSP 2011

3. Scope of Problem Insomnia cost > US $100 billion/yr. Insomnia cost > US $100 billion/yr. Alcohol related insomnia = $18.5 billion/yr. Alcohol related insomnia = $18.5 billion/yr. 7% US  alcohol abuse 7% US  alcohol abuse 10%  alcohol dependence. 10%  alcohol dependence. 3 © AMSP 2011

4. Insomnia & Functionality 2.5 X  motor vehicle accidents 2.5 X  motor vehicle accidents  quality of life  quality of life  productivity/job satisfaction  productivity/job satisfaction 4 © AMSP 2011

5. Other Consequences  depression / anxiety  depression / anxiety  immunity  immunity  B.P. / cardiovascular dx.  B.P. / cardiovascular dx.  mortality  mortality 5 © AMSP 2011

6. Sleep and Substances Alcohol, cocaine, caffeine  poor sleep Alcohol, cocaine, caffeine  poor sleep Poor sleep  risk substance use disorders (SUD’s) Poor sleep  risk substance use disorders (SUD’s) Alcohol + sleep  most studied Alcohol + sleep  most studied 6 © AMSP 2011

7. This Lecture Reviews Definitions : Sleep Definitions : Sleep Definitions: Substances Definitions: Substances Effects of alcohol on sleep Effects of alcohol on sleep Treatment Treatment 7 © AMSP 2011

8. Normal Sleep Reversible unresponsiveness to environment Reversible unresponsiveness to environment Two Stages Two Stages Rapid Eye Movement Sleep [ REM ] Rapid Eye Movement Sleep [ REM ] Non-Rapid Eye Movement Sleep [NREM] Non-Rapid Eye Movement Sleep [NREM] 8 © AMSP 2011

9. Normal Sleep Cycle 9 © AMSP 2011

10. NREM Sleep   First ½ of night     Serotonin / nor epinephrine Stage 1 and 2 = low arousal threshold Stage 1 and 2 = low arousal threshold Stage 3 and 4 = slow wave sleep =deep Stage 3 and 4 = slow wave sleep =deep 10 © AMSP 2011

11. NREM Stages  Stage 1  1-7 minutes  Stage 2  25 minutes  Stage 3 & 4  Time varies 11 © AMSP 2011

12. REM Sleep  2 nd ½ night  2 nd ½ night REM  dreaming, limb paralysis REM  dreaming, limb paralysis  Acetylcholine  Acetylcholine  Dopamine/ norepinephrine / epinephrine  Dopamine/ norepinephrine / epinephrine  With age  With age 12 © AMSP 2011

13. Sleep Definitions Sleep Latency  time to go to sleep Sleep Latency  time to go to sleep 15-20 minutes 15-20 minutes REM Latency  sleep to first REM episode REM Latency  sleep to first REM episode 90-120 minutes 90-120 minutes 13 © AMSP 2011

14. Insomnia Problem initiating sleep Problem initiating sleep Problem maintain sleep Problem maintain sleep Non-restful sleep Non-restful sleep Early morning awakening Early morning awakening 14 © AMSP 2011

15. DSM IV Primary Insomnia Difficulty starting / maintaining sleep X 1 month Difficulty starting / maintaining sleep X 1 month Disturbance   function Disturbance   function Disturbance  due to other condition Disturbance  due to other condition 15 © AMSP 2011

16. This Lecture Reviews Definitions : Sleep ✓ Definitions : Sleep ✓ Definitions: Substances Definitions: Substances Effects of alcohol on sleep Effects of alcohol on sleep Treatment Treatment 16 © AMSP 2011

17. Depressants  Depression of brain tissues Alcohol, benzodiazepines, barbiturates Alcohol, benzodiazepines, barbiturates  Sleep with intoxication  Sleep with intoxication  Sleep with withdrawal  Sleep with withdrawal 17 © AMSP 2011

18. Stimulants Stimulation of brain tissues Stimulation of brain tissues Cocaine, amphetamine, caffeine Cocaine, amphetamine, caffeine  Sleep with intoxication  Sleep with intoxication  Sleep with withdrawal  Sleep with withdrawal 18 © AMSP 2011

19. Alcohol CNS  depressant CNS  depressant Acute + chronic use disrupts sleep Acute + chronic use disrupts sleep 50% alcoholics use for sleep 50% alcoholics use for sleep Alc. as self medication 2X in alcoholics Alc. as self medication 2X in alcoholics 19 © AMSP 2011

20. Alcohol Use Disorders 20 © AMSP 2011 Alcohol abuse 1 + in same 12 mos.: -  Role obligations -Hazardous use -Legal problems -Interpersonal problems -  Dependence Alcohol dependence 3+ in same 12 mos: -Tolerance -Withdrawal -  Amts. -  Time -Desire/inability to  -  Other activities -  Consequences Alcohol withdrawal 2+: -  Sweating, pulse -Tremor -Nausea/vomitting -Insomnia -Anxiety/agitation -Seizures

21. This Lecture Reviews Definitions : Sleep ✓ Definitions : Sleep ✓ Definitions: Substances ✓ Definitions: Substances ✓ Effects of alcohol on sleep Effects of alcohol on sleep Treatment Treatment 21 © AMSP 2011

22. Alcohol Related Insomnia Insomnia in alcoholics 2X gen pop. Insomnia in alcoholics 2X gen pop.  Prevalence with :  Prevalence with :  Age  Age  Severity alcoholism  Severity alcoholism 7+ yrs. heavy drinking 7+ yrs. heavy drinking 22 © AMSP 2011

23. Acute Use and Sleep 1 st ½ Night : 1 st ½ Night :  Sleep latency  Sleep latency  REM  REM  Other stages  Other stages 23 © AMSP 2011

24. Acute Use and Sleep 2 nd ½ Night: 2 nd ½ Night:  Sleep quantity  Sleep quantity  Awakenings  Awakenings  REM  REM 24 © AMSP 2011

25. How Alcohol Disrupts Sleep Complex mechanism  involves HPA axis Complex mechanism  involves HPA axis 25 © AMSP 2011 ↑Corticotrophin Releasing Factor(CRF) ↑ Cortisol↑ Sleepiness

26. How Alcohol Disrupts Sleep 26 © AMSP 2011 ↓ Alcohol HPA reboundSleep Disturbance

27. Alcohol and Sleep Apnea Acute alcohol  inspiratory resistance Acute alcohol  inspiratory resistance Contributes to sleep apnea Contributes to sleep apnea 2 X sleep latency 2 X sleep latency 20% ↓ sleep time 20% ↓ sleep time 2 X ↑ premature death 2 X ↑ premature death 27 © AMSP 2011

28. This Lecture Reviews Definitions : Sleep ✓ Definitions : Sleep ✓ Definitions: Substances ✓ Definitions: Substances ✓ Effects of alcohol on sleep ✓ Effects of alcohol on sleep ✓ Treatment Treatment 28 © AMSP 2011

29. Treatment Guidelines  Assessment Education Education Sleep Assessment instruments Sleep Assessment instruments Behavior therapies Behavior therapies Medication Medication 29 © AMSP 2011

30. Assessment &Treatment Identify Alcohol use Identify Alcohol use Detailed history Detailed history Assessment instruments Assessment instruments 10 Item Alcohol Use disorder Identification Test [ AUDIT ] 10 Item Alcohol Use disorder Identification Test [ AUDIT ] 4 Item CAGE questionnaire 4 Item CAGE questionnaire 30 © AMSP 2011

31. Detoxification & Rehabilitation Physical exam & labs Physical exam & labs Reassurance Reassurance Benzodiazepines [BZDs] Benzodiazepines [BZDs] Motivate Motivate Therapy Therapy 31 © AMSP 2011

32. Education Sleep disruption due to Alcohol use Sleep disruption due to Alcohol use May persist up to 6 months May persist up to 6 months Sleeping pills may worsen problem Sleeping pills may worsen problem Body must adjust to  Alcohol Body must adjust to  Alcohol 32 © AMSP 2011

33. Pittsburg Rating Scale Pittsburg Rating Scale  Sleep self report  Sleep quality & disturbance Sleep prob. 1 mo. + Sleep prob. 1 mo. + 19 items / 7 Components 19 items / 7 Components Scores 0-21 Scores 0-21 33 © AMSP 2011

34. Sleep Diary Sleep Diary  Self assessment tool  No scoring  Daily x 2 weeks Continuity of sleep Continuity of sleep Weekly averages compared Weekly averages compared 34 © AMSP 2011

35. Continuity Of Sleep 35 © AMSP 2011 Time to bed Time to wake Minutes to fall asleep # & duration of wakings Final awakening Minutes awake in bed

36. Sleep Hygiene Sleep Hygiene  Good sleeping habits Same bedtime / wake time Same bedtime / wake time Use bed for sleep Use bed for sleep After 6 PM : After 6 PM :  alcohol,nicotine, caffeine & large meals  alcohol,nicotine, caffeine & large meals  Strenuous exercise  Strenuous exercise 36 © AMSP 2011

37. Cognitive Behavioral Therapy Avoids medication Avoids medication Time limited Time limited Targets cognitive distortions Targets cognitive distortions  Hopelessness Catastrophic thinking Catastrophic thinking Loss of control Loss of control 37 © AMSP 2011

38. Relaxation Training  Arousal  Arousal Collaborate to choose method Collaborate to choose method Progressive muscle relaxation Progressive muscle relaxation Diaphragmatic breathing Diaphragmatic breathing Biofeedback Biofeedback Meditation Meditation 38 © AMSP 2011

39. Melatonin Melatonin Melatonin Restores circadian rhythm Restores circadian rhythm Secreted by pineal gland Secreted by pineal gland Regulated by light stimulus Regulated by light stimulus  in alcoholism  in alcoholism Dose = 6 mg nightly Dose = 6 mg nightly 39 © AMSP 2011

40. Benzodiazepines Avoid if possible Avoid if possible Discourage daily use Discourage daily use  GABA  GABA Sedating Sedating Similar effect as Alcohol Similar effect as Alcohol Abuse / Dependence potential Abuse / Dependence potential 40 © AMSP 2011

41. Less Addictive Medication Eszopiclone (Lunesta) 10 mg Zolpidem ( Ambien) 10 mg Zaleplon ( Sonata ) 10 mg 41 © AMSP 2011

42. This Lecture Reviews Definitions : Sleep ✓ Definitions : Sleep ✓ Definitions: Substances ✓ Definitions: Substances ✓ Effects of alcohol on sleep ✓ Effects of alcohol on sleep ✓ Treatment ✓ Treatment ✓ 42 © AMSP 2011