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

Sleep Problems and Sleep Problems and Alcohol Use DisordersAlcohol Use Disorders

Fauzia Mahr, MDFauzia Mahr, MD

Penn State Milton S. Hershey Penn State Milton S. Hershey Medical CenterMedical Center

1© AMSP 2011

Scope of ProblemScope of Problem

2© AMSP 2011

Scope of ProblemScope 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 7% US alcohol abuse alcohol abuse

10% 10% alcohol dependence. alcohol dependence.

3© AMSP 2011

Insomnia & FunctionalityInsomnia & Functionality

2.5 X 2.5 X motor vehicle accidents motor vehicle accidents

quality of lifequality of life

productivity/job satisfactionproductivity/job satisfaction4© AMSP 2011

Other ConsequencesOther Consequences

depression / anxietydepression / anxiety

immunityimmunity

B.P. / cardiovascular dx.B.P. / cardiovascular dx.

mortalitymortality

5© AMSP 2011

Sleep and SubstancesSleep and Substances

Alcohol, cocaine, caffeine Alcohol, cocaine, caffeine poor sleep poor sleep

Poor sleep Poor sleep risk substance use risk substance use

disorders (SUD’s)disorders (SUD’s)

Alcohol + sleep Alcohol + sleep most studied most studied

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This Lecture ReviewsThis Lecture Reviews

Definitions : SleepDefinitions : Sleep

Definitions: SubstancesDefinitions: Substances

Effects of alcohol on sleepEffects of alcohol on sleep

TreatmentTreatment7© AMSP 2011

Normal SleepNormal Sleep

Reversible unresponsiveness to Reversible unresponsiveness to environmentenvironment

Two StagesTwo 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

Normal Sleep CycleNormal Sleep Cycle

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A PICTURE OF NORMAL SLEEP8-Hr EEG Recording in a Healthy Person

Hours in Bed

0 1 2 3 4 5 6 7 8

Slow-Wave Sleep (N3)

Stage 2 Sleep (N2)

Stage 1 Sleep (N1)

REM Sleep ( R )

Wake

NREM SleepNREM Sleep

First ½ of nightFirst ½ of night Serotonin / nor epinephrineSerotonin / nor epinephrine

Stage 1 and 2 = low arousal thresholdStage 1 and 2 = low arousal threshold

Stage 3 and 4 = slow wave sleep =deepStage 3 and 4 = slow wave sleep =deep

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NREM StagesNREM Stages

Stage 1 Stage 1 1-7 minutes1-7 minutes

Stage 2 Stage 2 25 minutes25 minutes

Stage 3 & 4 Stage 3 & 4 Time variesTime varies

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REM SleepREM Sleep

22ndnd ½ night ½ night

REM REM dreaming, limb paralysis dreaming, limb paralysis

AcetylcholineAcetylcholine

Dopamine/ norepinephrine / epinephrineDopamine/ norepinephrine / epinephrine

With ageWith age

12© AMSP 2011

Sleep DefinitionsSleep Definitions

Sleep Latency Sleep Latency time to go to sleeptime to go to sleep

15-20 minutes15-20 minutes

REM Latency REM Latency sleep to first REM sleep to first REM

episodeepisode

90-120 minutes90-120 minutes

13© AMSP 2011

InsomniaInsomnia

Problem initiating sleepProblem initiating sleep

Problem maintain sleepProblem maintain sleep

Non-restful sleepNon-restful sleep

Early morning awakeningEarly morning awakening

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DSM IV Primary InsomniaDSM IV Primary Insomnia

Difficulty starting / maintaining sleep Difficulty starting / maintaining sleep X 1 monthX 1 month

Disturbance Disturbance functionfunction

Disturbance Disturbance due to other condition due to other condition15© AMSP 2011


Definitions : Sleep Definitions : Sleep ✓✓

Definitions: SubstancesDefinitions: Substances



DepressantsDepressants

Depression of brain tissuesDepression of brain tissues

Alcohol, benzodiazepines, barbituratesAlcohol, benzodiazepines, barbiturates

Sleep with intoxicationSleep with intoxication

Sleep with withdrawalSleep with withdrawal

17© AMSP 2011

StimulantsStimulants

Stimulation of brain tissuesStimulation of brain tissues

Cocaine, amphetamine, caffeineCocaine, amphetamine, caffeine

Sleep with intoxicationSleep with intoxication

Sleep with withdrawalSleep with withdrawal

18© AMSP 2011

AlcoholAlcohol

CNS CNS depressant depressant

Acute + chronic use disrupts sleepAcute + chronic use disrupts sleep

50% alcoholics use for sleep50% alcoholics use for sleep

Alc. as self medication 2X in alcoholicsAlc. as self medication 2X in alcoholics

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Alcohol Use DisordersAlcohol 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



Definitions: Substances Definitions: Substances ✓✓



Alcohol Related InsomniaAlcohol Related Insomnia

Insomnia in alcoholics 2X gen pop.Insomnia in alcoholics 2X gen pop.

Prevalence with :Prevalence with :

AgeAge

Severity alcoholismSeverity alcoholism

7+ yrs. heavy drinking7+ yrs. heavy drinking

22© AMSP 2011

Acute Use and SleepAcute Use and Sleep

11stst ½ Night ½ Night::

Sleep latencySleep latency

REMREM

Other stagesOther stages

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Acute Use and SleepAcute Use and Sleep

22ndnd ½ Night: ½ Night:

Sleep quantitySleep quantity

AwakeningsAwakenings

REMREM24© AMSP 2011

How Alcohol Disrupts SleepHow Alcohol Disrupts Sleep

Complex mechanism Complex mechanism involves HPA axisinvolves HPA axis

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How Alcohol Disrupts SleepHow Alcohol Disrupts Sleep

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Alcohol and Sleep ApneaAlcohol and Sleep Apnea

Acute alcohol Acute alcohol inspiratory resistance inspiratory resistance

Contributes to sleep apneaContributes to sleep apnea

2 X sleep latency2 X sleep latency

20% ↓ sleep time20% ↓ sleep time

2 X 2 X ↑↑ premature death premature death

27© AMSP 2011




Effects of alcohol on sleep Effects of alcohol on sleep ✓✓


Treatment GuidelinesTreatment Guidelines

AssessmentAssessment

EducationEducation

Sleep Assessment instrumentsSleep Assessment instruments

Behavior therapiesBehavior therapies

MedicationMedication29© AMSP 2011

Assessment &TreatmentAssessment &Treatment

Identify Alcohol useIdentify Alcohol use Detailed historyDetailed history Assessment instrumentsAssessment instruments

10 Item Alcohol Use disorder 10 Item Alcohol Use disorder

Identification Test [ AUDIT ]Identification Test [ AUDIT ]

4 Item CAGE questionnaire4 Item CAGE questionnaire

30© AMSP 2011

Detoxification & Rehabilitation Detoxification & Rehabilitation

Physical exam & labsPhysical exam & labs

ReassuranceReassurance

Benzodiazepines [BZDs]Benzodiazepines [BZDs]

MotivateMotivate

TherapyTherapy

31© AMSP 2011

EducationEducation

Sleep disruption due to Alcohol useSleep disruption due to Alcohol use

May persist up to 6 monthsMay persist up to 6 months

Sleeping pills may worsen problemSleeping pills may worsen problem

Body must adjust to Body must adjust to Alcohol Alcohol

32© AMSP 2011

Pittsburg Rating ScalePittsburg Rating Scale

Sleep self reportSleep self report

Sleep quality & disturbanceSleep quality & disturbance

Sleep prob. 1 mo. +Sleep prob. 1 mo. +

19 items / 7 Components19 items / 7 Components

Scores 0-21Scores 0-21

33© AMSP 2011

Sleep DiarySleep Diary

Self assessment toolSelf assessment tool

No scoringNo scoring

Daily x 2 weeksDaily x 2 weeks

Continuity of sleepContinuity of sleep

Weekly averages comparedWeekly averages compared

34© AMSP 2011

Continuity Of SleepContinuity Of Sleep

35© AMSP 2011

Time to bed

Time to wake

Minutes to fall asleep

# & duration of wakings

Final awakening

Minutes awake in bed

Sleep HygieneSleep Hygiene

Good sleeping habitsGood sleeping habits Same bedtime / wake timeSame bedtime / wake time Use bed for sleepUse bed for sleep After 6 PM :After 6 PM :

alcohol ,nicotine , caffeine & large alcohol ,nicotine , caffeine & large mealsmeals

Strenuous exercise Strenuous exercise

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Cognitive Behavioral TherapyCognitive Behavioral Therapy

Avoids medicationAvoids medication Time limitedTime limited Targets cognitive distortionsTargets cognitive distortions

HopelessnessHopelessness Catastrophic thinkingCatastrophic thinking Loss of controlLoss of control

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Relaxation TrainingRelaxation Training

ArousalArousal

Collaborate to choose methodCollaborate to choose method

Progressive muscle relaxationProgressive muscle relaxation

Diaphragmatic breathingDiaphragmatic breathing

BiofeedbackBiofeedback

MeditationMeditation38© AMSP 2011

MelatoninMelatonin

MelatoninMelatonin Restores circadian rhythmRestores circadian rhythm Secreted by pineal glandSecreted by pineal gland Regulated by light stimulusRegulated by light stimulus in alcoholismin alcoholism

Dose = 6 mg nightlyDose = 6 mg nightly

39© AMSP 2011

BenzodiazepinesBenzodiazepines

Avoid if possibleAvoid if possible

Discourage daily useDiscourage daily use

GABA GABA

SedatingSedating

Similar effect as AlcoholSimilar effect as Alcohol

Abuse / Dependence potentialAbuse / Dependence potential40© AMSP 2011

Less Addictive MedicationLess Addictive Medication

Eszopiclone (Lunesta) 10 mg

Zolpidem ( Ambien) 10 mg

Zaleplon ( Sonata ) 10 mg

41© AMSP 2011

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

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