Sleeplessness Increases Risk of Relapse for Some But Not Others

For some patients in recovery from alcohol use disorder, sleep disturbances can be common and persistent. While some studies have supported the association between sleep disturbances and risk of relapse, small sample sizes and use of unvalidated measures have limited the field’s ability to draw definitive conclusions.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

This study aimed to use more rigorous methods to investigate the relationship between sleep disturbances at time of admission/discharge from residential treatment and relapse over 12 months. The authors also examined the relationship between relapse and patients’ self-reported use of alcohol/hypnotics, explicitly stated to help them fall asleep.

HOW WAS THIS STUDY CONDUCTED?

To examine the relationship between sleep disturbances and relapse risk, researchers recruited patients with DSM-IV alcohol dependence who were admitted to the 30-day residential Intensive Addiction Program (IAP) at the Mayo Clinic between June 2009 and June 2010.

For this analysis focusing solely on alcohol addiction, patients with a different drug use disorder or who had used drugs in the prior 6 months were excluded, resulting in an eligible sample of 119 patients. Sleep quality over the past 4 weeks was assessed using the Pittsburgh Sleep Quality Index (PSQI), and alcohol relapse was measured over the 12 months following treatment. This self-report questionnaire includes seven sub-scales measuring how long it takes people to fall asleep (sleep latency), duration, disturbance, habitual sleep efficiency, quality, daytime dysfunction related to sleep difficulties, and medication use; a score over 5 indicates sleep disturbance.

WHAT DID THIS STUDY FIND?

During treatment, 52 patients reported that they used alcohol explicitly to help them fall asleep.

Sixty-nine percent of patients had sleep disturbances upon admission as indicated by a score over 5 on the PSQI. This decreased to 49% at discharge; however, 9% of patients developed sleep disturbances while in the treatment program. During the 12-months following discharge, contact was made with 73 patients (61%). Of these, 35 patients (48%) relapsed during the 12-month follow-up period.

Sleep disturbance (i.e., PSQI score) was not associated with relapse at 12 months and patients with a PSQI score greater than 5 were not at increased risk of relapse at 12 months.

However, of note, for patients who reported using alcohol specifically to fall asleep, the risk of relapse was over 3 times higher. This risk of relapse was 4 times higher for patients who were taking hypnotic medication at the time of admission.

Sleep disturbance is common in early recovery and can lead to disruption of normal functioning. Contrary to the author’s hypothesis, sleep disturbance may not negatively influence relapse risk overall, however, it does impact relapse risk if patients report using alcohol specifically as a sleep aid when they come in to treatment.

WHY IS THIS STUDY IMPORTANT?

In studies that examine sleep in context of alcohol recovery, rates of sleep problems range from 25 to 72 percent. It is important to identify and determine causes of these disturbances and treat them appropriately as persistent sleep disturbances can increase stress and negatively impact the recovery process. Since medications for insomnia and sleep disturbance have the potential for misuse (e.g., zolpidem, brand name Ambien), this can be a difficult condition to treat for people in early stages of recovery.

Understanding the reasoning behind the use of alcohol and other drugs is critical for ensuring proper treatment. Patients who used these substances for the purpose of falling asleep were more likely to experience a relapse in the 12 months following treatment discharge.

By assessing the functional reasons for using alcohol (i.e., inquiring specifically whether patients use alcohol to help them fall asleep), clinicians can address patients’ substance use and sleep-related issues concurrently, help the patient become more aware of this relapse risk, and help the patient find and deploy alternative strategies to prevent relapse. For example, cognitive-behavioral strategies may help patients challenge automatic thoughts about alcohol consumption as an effective way to help them sleep better.

LIMITATIONS

This study sample consisted of alcohol dependent patients who were largely older, male, and White, which limits the generalizability of the results.
Additionally, this study was conducted in a healthcare setting so patients without access to treatment may experience outcomes differently.

NEXT STEPS

Future research is needed to determine if sleep is truly not associated with relapse among patients with alcohol use disorders or if patients with sleep disturbances are compensating in other ways (e.g., exercise or social support) such that positive involvement in these other areas counteract the negative effects of poor sleep.

Replications are needed to help determine how robust the current set of findings are and if other patient samples (including those with other drug use disorders or mixed substance use disorders) show similar effects if they report use of a substance to help them sleep.

BOTTOM LINE

For individuals & families seeking recovery: If alcohol was used as a sleep aid, consult an addiction specialist to find an appropriate treatment for sleep disturbances within the context of recovery from alcohol addiction.
For scientists: More research is needed in different samples (e.g., more diverse and/or non-treatment samples) to determine if specific subgroups of patients experiencing sleep disturbances may be at increased risk of relapse.
For policy makers: More funding for sleep-related research in the context of substance use disorder recovery is needed.
For treatment professionals and treatment systems: Quality sleep is vital for efficient cognitive processing and optimal behavioral functioning and can be crucial for helping individuals cope with stress and sustain recovery. If your patient is experiencing sleep disturbances, make sure they are not relying on alcohol or hypnotic medications to fall asleep, and work with them to determine an appropriate alternative remedy.

CITATIONS

Kolla, B. P., Schneekloth, T., Mansukhani, M. P., Biernacka, J. M., Hall-Flavin, D., Karpyak, V., . . . Frye, M. A. (2015). The association between sleep disturbances and alcohol relapse: A 12-month observational cohort study. Am J Addict, 24(4), 362-367. doi: 10.1111/ajad.12199