Sleep Profile in Opioid Dependence: A Polysomnographic Case–Control Study

Dopamine D2 receptors in the accumbal core region mediates the effects of fentanyl on sleep-wakefulness

Fentanyl, a potent analgesic and addictive substance, significantly impacts sleep-wakefulness (S-W). Acutely, it promotes wake, whereas chronic abuse leads to severe sleep disruptions, including insomnia, which contributes to opioid use disorders (OUD), a chronic brain disease characterized by compulsive opioid use and harmful consequences. Although the critical association between sleep disruptions and fentanyl addiction is acknowledged, the precise mechanisms through which fentanyl influences sleep remain elusive. Recent studies highlight the role of the dopaminergic system of the nucleus accumbens (NAc) in S-W regulation, but its specific involvement in mediating fentanyl's effects on S-W remains unexplored. We hypothesized that dopamine D2 receptors mediate fentanyl-induced effects on S-W. To test this hypothesis, male C57BL/6J mice, instrumented with sleep recording electrodes and bilateral guide cannulas above the accumbal core region (NAcC), were utilized in this study. At dark onset, animals were bilaterally administered sulpiride (D2 receptors antagonist; 250 ng/side) in the NAcC followed by an intraperitoneal injection of fentanyl (1.2 mg/Kg). S-W was examined for the next 12 h. We found that systemic administration of fentanyl significantly increased wakefulness during the first 6 h of the dark which was followed by a significant increase in NREM and REM sleep during the second 6 h of the dark period. D2-receptor blockade significantly reduced this effect as evidenced by a significant reduction in fentanyl-induced wakefulness during first 6 h of dark period and sleep rebound during the second 6 h. Our findings suggest that D2 receptors in the NAcC plays a vital role in mediating the fentanyl-induced changes in S-W.

A randomized controlled trial of propofol-remifentanil total intravenous anesthesia and sevoflurane-fentanyl anesthesia on early postoperative fatigue in patients undergoing laparoscopic colorectal surgery

PURPOSE

Even after uncomplicated surgery, postoperative fatigue prevalence has been reported to be 30-80% for various surgeries. We evaluated postoperative fatigue according to anesthetic technique in patients who underwent colorectal surgery.

METHODS

One hundred thirty patients who underwent colorectal surgery were randomly assigned to either propofol-remifentanil total intravenous anesthesia (propofol-remifentanil group, n = 65) or sevoflurane-fentanyl anesthesia (sevoflurane-fentanyl group, n = 65). The primary outcome was the prevalence of postoperative fatigue, as defined by the Chalder Fatigue Questionnaire (total score ≥ 16), at 24 h postoperatively. Secondary outcomes were early postoperative complications during hospitalization and laboratory examination.

RESULTS

The final analyses included 127 patients. The prevalence of postoperative fatigue on the 1st postoperative day was lower in the propofol-remifentanil group than the sevoflurane-fentanyl group: 56.3% (36/64) in the propofol-remifentanil group and 73.0% (46/63) in the sevoflurane-fentanyl group (relative risk [RR] = 0.77, 95% confidence interval [CI] 0.59-1.00; P = 0.048). However, there was no difference between the two groups in postoperative fatigue at postoperative day 3. Other postoperative outcomes including the severity of pain and the incidence of nausea/vomiting were not different between the two groups, but postoperative atelectasis on chest X-ray was higher in the sevoflurane-fentanyl group (2/64 [3.1%] vs. 9/63 [14.3%], P = 0.025). C-reactive protein change from preoperative to postoperative day 1 and 5 was significantly lower in the propofol-remifentanil group (P = 0.044).

CONCLUSION

Propofol-remifentanil total intravenous anesthesia was associated with reduced postoperative fatigue at the 1st postoperative day compared with sevoflurane-fentanyl anesthesia. Clinical trial The Korean Clinical Research Registry (study identifier: KCT0006917, principal investigator's name: MiHye Park, date of registration: January 12, 2022).

The effects of sleep restriction during abstinence on oxycodone seeking: Sex-dependent moderating effects of behavioral and hypothalamic-pituitary-adrenal axis-related phenotypes

During opioid use and abstinence, sleep disturbances are common and are thought to exacerbate drug craving. In this study, we tested the hypothesis that sleep restriction during abstinence from oxycodone self-administration would increase drug seeking during extinction and footshock reinstatement tests. We also performed behavioral phenotyping to determine if individual variation in responses to stressors and/or pain are associated with oxycodone seeking during abstinence, as stress, pain and sleep disturbance are often co-occurring phenomena. Sleep restriction during abstinence did not have selective effects on oxycodone seeking for either sex in extinction and footshock reinstatement tests. Some phenotypes were associated with drug seeking; these associations differed by sex and type of drug seeking assessment. In female rats, pain-related phenotypes were related to high levels of drug seeking during the initial extinction session. In male rats, lower anxiety-like behavior in the open field was associated with greater drug seeking, although this effect was lost when correcting for oxycodone intake. Adrenal sensitivity prior to oxycodone exposure was positively associated with footshock reinstatement in females. This work identifies sex-dependent relationships between HPA axis function and opioid seeking, indicating that HPA axis function could be a therapeutic target for the treatment of opioid use disorder, with tailored approaches based on sex. Sleep disturbance during abstinence did not appear to be a major contributing factor to opioid seeking.

Sleep restriction during opioid abstinence affects the hypothalamic-pituitary-adrenal (HPA) axis in male and female rats

Hypothalamic-pituitary-adrenal (HPA) axis dynamics are disrupted by opioids and may be involved in substance abuse; this persists during withdrawal and abstinence and is associated with co-morbid sleep disruption leading to vulnerability to relapse. We hypothesized that chronic sleep restriction (SR) alters the HPA axis diurnal rhythm and the sexually dimorphic response to acute stressor during opioid abstinence. We developed a rat model to evaluate the effect of persistent sleep loss during opioid abstinence on HPA axis dynamics in male and female rats. Plasma ACTH and corticosterone were measured diurnally and in response to acute restraint stress in rats Before (control) compared to During subsequent opioid abstinence without or with SR. Abstinence, regardless of sleep state, led to an increase in plasma ACTH and corticosterone in the morning in males. There was a tendency for higher PM plasma ACTH during abstinence in SR males (p = 0.076). ACTH and corticosterone responses to restraint were reduced in male SR rats whereas there was a failure to achieve the post-restraint nadir in female SR rats. There was no effect of the treatments or interventions on adrenal weight normalized to body weight. SR resulted in a dramatic increase in hypothalamic PVN AVP mRNA and plasma copeptin in male but not female rats. This corresponded to the attenuation of the HPA axis stress response in SR males during opioid abstinence. We have identified a potentially unique, sexually dimorphic role for magnocellular vasopressin in the control of the HPA axis during opioid abstinence and sleep restriction.

Sleep disturbance as a therapeutic target to improve opioid use disorder treatment

Sleep health is an important factor across several physical and mental health disorders, and a growing scientific consensus has identified sleep as a critical component of opioid use disorder (OUD), both in the active disease state and during OUD recovery. The goal of this narrative review is to collate the literature on sleep, opioid use, and OUD as a means of identifying therapeutic targets to improve OUD treatment outcomes. Sleep disturbance is common and often severe in persons with OUD, especially during opioid withdrawal, but also in persons on opioid maintenance therapies. There is ample evidence that sleep disturbances including reduced total sleep time, disrupted sleep continuity, and poor sleep quality often accompany negative OUD treatment outcomes. Sleep disturbances are bidirectionally associated with several other factors related to negative treatment outcomes, including chronic stress, stress reactivity, low positive affect, high negative affect, chronic pain, and drug craving. This constellation of outcome variables represents a more comprehensive appraisal of the quality of life and quality of recovery than is typically assessed in OUD clinical trials. To date, there are very few clinical trials or experimental studies aimed at improving sleep health in OUD patients, either as a means of improving stress, affect, and craving outcomes, or as a potential mechanistic target to reduce opioid withdrawal and drug use behaviors. As such, the direct impact of sleep improvement in OUD patients is largely unknown, yet mechanistic and clinical research suggests that therapeutic interventions that target sleep are a promising avenue to improve OUD treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Suvorexant ameliorated sleep disturbance, opioid withdrawal, and craving during a buprenorphine taper

Increased orexin/hypocretin signaling is implicated in opioid withdrawal, sleep disturbances, and drug-seeking behaviors. This study examined whether a dual-orexin receptor antagonist would improve sleep and withdrawal outcomes when compared with placebo during a buprenorphine/naloxone taper. Thirty-eight participants with opioid use disorder were recruited to a clinical research unit and maintained on 8/2 to 16/4 mg of buprenorphine/naloxone treatment for 3 days before being randomized to 20 mg of suvorexant (n = 14), 40 mg of suvorexant (n = 12), or placebo (n = 12); 26 individuals completed the study. After randomization, participants underwent a 4-day buprenorphine/naloxone taper and 4-day post-taper observation period. Total sleep time (TST) was collected nightly with a wireless electroencephalography device and wrist-worn actigraphy; opioid withdrawal symptoms were assessed via the Subjective Opiate Withdrawal Scale (SOWS); and abuse potential was assessed on a 0- to 100-point visual analog scale of "High" every morning. A priori outcomes included two-group (collapsing suvorexant doses versus placebo) and three-group comparisons of area-under-the-curve (AUC) scores for TST, SOWS, and High. In two-group comparisons, participants receiving suvorexant displayed increased TST during the buprenorphine/naloxone taper and decreased SOWS during the post-taper period. In three-group comparisons, participants receiving 20 mg of suvorexant versus placebo displayed increased AUC for TST during the buprenorphine/naloxone taper, but there was no difference in SOWS among groups. There was no evidence of abuse potential in two- or three-group analyses. The results suggest that suvorexant might be a promising treatment for sleep and opioid withdrawal in individuals undergoing a buprenorphine/naloxone taper.

Zebrafish as a tool in the study of sleep and memory-related disorders

Sleep is an evolutionarily conserved phenomenon, being an essential biological necessity for the learning process and memory consolidation. The brain displays two types of electrical activity during sleep: slow-wave activity or non-rapid eye movement (NREM) sleep and desynchronized brain wave activity or rapid eye movement (REM) sleep. There are many theories about "Why we need to sleep?" among them the synaptic homeostasis. This theory proposes that the role of sleep is the restoration of synaptic homeostasis, which is destabilized by synaptic strengthening triggered by learning during waking and by synaptogenesis during development. Sleep diminishes the plasticity load on neurons and other cells to normalize synaptic strength. In contrast, it re-establishes neuronal selectivity and the ability to learn, leading to the consolidation and integration of memories. The use of zebrafish as a tool to assess sleep and its disorders is growing, although sleep in this animal is not yet divided, for example, into REM and NREM states. However, zebrafish are known to have a regulated daytime circadian rhythm. Their sleep state is characterized by periods of inactivity accompanied by an increase in arousal threshold, preference for resting place, and the "rebound sleep effect" phenomenon, which causes an increased slow-wave activity after a forced waking period. In addition, drugs known to modulate sleep, such as melatonin, nootropics, and nicotine, have been tested in zebrafish. In this review, we discuss the use of zebrafish as a model to investigate sleep mechanisms and their regulation, demonstrating this species as a promising model for sleep research.

Non-Opioid Neurotransmitter Systems that Contribute to the Opioid Withdrawal Syndrome: A Review of Preclinical and Human Evidence

Opioid misuse and abuse is a major international public health issue. Opioid use disorder (OUD) is largely maintained by a desire to suppress aversive opioid withdrawal symptoms. Opioid withdrawal in patients seeking abstinence from illicit or prescribed opioids is often managed by provision of a μ-opioid agonist/partial agonist in combination with concomitant medications. Concomitant medications are administered based on their ability to treat specific symptoms rather than a mechanistic understanding of the opioid withdrawal syndrome; however, their use has not been statistically associated with improved treatment outcomes. Understanding the central and/or peripheral mechanisms that underlie individual withdrawal symptom expression in humans will help promote medication development for opioid withdrawal management. To support focused examination of mechanistically supported concomitant medications, this review summarizes evidence from preclinical (N = 68) and human (N = 30) studies that administered drugs acting on the dopamine, serotonin, cannabinoid, orexin/hypocretin, and glutamate systems and reported outcomes related to opioid withdrawal. These studies provide evidence that each of these systems contribute to opioid withdrawal severity. The Food and Drug Administration has approved medications acting on these respective systems for other indications and research in this area could support the repurposing of these medications to enhance opioid withdrawal treatment. These data support a focused examination of mechanistically informed concomitant medications to help reduce opioid withdrawal severity and enhance the continuum of care available for persons with OUD.

Differential Effects of Addictive Drugs on Sleep and Sleep Stages

Addictive drugs affect sleep both in individuals currently using drugs and in individuals who have withdrawn from drugs. In fact, sleep disturbances are reported by individuals for some drugs long after they have quit taking them and after other withdrawal symptoms have subsided. This suggests that addictive drugs and sleep share some of the same neurobiological mechanisms. Sleep researchers may be studying the neurobiology of addictive drugs without knowing it. The purpose of this survey is to summarize the effects that addictive drugs have on sleep and stages of sleep. We demonstrate that different addictive drugs have differential effects on disturbance of sleep, in general, and on specific stages of sleep either while the drug is on board or after withdrawal. Accordingly, these results are intended to encourage sleep researchers to use their knowledge of sleep mechanisms to offer researchers of addictive drugs new insights of how addictive drugs might affect brain mechanisms. Also, these results should alert researchers of addiction that treatment for drug effects needs to consider treatment for sleep disturbances as well. Treatment for addiction is rarely accompanied by treatment for sleep disturbances even though this survey demonstrates they are clearly related.

Predictors of sleep disturbance in heroin users receiving methadone maintenance therapy: a naturalistic study in Taiwan

INTRODUCTION

Sleep disturbance is a major health concern for heroin users receiving methadone maintenance treatment (MMT). The present study was aimed to investigate the predictors for new-onset clinically predominant sleep disturbance (CPSD) among heroin users receiving MMT.

METHODS

This 2-year retrospective study included 152 individuals (127 males and 25 females) with heroin use disorder who visited our MMT clinics for the first time. A univariate Cox proportional hazards regression model (Cox model) was used to estimate the potential factors of subsequent CPSD, followed by a multivariate Cox model to identify significant predictors of CPSD after adjusting for other covariates.

RESULTS

Twenty-nine (19.1%) participants developed CPSD during the 2-year period. After forward selection in the Cox model, earlier age at onset of heroin exposure (OR=0.95; P=0.044), lower attendance rate (OR =0.04; P=0.03), greater maximum dose of methadone (OR =1.01; P=0.022), and shorter time to maximum methadone dose (OR =0.98; P=0.007) were significantly associated with new-onset CPSD.

CONCLUSION

We identified predictors that were significantly associated with new-onset CPSD, and clinicians should be aware of sleep disturbance in heroin users receiving MMT with these risk factors. Future studies are necessary to verify our findings and extend the applicability.

Incremental predictive validity of the Addiction Severity Index psychiatric composite score in a consecutive cohort of patients in residential treatment for drug use disorders

BACKGROUND

The Addiction Severity Index (ASI) is a widely used assessment instrument for substance abuse treatment that includes scales reflecting current status in seven potential problem areas, including psychiatric severity. The aim of this study was to assess the ability of the psychiatric composite score to predict suicide and psychiatric care after residential treatment for drug use disorders after adjusting for history of psychiatric care.

METHODS

All patients treated for drug use disorders in residential treatment centers in Denmark during the years 2000-2010 with complete ASI data were followed through national registers of psychiatric care and causes of death (N=5825). Competing risks regression analyses were used to assess the incremental predictive validity of the psychiatric composite score, controlling for previous psychiatric care, length of intake, and other ASI composite scores, up to 12years after discharge.

RESULTS

A total of 1769 patients received psychiatric care after being discharged from residential treatment (30.3%), and 27 (0.5%) committed suicide. After adjusting for all covariates, psychiatric composite score was associated with a higher risk of receiving psychiatric care after residential treatment (subhazard ratio [SHR]=3.44, p<0.001), and of committing suicide (SHR=11.45, p<0.001).

CONCLUSIONS

The ASI psychiatric composite score has significant predictive validity and promises to be useful in identifying patients with drug use disorders who could benefit from additional mental health treatment.

Sleep disturbances at the time of a new diagnosis: a comparative study of human immunodeficiency virus patients, cancer patients, and general population controls

OBJECTIVES

Sleep disturbances are a prevalent and troubling symptom of patients with highly stressful illnesses, such as human immunodeficiency virus (HIV) and cancer. The aim of this study was to compare the prevalence and incidence of sleep disturbances among persons with HIV, those with cancer, and the general population of Taiwan.

METHODS

A matched cohort study design was used to compare the risk of sleep disturbances among three groups using reimbursement claims recorded in Taiwan's National Health Insurance Research Database (NHIRD). A total of 14,531 HIV-infected persons were compared with 1493 cancer patients and 1373 general population controls matched by gender and age. Cox proportional hazard regression models were used to test the hazard risk of sleep disturbances among the groups.

RESULTS

The mean durations between the date of the initial HIV/cancer diagnosis and onset of sleep disturbances of HIV-infected persons, cancer patients, and controls were 1.7, 2.3, and 1.8 years, respectively. The risk of developing sleep disturbances was significantly higher in HIV-infected persons (adjusted hazard ratio [AHR] = 3.74, p < 0.001) and cancer patients (AHR = 2.72, p < 0.001) than in controls. HIV-infected persons had a 20% higher risk of sleep disturbances than cancer patients (AHR = 1.20, p < 0.001).

CONCLUSIONS

HIV-infected persons exhibited a higher risk of developing sleep disturbances than cancer patients and general population controls. With efficacious treatments for sleep disturbances, we should focus on training and research programs for health care providers to intervene and treat earlier for the present and future health of cancer patients and HIV-infected persons.

Obese Veterans Enrolled in a Veterans Affairs Medical Center Outpatient Weight Loss Clinic Are Likely to Experience Disordered Sleep and Posttraumatic Stress

STUDY OBJECTIVES

This cross-sectional study aimed to characterize sleep patterns, the quality and duration of sleep, and estimate the prevalence of common sleep disorders and posttraumatic stress disorder (PTSD) in a hospital-based Veterans Affairs MOVE! (Managing Overweight Veterans Everywhere) clinic.

METHODS

Participants completed five instruments: the Pittsburgh Sleep Quality Index (PSQI), Smith's Measure of Morningness/Eveningness, Restless Legs Syndrome Rating Scale, the STOP Questionnaire, and the Posttraumatic Stress Disorder (PTSD) Checklist - Civilian Version (PCL-C).

RESULTS

Enrolled Veterans (n = 96) were mostly male (78%), African American (49%), mean age 58 (standard deviation [SD] 10.6) years, and mean body mass index (BMI) 38.4 kg/m(2) (SD 8.4). By PSQI, 89% rated sleep quality as "poor" (mean = 11.1, SD = 5.1), consistent with severely impaired sleep. Most were at high risk for sleep disorders including restless leg syndrome (53%), obstructive sleep apnea (66%), and circadian sleep disorders (72%). Forty-seven percent endorsed clinically significant symptoms of PTSD. Hypotheses-generating regression models suggest sleep latency (minutes before falling asleep) was associated with BMI (p = 0.018). Bedtime, getting up time, hours of sleep, waking up in the middle of the night or early morning, having to get up to use the bathroom, inability to breathe comfortably, cough or snore loudly, feeling too cold or too hot, having bad dreams, pain, and frequency of having trouble sleeping, were not significantly associated with BMI.

CONCLUSIONS

Our cross-sectional study suggests that sleep difficulties are common among Veterans referred to a weight loss program at a Veterans Affairs Hospital. Controlled studies are needed to investigate whether the results are generalizable and whether obesity among veterans is a risk factor for sleep disorders and PTSD.

COMMENTARY

A commentary on this article appears in this issue on page 943.

A prospective, longitudinal study of sleep disturbance and comorbidity in opiate dependence (the ANRS Methaville study)

RATIONALE/OBJECTIVES

Sleep disturbance is frequent in opioid-dependent patients. To date, no data are available about the impact of methadone maintenance treatment on sleep disturbance. Using 1-year follow-up data from the Methaville trial, we investigated the impact of methadone initiation and other correlates on sleep disturbance in opioid-dependent patients.

METHODS

Sleep disturbance severity was evaluated using two items from different scales (Center for Epidemiological Studies Depression Scale for depression and Opiate Treatment Index). We assessed the effect of methadone and other correlates on sleep disturbance severity during follow-up (months 0, 6, and 12) using a mixed multinomial logistic regression model.

RESULTS

We included 173 patients who had 1-year follow-up data on sleep disturbance, corresponding to 445 visits. At enrolment, 60.5 % reported medium to severe sleep disturbance. This proportion remained stable during methadone treatment: 54.0 % at month 6 and 55.4 % at month 12. The final multivariate model indicated that younger patients (odds ratio (OR) [95 % CI] 0.95 [0.90-1.00]), patients with pain (OR [95 % CI] 2.45 [1.13-5.32]), patients with high or very high nicotine dependence (OR [95 % CI] 5.89 [2.41-14.39]), and patients at suicidal risk (2.50 [1.13-5.52]) had a higher risk of severe sleep disturbance. Because of collinearity between suicidal risk and attention deficit hyperactivity disorder (ADHD) symptoms, ADHD was not associated with sleep disturbance in the final model. Receiving methadone treatment had no significant effect on sleep disturbance.

CONCLUSIONS

Sleep disturbance is frequent among opioid-dependent patients. It can be regarded as an important signal of more complex psychiatric comorbidities such as suicidal risk and ADHD. However, sleep disturbance should not be considered an obstacle to methadone maintenance treatment (MMT) initiation or continuation.

Endogenous opiates and behavior: 2014

This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants). This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants).