Treatment of sleep disturbance in alcohol recovery: a national survey of addiction medicine physicians

Civil Commitment for Substance Use Disorders: A National Survey of Addiction Medicine Physicians

BACKGROUND

Civil commitment (CC) for substance use disorders (SUDs) is a legal mechanism, initiated by family members, healthcare professionals, or others, that compels individuals with substance use problems into involuntary treatment. With the recent rise of US overdose deaths, more states are considering these laws. Yet little is known about physicians' perspectives regarding CC in treating patients with SUDs.

METHODS

We conducted a web-based survey of American Society of Addiction Medicine (ASAM) physician members regarding their awareness of, attitudes towards, and experiences with CC for adults with SUDs.

RESULTS

One hundred sixty-five addiction physicians completed the survey; 60.7% favored, 21.5% opposed, and 17.8% were unsure regarding CC for SUDs. More than a third (38.4%) were unfamiliar with these laws and more than a quarter (28.8%) were unsure if CC for SUDs was permitted in their state. Support for CC was strongest for SUDs involving heroin (79.0%), alcohol (74.7%), and nonheroin opioids (74.7%). Those opposing CC were more likely to believe it would jeopardize patient rapport (P < 0.001), would be ineffective for unmotivated individuals (P < 0.001), and should only be permitted for certain substances (P = 0.007). A majority of respondents endorsed the need for more clinician education (91.5%) and research (87.1%) on this topic.

CONCLUSIONS

Although most addiction physicians in this study approve of CC for SUDs, enthusiasm for this compulsory intervention is mixed with strongest support for patients with opioid and alcohol use disorders. At the same time, many respondents are unfamiliar with these laws and most believe more education and research are needed.

Treatment Disruption and Childcare Responsibility as Risk Factors for Drug and Alcohol Use in Persons in Treatment for Substance Use Disorders During the COVID-19 Crisis

The novel 2019 coronavirus (COVID-19) crisis has caused considerable upheaval in the U.S. healthcare system. The current study examined patient-reported experiences in substance use disorder (SUD) treatment during the early stages of the COVID-19 crisis.

Relationships between insomnia and alcohol and cocaine use frequency with aggression among veterans engaged in substance use treatment

BACKGROUND

Veterans with substance use problems have rates of partner and non-partner violence that typically exceed the general population. Sleep problems may exacerbate violence and maintain addictive behaviors in non-veterans, but requires study in veterans. Therefore, we examine the interrelationships between substance use, insomnia, and violence in veterans.

METHODS

Veterans (N = 762) screened for a randomized controlled trial at veterans affairs mental health and substance use clinics. Participants completed modified Conflict Tactics Scales to quantify past-year violence and the Insomnia Symptom Questionnaire to assess sleep disturbance. We evaluated associations between substance use and sleep in predicting the target of aggression (partner or non-partner) and degree of violence (aggression or injury) using binomial logistic regressions.

RESULTS

Half of participants endorsed symptoms suggestive of insomnia, 23.2% endorsed physical aggression toward partners (PA-P) and 33.9% non-partners (PA-NP), and 9.7% endorsed physical injury of partners (PI-P) and 17.6% of non-partners (PI-NP). Regressions revealed significant models for PA-P, PA-NP, and PI-NP, whereas the PI-P model was not significant. PA-P was higher among non-Caucasian race and older veterans. PA-NP was more common in those with insomnia and increased with frequency of cocaine use. Insomnia moderated the relationship between cocaine use and PA-NP; there was a weaker relationship between cocaine use and PA-NP in those with insomnia. PI-NP was more common with higher frequency of alcohol and cocaine use, and in those with insomnia.

CONCLUSIONS

This study finds sleep disturbances are meaningful predictors of violence among veterans with differential relationships with aggression severity, victims, and substance use concurrence.

Current and potential pharmacological treatment options for insomnia in patients with alcohol use disorder in recovery

Alcohol use disorder (AUD) is characterized by dysfunction in motivational, mood-stress regulation, and sleep systems that interact in complex ways to heighten the risk of relapse during abstinence. Emerging data suggest that excessive and chronic alcohol use disrupts sleep homeostasis and, in abstinence, subjects with AUD are known to experience insomnia that may persist for weeks to years, which we propose to refer to as insomnia associated with alcohol cessation (IAAC). The purpose of this review is to provide an update of pharmacological approaches to therapy including compounds in development, to raise awareness of the prevalence of and unmet need in IAAC and highlight differences in treatment consideration for IAAC as compared to insomnia disorder. We performed a search of select electronic databases to identify studies of pharmacological agents used to treat sleep disturbances in abstinent or treatment-seeking patients with alcohol use disorder. The search, conducted in June 2019 and updated in December 2019, yielded 1,188 abstracts after duplicates were removed, of which 36 full-text articles were assessed for eligibility. Eighteen studies were included, 15 randomized controlled trials and three open-label studies. Several classes of medications including antidepressants, anticonvulsants, and antipsychotics have been evaluated for their effectiveness in treating sleep disturbances in abstinent or treatment-seeking patients with AUD. None of these medications are approved by the FDA for the treatment of IAAC, and the currently available evidence for these agents is limited. Randomized, controlled clinical trials are warranted to evaluate the efficacy and safety of medications in the treatment of IAAC.

Eszopiclone for insomnia

BACKGROUND

Insomnia is a major public health issue affecting between 6% to 10% of the adult population in Western countries. Eszopiclone is a hypnotic drug belonging to a newer group of hypnotic agents, known as new generation hypnotics, which was marketed as being just as effective as benzodiazepines for this condition, while being safer and having a lower risk for abuse and dependence. It is the aim of the review to integrate evidence from randomised controlled trials and to draw conclusions on eszopiclone's efficacy and safety profile, while taking methodological features and bias risks into consideration.

OBJECTIVES

To assess the efficacy and safety of eszopiclone for the treatment of insomnia compared to placebo or active control.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, Embase, PsycINFO, PSYNDEX and registry databases (WHO trials portal, ClinicalTrials.gov) with results incorporated from searches to 10 February 2016. To identify trials not registered in electronic databases, we contacted key informants and searched reference lists of identified studies. We ran an update search (21 February 2018) and have placed studies of interest in awaiting classification/ongoing studies. These will be incorporated into the next version of the review, as appropriate.

SELECTION CRITERIA

Parallel group randomised controlled trials (RCTs) comparing eszopiclone with either placebo or active control were included in the review. Participants were adults with insomnia, as diagnosed with a standardised diagnostic system, including primary insomnia and comorbid insomnia.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted outcome data; one reviewer assessed trial quality and the second author cross-checked it.

MAIN RESULTS

A total of 14 RCTs, with 4732 participants, were included in this review covering short-term (≤ 4 weeks; 6 studies), medium-term (> 4 weeks ≤ 6 months; 6 studies) and long-term treatment (> 6 months; 2 studies) with eszopiclone. Most RCTs included in the review included participants aged between 18 and 64 years, three RCTs only included elderly participants (64 to 85 years) and one RCT included participants with a broader age range (35 to 85 years). Seven studies considered primary insomnia; the remaining studies considered secondary insomnia comorbid with depression (2), generalised anxiety (1), back pain (1), Parkinson's disease (1), rheumatoid arthritis (1) and menopausal transition (1).Meta-analytic integrations of participant-reported data on sleep efficacy outcomes demonstrated better results for eszopiclone compared to placebo: a 12-minute decrease of sleep onset latency (mean difference (MD) -11.94 min, 95% confidence interval (CI) -16.03 to -7.86; 9 studies, 2890 participants, moderate quality evidence), a 17-minute decrease of wake time after sleep onset (MD -17.02 min, 95% CI -24.89 to -9.15; 8 studies, 2295 participants, moderate quality evidence) and a 28-minute increase of total sleep time (MD 27.70 min, 95% CI 20.30 to 35.09; 10 studies, 2965 participants, moderate quality evidence). There were no significant changes from baseline to the first three nights after drug discontinuation for sleep onset latency (MD 17.00 min, 95% CI -4.29 to 38.29; 1 study, 291 participants, low quality evidence) and wake time after sleep onset (MD -6.71 min, 95% CI -21.25 to 7.83; 1 study, 291 participants, low quality evidence). Adverse events during treatment that were documented more frequently under eszopiclone compared to placebo included unpleasant taste (risk difference (RD) 0.18, 95% CI 0.14 to 0.21; 9 studies, 3787 participants), dry mouth (RD 0.04, 95% CI 0.02 to 0.06; 6 studies, 2802 participants), somnolence (RD 0.04, 95% CI 0.02 to 0.06; 8 studies, 3532 participants) and dizziness (RD 0.03, 95% CI 0.01 to 0.05; 7 studies, 2933 participants). According to the GRADE criteria, evidence was rated as being of moderate quality for sleep efficacy outcomes and adverse events and of low quality for rebound effects and next-day functioning.

AUTHORS' CONCLUSIONS

Eszopiclone appears to be an efficient drug with moderate effects on sleep onset and maintenance. There was no or little evidence of harm if taken as recommended. However, as certain patient subgroups were underrepresented in RCTs included in the review, findings might not have displayed the entire spectrum of possible adverse events. Further, increased caution is required in elderly individuals with cognitive and motor impairments and individuals who are at increased risk of using eszopiclone in a non-recommended way.

Insomnia treatment in the context of alcohol use disorder: A systematic review and meta-analysis

PURPOSE

To determine the efficacy of behavioral and pharmacological interventions for insomnia among individuals with alcohol use disorder (AUD).

PROCEDURES

Comprehensive literature searches of psychological, medical, and educational databases were conducted through October 2016. Eligible studies evaluated the efficacy of an insomnia intervention, included a comparison condition, sampled individuals with AUD and either insomnia disorder or complaints of insomnia, assessed sleep-related outcomes, and provided relevant statistics to calculate between-group effect sizes. Effect sizes were estimated for sleep quality, days of alcohol abstinence, and symptoms of depression. Type of intervention (behavioral versus pharmacological) was tested as a moderator of intervention efficacy.

MAIN FINDINGS

Nine studies met eligibility criteria and were included in the final review and meta-analysis. Random-effects models indicated that intervention participants reported greater improvements in sleep quality (d+=0.62, 95% CI=0.28, 0.97) and symptoms of depression (d+=0.52, 95% CI=0.06, 0.98) than control participants. Participants reported significantly greater improvements in sleep quality in response to behavioral (d+=1.20, 95% CI=0.70, 1.70) as opposed to pharmacological (d+=0.43, 95% CI=0.19, 0.67) interventions. Behavioral (d+=0.74, 95% CI=0.31, 1.18) and pharmacological (d+=0.08, 95% CI=-0.64, 0.78) interventions did not have significantly different effects on depressive symptoms. Neither behavioral nor pharmacological interventions improved rates of alcohol abstinence.

CONCLUSIONS

Insomnia interventions improve sleep quality and reduce symptoms of depression among individuals with comorbid AUD. Given the methodological weaknesses of studies reviewed, additional research is needed to determine the efficacy of insomnia treatment in improving rates of alcohol relapse within this population.

Alcohol Dependence and Its Relationship With Insomnia and Other Sleep Disorders

Sleep-related complaints are widely prevalent in those with alcohol dependence (AD). AD is associated not only with insomnia, but also with multiple sleep-related disorders as a growing body of literature has demonstrated. This article will review the various aspects of insomnia associated with AD. In addition, the association of AD with other sleep-related disorders will be briefly reviewed. The association of AD with insomnia is bidirectional in nature. The etiopathogenesis of insomnia has demonstrated multiple associations and is an active focus of research. Treatment with cognitive behavioral therapy for insomnia is showing promise as an optimal intervention. In addition, AD may be associated with circadian abnormalities, short sleep duration, obstructive sleep apnea, and sleep-related movement disorder. The burgeoning knowledge on insomnia associated with moderate-to-severe alcohol use disorder has expanded our understanding of its underlying neurobiology, clinical features, and treatment options.

Primary Care Management of Alcohol Misuse

More than one in four American adults consume alcohol in quantities exceeding recommended limits. One in 12 have an alcohol use disorder marked by harmful consequences. Both types of alcohol misuse contribute to acute injury and chronic disease, making alcohol the third largest cause of preventable death in the United States. Alcohol misuse alters the management of common conditions from insomnia to anemia. Primary care providers should screen adult patients to identify the full spectrum of alcohol misuse. A range of effective treatments are available - from brief counselling interventions and mutual help groups to medications and behavioral therapies.

Assessment and treatment of insomnia in adult patients with alcohol use disorders

Insomnia in patients with alcohol dependence has increasingly become a target of treatment due to its prevalence, persistence, and associations with relapse and suicidal thoughts, as well as randomized controlled studies demonstrating efficacy with behavior therapies and non-addictive medications. This article focuses on assessing and treating insomnia that persists despite 4 or more weeks of sobriety in alcohol-dependent adults. Selecting among the various options for treatment follows a comprehensive assessment of insomnia and its multifactorial causes. In addition to chronic, heavy alcohol consumption and its effects on sleep regulatory systems, contributing factors include premorbid insomnia; co-occurring medical, psychiatric, and other sleep disorders; use of other substances and medications; stress; environmental factors; and inadequate sleep hygiene. The assessment makes use of history, rating scales, and sleep diaries as well as physical, mental status, and laboratory examinations to rule out these factors. Polysomnography is indicated when another sleep disorder is suspected, such as sleep apnea or periodic limb movement disorder, or when insomnia is resistant to treatment. Sobriety remains a necessary, first-line treatment for insomnia, and most patients will have some improvement. If insomnia-specific treatment is needed, then brief behavioral therapies are the treatment of choice, because they have shown long-lasting benefit without worsening of drinking outcomes. Medications work faster, but they generally work only as long as they are taken. Melatonin agonists; sedating antidepressants, anticonvulsants, and antipsychotics; and benzodiazepine receptor agonists each have their benefits and risks, which must be weighed and monitored to optimize outcomes. Some relapse prevention medications may also have sleep-promoting activity. Although it is assumed that treatment for insomnia will help prevent relapse, this has not been firmly established. Therefore, insomnia and alcohol dependence might be best thought of as co-occurring disorders, each of which requires its own treatment.

The Association of Alcohol Severity and Sleep Quality in Problem Drinkers

AIMS

The association between alcohol use and sleep problems is well established and clinically meaningful, particularly as predictors of relapse. This study aims to elucidate the relationship between sleep disturbances and alcohol problems in a non-treatment-seeking community sample using an alcoholism problem severity factor.

METHODS

Participants were problem drinkers (N = 295) from the Los Angeles community who had a breath alcohol content (BrAC) of 0.00 g/dl when they completed an in-person assessment battery comprised of measures of sleep quality, anxiety and depression, cigarette smoking, as well as multiple assessments of alcohol use and alcohol use problems.

RESULTS

A series of hierarchical regressions showed that alcohol problem severity explained a significant amount of variance in sleep disturbance beyond demographic, mood and smoking variables. Alcohol problem severity was predictive of the PSQI global score (B = 1.11, P < 0.001), perceived sleep quality factor (B = 0.18, P < 0.001) and daily disturbance factor (B = 0.28, P < 0.001). However, contrary to study hypothesis, alcohol problem severity was predictive of improved sleep efficiency (B = -0.14, P < 0.05).

CONCLUSIONS

In sum, alcohol problem severity may be predictive of sleep disturbances. Given the complex nature of these relationships, further work is needed to develop adequate treatment for sleep disturbance during alcohol recovery. Nonetheless, this study suggests that as alcohol problem severity increases so do sleep problems. Thus, attending to sleep problems at early stages of alcohol problems may be warranted.

Sleep Disturbances in Individuals with Alcohol-Related Disorders: A Review of Cognitive-Behavioral Therapy for Insomnia (CBT-I) and Associated Non-Pharmacological Therapies

Sleep disturbances are common among alcohol-dependent individuals and are often associated with relapse. The utility of behavioral therapies for sleep disturbances, including cognitive-behavioral therapy for insomnia (CBT-I), among those with alcohol-related disorders is not well understood. This review systematically evaluates the evidence of CBT-I and related behavioral therapies applied to those with alcohol-related disorders and accompanying sleep disturbances. A search of four research databases (PubMed, PsycINFO, Embase, and CINAHL Plus) yielded six studies that met selection criteria. Articles were reviewed using Cochrane's Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) scoring system. A majority of the studies demonstrated significant improvements in sleep efficiency among behavioral therapy treatment group(s), including but not limited to CBT-I. While behavioral sleep interventions have been successful in varied populations, they may not be utilized to their full potential among those with alcohol-related disorders as evidenced by the low number of studies found. These findings suggest a need for mixed-methods research on individuals' sleep experience to inform interventions that are acceptable to the target population.

Quetiapine versus trazodone in reducing rehospitalization for alcohol dependence: a large data-base study

Clinicians commonly use nonindicated (or "off-label") medications for the treatment of alcoholism, although there is no clear evidence to support this practice. Quetiapine and trazodone are 2 medications frequently used in this manner, especially to treat sleep disturbance associated with alcohol withdrawal. Using national administrative data from the Department of Veterans Affairs, we compared the differences among these medications in time to rehospitalization after discharge from an index hospitalization for alcohol dependence. Our outcome measure was the difference in time (weeks) to rehospitalization for patients given medications in 1 of 4 groups: quetiapine alone (median, 6.1 weeks); trazodone alone (median, 10.1 weeks); quetiapine combined (median, 7.1 weeks); and trazodone combined (median, 10.3 weeks) with other frequently used psychotropic drugs. Differences between groups were examined with Cox's proportional hazards regression using trazodone in combination with other medications as the reference category. Crude hazard ratios were determined first and then adjusted for covariates. There was no difference in the risk of rehospitalization when patients using quetiapine in combination were compared with the reference category (hazard ratio [HR] = 1.08; confidence interval [CI], 0.99-1.17; P < 0.0936). In contrast, when quetiapine was used alone there was a significantly higher risk of rehospitalization (HR = 1.22; CI = 1.06-1.41; P < 0.005). When trazodone was used alone there was no difference in risk in the unadjusted analysis (HR = 1.05; CI = 0.96-1.14; P < 0.3076); however, the HR increased to a significant level after adjusting for covariates (HR, 1.14; CI = 1.05-1.24; P < 0.0029) and for those with 2+ previous discharges (HR = 1.25; CI = 1.14-1.37; P < 0.0001). These findings suggest the need for additional studies to better understand what symptoms of alcoholism benefit from the use of these medications, at what dose levels, and with what other medication combinations.

Sleep and gambling severity in a community sample of gamblers

Although sleep has been extensively studied in substance related disorders, it has yet to be examined as thoroughly in gambling-related disorders. The purpose of this study is to examine the relationship between gambling severity and sleep disturbances in a sample of non-treatment seeking gamblers (N = 96) using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). Mean ESS scores for recreational, problem, and pathological gamblers were 4.13, 5.81, and 8.69, respectively, with a significant difference between pathological gamblers and both problem (P = .007) and recreational gamblers (P < .001). Mean PSQI scores for recreational, problem, and pathological gamblers were 3.35, 5.30, and 5.44, respectively, with a significant difference in sleep quality between recreational and problem gamblers (P = .018), as well as recreational and pathological gamblers (P = .008). As the first study to use objective sleep measures, these findings will not only increase awareness of this relationship, but also provide a foundation on which others can investigate the benefits of screening and adjunct treatment for sleep disorders in the gambling population.

Trazodone for sleep disturbance during methadone maintenance: a double-blind, placebo-controlled trial

BACKGROUND

To test whether trazodone, one of the most commonly prescribed medications for treatment of insomnia, improves subjective and/or objective sleep among methadone-maintained persons with sleep complaints, we performed a randomized, double-blind, placebo-controlled trial with 6-month follow-up.

METHODS

From eight methadone maintenance programs in the northeastern United States, we recruited 137 persons receiving methadone for at least 1 month who reported a Pittsburgh Sleep Quality Index (PSQI) score of six or higher. Two-night home polysomnography (PSG) was completed at baseline and 1 month later, with morning surveys and urine drug toxicologies. Interviews assessed sleep over the past 30 days at baseline and 1-, 3-, and 6-month follow-ups.

RESULTS

Participants averaged 38 years of age, were 47% male, and had a mean PSQI total score of 12.9 (±3.1). At baseline, intervention groups did not significantly differ on 10 PSG-derived objective sleep measures and 11 self-reported measures. Over 88% (n=121) of participants completed the PSG at 1-month. Without adjusting p-values for multiple comparisons, only 1 of 21 sleep measure comparisons was statistically significant (p<.05). The effect of trazodone on mean PSQI scores during the 6-month follow-up was not statistically significant (p=.10). Trazodone neither significantly increased nor decreased illicit drug use relative to placebo.

CONCLUSIONS

Trazodone did not improve subjective or objective sleep in methadone-maintained persons with sleep disturbance. Other pharmacologic and non-pharmacologic treatments should be investigated for this population with high rates of insomnia.

Sleep homeostasis in alcohol-dependent, depressed and healthy control men

Visually scored and power spectral analyses (PSA) of polysomnography (PSG) recordings reveal abnormalities in alcohol dependence (AD) and major depressive disorder (MDD), including deficiencies in slow wave activity (SWA) during non-rapid eye movement (NREM) sleep. SWA parameters reflect the integrity of the homeostatic sleep drive, which have not been compared in those with AD or MDD. Ten men with AD were compared with 10 men with MDD and 10 healthy controls (HCs), all aged 20-40 years. They maintained an 11 pm to 6 am sleep schedule for 5-7 days, followed by 3 consecutive nights of PSG in the laboratory: night 1 for adaptation/screening; night 2 for baseline recordings; and night 3 as the challenge night, delaying sleep until 2 am. SWA was quantified with PSA across 4 NREM periods. Men with AD generated the least SWA at baseline. In response to sleep delay, HC men showed the expected SWA enhancement and a sharper exponential decline across NREM periods. Both the MDD and the AD groups showed a significantly blunted SWA response to sleep delay. Men with MDD had the least SWA in the first NREM period (impaired accumulation of sleep drive), whereas men with AD had the slowest SWA decay rate (impaired dissipation of sleep drive). These results suggest that both SWA generation and its homeostatic regulation are impaired in men with either AD or MDD. Finding interventions that selectively improve these different components of sleep homeostasis should be a goal of treatment for AD and MDD.

Trazodone and alcohol relapse: a retrospective study following residential treatment

Trazodone is one of the most commonly prescribed hypnotic medications in patients with sleep disturbances in alcohol recovery. A recent study concluded that treating insomnia with trazodone in patients with alcohol dependence might impede improvements in alcohol consumption and lead to increased drinking when trazodone is stopped. We set out to investigate the relationship between trazodone use during alcoholism treatment and relapse rates in patients who were discharged from a residential alcohol treatment program. We retrospectively reviewed records of patients with a diagnosis of alcohol dependence in a residential addiction treatment center from 2005 to 2008 and analyzed the association of trazodone use at discharge and alcohol relapse at 6 months. We also assessed the association between trazodone use and relapse at 6 months adjusting for sex, drug dependence, nonsubstance use Axis I psychiatric diagnoses, patient self-report of difficulties with sleep, and anti-dipsotropic medication use at discharge and evaluated pair-wise interactions of trazodone use with the adjustment variables. Of 283 patients eligible for inclusion, 85 (30%) were taking trazodone at discharge. Older age, self-reported sleep problems, and having a nonsubstance use Axis I psychiatric diagnosis were associated with trazodone use. After discharge, 170 (60%) subjects responded to follow-up efforts. Neither intent to treat nor responder only analysis revealed any association between trazodone use and relapse. Our retrospective study of a complex patient population discharged from a residential treatment setting did not find an association between trazodone use at discharge and relapse rates at 6 months.

Patients with insomnia and subthreshold depression show marked worsening of insomnia after discontinuation of sleep promoting medication

OBJECTIVE

To investigate whether the outcome of treatment with trazodone CR in primary insomnia differs between patients with and without subthreshold depression.

METHODS

14 patients (9 females, mean age 57.3 ± 13.3) with primary insomnia and increased Beck Depression Inventory (BDI) scores (>10) and 15 sex- and age-matched patients with primary insomnia and low BDI scores (≤ 10) were treated with trazodone CR 25-150 mg/d for 3 months and followed for 1 month after discontinuation of the medication. The Athens Insomnia Scale (AIS), Sheehan Disability Scale (SDS), and Clinical Global Impression scale (CGI) were completed at baseline, after each month of treatment and after the first week of run-out phase. Additional assessment tools comprised sleep diaries, the Leeds Sleep Evaluation Questionnaire (LSEQ) and actigraphic recordings.

RESULTS

Subjective sleep time increased by 61.5 ± 72.3 min in the group with low BDI and 60.0 ± 59.4 min in the group with increased BDI at the end of the treatment phase. The significant improvements were also observed in the AIS, CGI, LSEQ and SDS. During the run-out phase the improvement was sustained in patients with low BDI, while AIS scores, sleep latency and total sleep time deteriorated in patients with increased BDI.

CONCLUSIONS

Patients with subthreshold depression, even if the depressive symptoms do not fulfill the time criteria for depressive episode, show marked worsening of insomnia after discontinuation of sleep promoting medication.

Pharmacological treatment of insomnia in alcohol recovery: a systematic review

AIMS

To conduct a systematic review of pharmacological agents used to treat sleep problems in alcohol recovery.

METHODS

In accordance with the Quorum statement, we searched PubMed, EMBASE, Psych Info and Medline databases using the terms alcohol, insomnia/sleep and treatment/management with no year/language restrictions.

RESULTS

The search revealed 1239 articles and 20 met inclusion criteria. Trazodone was compared against placebo and found to be superior in two trials. Trazodone and gabapentin improved sleep measures with gabapentin performing significantly better in an open-label study. The data regarding gabapentin are equivocal with few studies showing a clear benefit. In one randomized trial, topiramate resulted in improved subjective sleep measures and a reduction in the percentage of heavy drinking days. Two randomized control trials of carbamazepine revealed improvement in subjective sleep measures. A randomized study showed lormetazepam was better than zopiclone on some measures. In a small placebo-controlled trial, acamprosate was found to result in improvements on some sleep measures. In single, small, mostly open-label studies, quetiapine, triazolam, ritanserin, bright light and magnesium have shown efficacy, while chlormethiazole, scopolamine and melperone showed no difference or worsening.

CONCLUSION

Trazodone has the most data suggesting efficacy. This finding is tempered by a study suggesting its association with a return to heavy drinking in some patients. Data regarding the efficacy of gabapentin are unclear at this point.

A randomized double-blind pilot trial of gabapentin versus placebo to treat alcohol dependence and comorbid insomnia

BACKGROUND

Insomnia and other sleep disturbances are common, persistent, and associated with relapse in alcohol-dependent patients. The purpose of this pilot study was to compare gabapentin versus placebo for the treatment of insomnia and prevention of relapse in alcohol-dependent patients.

METHODS

Twenty-one subjects, including 10 women who met study criteria for alcohol dependence and insomnia and expressed a desire to abstain from alcohol, were recruited to the study. During a 1 to 2 week placebo lead-in and screening phase, a complete medical history, physical exam, blood tests, urine drug test, and structured interviews were performed to determine eligibility and patterns of alcohol use and sleep. Insomnia due to intoxication or acute withdrawal, psychiatric or medical illness, medications, and other sleep disorders were ruled out. Subjects were then randomized to either placebo (n = 11) or gabapentin (n = 10) for 6 weeks and titrated over a 10-day period to 1,500 mg or 5 pills at bedtime. After a 4-day taper, subjects were reassessed 6 weeks after ending treatment.

RESULTS

Gabapentin significantly delayed the onset to heavy drinking, an effect which persisted for 6 weeks after treatment ended. Insomnia improved in both treatment groups during the medication phase, but gabapentin had no differential effects on sleep as measured by either subjective report or polysomnography.

CONCLUSION

Because gabapentin is a short-acting medication that was taken only at nighttime in this study, it may possibly exert a nocturnal effect that prevents relapse to heavy drinking by a physiological mechanism not measured in this pilot study.

Trazodone for sleep disturbance after alcohol detoxification: a double-blind, placebo-controlled trial

BACKGROUND

Trazodone is a commonly prescribed off-label for sleep disturbance in alcohol-dependent patients, but its safety and efficacy for this indication is unknown.

METHODS

We conducted a randomized, double-blind, placebo-control trial of low-dose trazodone (50 to 150 mg at bedtime) for 12 weeks among 173 alcohol detoxification patients who reported current sleep disturbance on a validated measure of sleep quality or during prior periods of abstinence. Primary outcomes were the proportion of days abstinent and drinks per drinking day over 6-months; sleep quality was also assessed.

RESULTS

Urn randomization balanced baseline features among the 88 subjects who received trazodone and 85 who received placebo. The trazodone group experienced less improvement in the proportion of days abstinent during administration of study medication (mean change between baseline and 3 months: -0.12; 95% CI: -0.15 to -0.09), and an increase in the number of drinks per drinking day on cessation of the study medication (mean change between baseline and 6 months, 4.6; 95% CI: 2.1 to 7.1). Trazodone was associated with improved sleep quality during its administration (mean change on the Pittsburgh Sleep Quality Index between baseline and 3 months: -3.02; 95% CI: -3.38 to -2.67), but after it was stopped sleep quality equalized with placebo.

CONCLUSIONS

Trazodone, despite a short-term benefit on sleep quality, might impede improvements in alcohol consumption in the postdetoxification period and lead to increased drinking when stopped. Until further studies have established benefits and safety, routine initiation of trazodone for sleep disturbance cannot be recommended with confidence during the period after detoxification from alcoholism.

Adolescents with insomnia and substance abuse: consequences and comorbidities

Adolescents have high rates of sleep disorders and substance abuse, both of which have been associated with deleterious effects on mood, attention, and behavior. This article reviews data on the prevalence of sleep disorders, substance abuse problems, and comorbid psychiatric conditions in the adolescent population. Studies have consistently demonstrated that the prevalence of sleep problems is under-reported in adolescents in both clinical and community samples. The bidirectional correlation between substance use and sleep disturbances is also discussed. Based on the findings presented here, the authors conclude that it is imperative to improve the detection and treatment of sleep problems in children and adolescents. By treating sleep disturbances and targeting poor sleepers with additional counseling and education regarding the risk of substance use, clinicians may be able to prevent or delay the adverse effects of addiction. At the very least, the presence of insomnia should alert clinicians to the need for further evaluation for drug and alcohol abuse.

Treatment options for sleep disturbances during alcohol recovery

Sleep disturbances are extremely common in the early stages of recovery from alcohol dependence and may persist for several months despite continued abstinence. Studies indicate that sleep disturbances independently increase the risk for relapse to alcohol, suggesting that targeting these problems during recovery may support continued abstinence. However, there is limited information in the addiction literature about available and effective treatments for sleep disturbances in recovering alcoholic patients. The primary goals of this article are to describe the phenomenology of sleep disturbances during recovery from alcohol dependence, to outline the evidence linking sleep problems with alcohol relapse, and to describe available pharmacological and nonpharmacological treatment options, including the evidence regarding their efficacy in recovering alcoholic patients. Recommendations for future research are provided along with special considerations for treating insomnia in this population, including avoiding cross-dependent sedatives, such as benzodiazepines and benzodiazepine receptor agonists (BzRAs).

Screening for substance use patterns among patients referred for a variety of sleep complaints

Virtually all psychiatric and substance use disorders are associated with sleep disruption. Studies indicate that psychiatric disorders are related closely to chronic insomnia and that psychoactive substances have acute and chronic effects on sleep architecture. Several aspects of sleep are compromised in individuals taking these substances, ranging from difficulty initiating sleep to difficulty maintaining sleep and hypersomnia. Sleep disturbances are apparent in person taking psychoactive drugs or alcohol and have been found to persist long after withdrawing from these drugs. For some, sleep disturbance can be so severe as to reverse treatment success and precipitate relapse to addiction or dependence. There is increasing evidence that primary insomnia without a concurrent psychiatric disorder is a risk factor for later developing substance use disorders. Patients were asked to complete two brief screening tools, the Michigan Alcohol Screening Test and Drug Abuse Screening Test, to examine substance use patterns among patients referred for a variety of sleep complaints in a sleep disorders clinic. We found that patients who demonstrated a variety of sleep complaints were more likely to have alcohol and drug problems than those in the general populations.

Disturbed sleep and its relationship to alcohol use

STUDY OBJECTIVES

To review evidence of an association between disturbed sleep and alcohol use.

DESIGN

We searched MEDLINE, PSYCHINFO, ETOH, BIBLIOSLEEP and the Rutgers Alcohol Studies databases between January 1966 and August 2002. Search terms included alcohol-related disorders or alcoholism in combination with sleep, sleep initiation and maintenance disorders, or sleep apnea syndromes. The search produced over 440 citations. We reviewed 107 relevant articles, of which 60 included quantitative measures of both alcohol use and sleep.

MEASUREMENTS AND RESULTS

Behavioral studies suggest that up to 2 to 3 standard drinks before bedtime initially promotes sleep, but these effects diminish in as few as 3 days of continued use. Clinical investigations support a relationship between sleep disturbance and alcohol use, but variability in the definition and measurement of these domains and a preponderance of cross-sectional studies make uncertain the strength and direction of the association.

CONCLUSIONS

The association of insomnia with alcohol use disorders suggests that the clinical evaluation of patients with sleep problems should include a careful assessment of alcohol use. Future studies of this relationship should employ prospective designs with standardized, validated measures of both sleep and alcohol use. Rigorous treatment studies for chronic insomnia in alcohol dependent patients are also needed.

Agreement among subjective, objective, and collateral measures of insomnia in postwithdrawal recovering alcoholics

The level of agreement among objective, subjective, and collateral assessments of insomnia was examined in 56 recovering alcoholics. Participants underwent a multimodal sleep assessment protocol consisting of sleep logs, actigraph recordings, questionnaires, and collateral reports of insomnia severity. All sleep measures confirmed moderate to severe insomnia in the study sample. Over 1 week of simultaneous sleep log and actigraph recording, the average disagreement between methods ranged from 16 min for sleep onset latency to 1 hr for wake time after sleep onset. Interrater agreement for the severity of insomnia symptoms using the Sleep Impairment Index was poor for subject-clinician, subject-collateral, and collateral-clinician rating pairs (intraclass correlation coefficients < .35). In general, recovering alcoholics' self-reported sleep reflected a greater severity of insomnia symptoms than did the actigraph and collateral measures. Given that such high levels of disagreement can occur in individual participants, researchers are advised to use a combination of sleep measures to assess insomnia in this population.

Randomized controlled trial of brief cognitive-behavioural interventions for insomnia in recovering alcoholics

AIMS

To test the efficacy of a cognitive-behavioural approach to treating disturbed sleep in abstinent alcoholics.

DESIGN

Sixty recovering alcoholics with insomnia were assigned randomly to individual therapy, self-help with telephone support or waiting-list control.

SETTING

Participants were volunteers recruited from out-patient treatment programs and through the media.

MEASUREMENTS

Outcomes were assessed at post-treatment, 3-month and 6-month follow-ups using sleep diaries, the Pittsburgh Sleep Quality Index, wrist actigraphs and time-line follow-back interviews.

INTERVENTION

Five sessions of out-patient cognitive-behavioural therapy for insomnia or a self-help manual with five telephone support calls. Treatment duration was 7 weeks.

FINDINGS

Treated participants were significantly more improved than control participants on diary measures of sleep quality, sleep efficiency, awakenings and time to fall asleep. No significant differences between the individual therapy and self-help treatment conditions on measures of insomnia severity were evident at post-treatment. Self-reported improvement in sleep was corroborated by clinician and spousal ratings of insomnia severity, but not by actigraph recordings of nocturnal activity. At 3- and 6-month follow-up assessments treatment gains were reasonably maintained in both treatment groups, although individual therapy was associated with a higher rate of clinically significant improvement. At the 6-month follow-up, 60% participants who were regular users of sedative medication at baseline discontinued the use of their medication. Treatment appeared to have little impact in preventing relapses to alcohol.

CONCLUSIONS

Recovering alcoholics with insomnia can achieve better sleep by applying cognitive-behavioural strategies.

Pharmacologic approaches for the treatment of chronic insomnia

Insomnia is a common problem that for many sufferers persists chronically and may result from a wide range of causes. Specific treatments address particular underlying medical disorders. General therapeutic approaches, including pharmacologic and behavioral strategies, may have broad applicability to insomnia patients. Many different medications and substances have been used in an attempt to improve sleep. This article reviews the advantages and disadvantages of medications and other substances employed to promote improved sleep. Special emphasis is given to the use of the newer-generation benzodiazepine receptor agonist hypnotics.