Sleep, Substance use, and Addiction Behaviors

Many people who experience issues with sleep, substance use or misuse, and addiction behaviors have discovered that these challenges tend to be related. This is not a coincidence. There are a number of intersections between sleep and substance use or addiction. In this article, I'd like to briefly explore the link between substance use disorders and sleep disturbances. It's also worth discussing the neurobiological basis and effect on sleep, as well as some of the possible treatment options to consider.

Structural Organization of Sleep

"Sleep architecture" is a fancy term to describe the basic structural organization of normal sleep. There are two types of sleep: Non-Rapid Eye Movement Sleep (NREM) and Rapid Eye Movement (REM) sleep. NREM sleep is light and accounts for about 5-50% of our total sleep. Within this type of sleep there is also deep sleep or slow wave sleep, which affects our anabolic and immune process because it removes waste from the glymphatic system (a system for waste clearance in the central nervous system of vertebrates where cerebrospinal fluid flows into the paravascular space around cerebral arteries). This type of sleep leaves us feeling well rested and compromises about 20% of our total sleep.

On the other hand, Rapid Eye Movement (REM) sleep is a type of sleep that occurs with episodic eye movement bursts and loss of muscle tone. It involves vivid dreaming, plays a role in memory consolidation, emotional regulation, and executive function. It comprises about 20-25% of total sleep. Both types of sleep alternate in roughly 90-minute cycles, with REM episodes lengthening throughout the night. Both types of sleep decline with age.

Long Term Health Risks of Disordered Sleep

There are a variety of potential long term health risks associated with disordered sleep. For mental health, some people may experience anxiety, depression, substance use disorder, and suicide. For neurological and cognitive health, there are risks for Dementia. For cardiovascular health, there are risks for hypertension, myocardial infarction, ischemic stroke, and other cardiovascular disease. Some people may also develop type 2 diabetes or obesity.

Lesser Known Benefits of Sleep

It should be no surprise that there are many benefits of sleep. Some of the lesser known benefits of increased sleep are its association with things like empathy responses, a reduction in motor vehicle collisions, higher IQ scores and better grades in school, higher scores on standardized educational tests, and more.

Substance Use and Effect on Sleep

Substance use effects the time it takes to fall asleep, our ability to stay asleep, and the quality of our sleep. Addiction can contribute to insomnia, sleep apnea, and circadian rhythm disorders. A high percentage of people admitted for detoxification programs report sleep problems prior to admission. Long term abstinence from substance use can reverse sleep problems, but it may take weeks or months for this change to take place.

Sleep Disorders Contribute to Substance Use Disorder and Addiction

Slow wave sleep deficiency may be associated with alcohol use disorder. Sleep disturbance is a predictor of early onset alcohol and drug use in adolescents. People who suffer insomnia may be at an increased risk for substance use and may self-medicate their sleep problems with alcohol or other drugs that they believe are relaxing. A trigger for relapse can be insomnia. In fact, there is a psychological hypothesis which theorizes that sleep deprivation may be a classical conditioning response or environmental cue to times when a person was using drugs or alcohol. The neurobiological basis for sleep deprivation suggests that it causes an increased density and sensitivity of dopamine receptors and levels. This may shed light on the relationship between sleep deprivation and use of substances as a conditioned response. So, we should keep in mind that sleep disorders and other barriers to sleep are important factors to consider for substance use disorder prevention.

Alcohol and Sleep

The consumption of alcohol during the daytime can interfere with REM sleep and cause fragmented sleep during the night. It interrupts deep sleep needed to feel rested and rejuvenated. Our dreams are more vivid as the body craves REM sleep by the end of the night. REM sleep rebounds after stopping alcohol use and about two-thirds of patients develop insomnia during withdrawal from alcohol. The effects on sleep take months and up to three years of abstinence to normalize due to changes in the prefrontal cortex of our brain. Pharmaceuticals like Quetiapine have been known to assist with sleep improvements but have also had mixed results with substance use abstinence outcomes. Trazadone has also been associated with worse outcomes, whereas Melatonin is known to improve sleep measures and Gabapentin is known to improve both sleep and abstinence outcomes.

Opioids and Sleep

Opioids affect sleep cycle because they bind to the body’s opioid receptors and there are studies showing that this has an effect on our sleep cycle. Use can speed up the transition between stages of sleep and suppress slow wave sleep. The judicious use of opioids can assist sleep in pain related disorders. Insomnia is the most common withdrawal symptom with decreased sleep time and frequent arousals. With chronic use, there is sleep latency, fragmentation, less efficiency, and decreased sleep time. Sleep problems after abstinence can last for up to several years.

Stimulants and Sleep

Cocaine and amphetamines affect sleep cycle due to their effect on dopamine. Dopamine influences mood and reward feelings, but it also affects alertness with our sleep cycle. Stimulants repress REM sleep and this can last for weeks to months after abstinence, including cognitive performance deficits.

Cannabis and Sleep

Marijuana affects sleep cycle because there is binding to cannabinoid receptors. However, some intoxication can be sleep promoting. But chronic use of cannabis reduces the sleep promoting effects and leads to tolerance that requires larger amounts. The withdrawal effects include insomnia, poor sleep quality, and vivid dreams in some people after discontinuing use. The negative effects on sleep can last up to 45 days after discontinuing use.

Cannabis Treatment for Insomnia

Marijuana may subjectively improve complaints about sleep, at least initially. Cannabidiol may be responsible for disrupting circadian rhythm, whereas THC may change sleep architecture. CBD may have therapeutic potential for treating insomnia, but higher doses are stimulating. THC may also impair sleep quality over long term. There are potentially negative mental health issues that can arise, which include cognitive or synaptic pruning during brain development; development of psychosis; worsening of function in bipolar disorder and major depressive disorder; disruptions to substance use tolerance and addiction issues; and physical health issues with cardiovascular disease, chronic bronchitis, impaired respiratory function, and poor outcomes for babies as a result of pre-natal exposure.

Non-Pharmacological Treatment for Insomnia

The preferred evidence-based treatment choice for insomnia is Cognitive Behavioral Therapy for Insomnia (CBT-I) using a combination of techniques involving sleep restriction, relaxation training, and sleep education. It can be delivered online or in multiple formats.

Sleep Hygiene Practices with CBT-I

Practices to consider incorporating or increasing in your daily life include:

• Consistent sleep schedule for waking in the mornings.

• Increased exposure to bring light in during the day.

• Daily activity routine and exercise (not in late evenings).

• Relaxing bedtime routine and comfortable sleep environment. (bath/shower, quiet/dark room, cool temperature).

• Use of bed for sleep and sex only.

• Turn off electronic devices at least 30 minutes before bedtime.

Practices to consider reducing or eliminating in your daily life include:

• Napping.

• Caffeine, nicotine or stimulants in the afternoon or evening.

• Alcohol, especially before bedtime.

• Bright light during the night.

• Exercising within 3 hours of bedtime (body temperature rises).

• Large or heavy meals within 3 hours of bedtime.

• Excessive heat/cold temperatures in the bedroom.

• Watching the clock.

• High fluid intake before bedtime.

Non-Prescription or OTC Products

The majority of sleep medications are associated with the suppression of REM sleep, so there may be wisdom in exploring the use of non-prescription or OTC products which may have less negative side effects. An obvious one is Melatonin, which can increase sleep efficiency by 5%. 1-3mg is effective to use right before closing your eyes and when no ambient light exposure is present to drive Melatonin out of your system. L-tryptophan may also work well in combination for some people.

Insomnia, Orexin, and Excessive Wakefulness

Insomnia may be directly affected by excessive wakefulness. In this case, it could be that people with dysfunctional levels of Orexin, a neurohormone that surges and wakes people up, could benefit from a receptor antagonist to help treat their insomnia. The Orexin system plays an interesting role in feeding, narcolepsy, and arousal; as well as with our reward and reward dysfunction with addiction. When the system is disrupted, our cells become hyperactivated in response to stimulation that involves salient rewards. People with narcolepsy often have Orexin deficiencies. Chronic exposure to drugs can cause an upregulation of Orexin peptide production in the neurons. This is why Orexin receptor antagonists may be able to reduce addiction behaviors.

Summary

In summary, there is a strong correlation and potentially a bidirectional causation between sleep disorders and substance use disorders or addiction behaviors. The treatment of sleep disorders should include evidence based Cognitive Behavioral Therapy for Insomnia (CBT-I) and exploring other possible non-pharmacological or pharmacological options based on consultation and advice from your health care team, including primary care doctor, psychiatrist, sleep specialist, substance use and addiction specialists, and mental health treatment clinicians. The Orexin system plays a significant pathway in developing addiction and should be considered when assessing and recommending treatment options to improve sleep and reduce or manage substance use and addiction behaviors.

References

Ayas, T. (2023, April 20). Intersection of Sleep & Addiction. EHN Canada Webinar:

Intersection of Sleep & Addiction, Calgary, AB.