Alcohol and Sleep
James D. Geyer
Paul R. Carney
Kenneth L. Lichstein
SUBSTANCE DEPENDENCE AND SUBSTANCE ABUSE
Overview
Numerous licit and illicit substances can affect brain function. Many of these substances result in profound alterations in sleep. These effects on sleep can arise either from the acute effects of the substances or secondary to adaptations that can occur in the brain with repeated regular use of a substance over time (1). The acute effects are the intoxication syndrome, and the adaptive effects are referred to as dependence (2). Dependence is associated with a group of effects common to many substances including tolerance. Tolerance is a perceived need to increase dosage over time due to loss of substance effect. Withdrawal occurs when adverse symptoms arise upon substance discontinuation. Tolerance and withdrawal lead to difficulty stopping the use of certain substances. Dependence occurs when these late effects cause significant distress or impairment.
Criteria for Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following: Tolerance, Withdrawal, The substance is often taken in larger amounts or over a longer period than was intended, There is persistent desire or unsuccessful efforts to cut down or control substance use, A great deal of time is spent in activities necessary to obtain the substance, Important activities are given up or reduced because of substance use, and Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem likely to have been caused or exacerbated by the substance.
Dependence and abuse are easily confused. Abuse is not necessarily associated with the adaptive brain changes that are manifested in tolerance and withdrawal. The repeated direct effects of the substance, the intoxication syndrome, cause maladaptive problems in the patient’s life.
Sleep problems are associated with both dependence (tolerance and withdrawal) and abuse (intoxication syndrome) of a number of substances. Intoxication with caffeine, alcohol, amphetamines, cocaine, opioids, benzodiazepines, and barbiturates has been identified as having significant effects on sleep (2). The withdrawal syndromes associated with nicotine, caffeine, marijuana, alcohol, amphetamines, cocaine, opioids, benzodiazepines, and barbiturates also include alterations in sleep.
Approximately 20% of general medical patients and 35% of psychiatric patients are believed to present with substance-related disorders. An understanding of the presentation, typical course, and management of these conditions is clinically important for the management of these syndromes as well as primary sleep disorders (3).
Alcohol
Background and Prevalence
Alcohol is frequently associated with dependence and abuse, with a lifetime prevalence estimated to be 14% in the United States (4). Alcohol is associated with the greatest prevalence of difficulties primarily because of the relative ease of access to alcohol compared with illegal substances or those legally available only via prescription, such as marijuana, cocaine, amphetamines, sedative-hypnotic medications, and opiates.
In the United States, 10% of men and 3% to 5% of women who drink alcohol experience problems (3). Alcohol-related problems are relatively low in Asian countries and in women. This has been explained by an inherited form of an enzyme involved in the metabolism of alcohol (2). The influence of genetics on the susceptibility to alcohol-related problems is also suggested by evidence that monozygotic twins are more likely than dizygotic twins to be concordant for alcohol problems (2).
Course
The peak prevalence of onset of alcohol dependence occurs between the ages of 20 and 35 years (2). The course
is usually variable with multiple episodes of difficulties followed by temporary remission. Relapse is often precipitated by a crisis and begins with a period of drinking that is not associated with problems (2). The severely affected individual may suffer from recurrent recidivism. Many patients, however, respond well to treatment, with 65% being able to maintain abstinence for at least 1 year following treatment (2).
is usually variable with multiple episodes of difficulties followed by temporary remission. Relapse is often precipitated by a crisis and begins with a period of drinking that is not associated with problems (2). The severely affected individual may suffer from recurrent recidivism. Many patients, however, respond well to treatment, with 65% being able to maintain abstinence for at least 1 year following treatment (2).
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