Aug. 18, 2003 Using alcohol as a sleep aid is somewhat of a paradox: although alcohol can initially help someone fall asleep, it can also disrupt sleep in the latter part of the night. Clinicians already know that alcoholics often have significant sleep problems both while actively drinking as well as after they've stopped drinking. A study in the August issue of Alcoholism: Clinical & Experimental Research has found that alcoholics can continue to have sleep problems for many months after they quit drinking, that problems with sleep onset may be more pronounced than with sleep maintenance, and that many former alcoholics had sleep problems that predated the onset of alcohol dependence.
"Three or more drinks will cause the average person to fall asleep sooner than usual," said Shawn R. Currie, adjunct assistant professor , cross-appointed in psychiatry and psychology at the University of Calgary, and corresponding author for the study. "However, falling asleep faster is the only real benefit of alcohol for sleep. The more prevalent, disruptive effects include more frequent awakenings, worse sleep quality; reduction of deep sleep, and earlier-than-usual waking times, leading people to feel they did not get enough sleep."
An alcoholic who is actively drinking experiences similar, but more severe, types of sleep disruptions. An alcoholic who quits drinking often experiences sleep problems in the two to six months of abstinence following withdrawal. "They take a long time to fall asleep, have problems sleeping through the night, and feel their sleep is not restorative," said Currie. "Lab research supports claims of sleep disruption; overnight-sleep studies have documented reductions in deep sleep and abnormalities in REM sleep in persons with more than a year of sobriety."
"Sleep has a reputation among the recovering community of being one of the last things that fall back into place for an individual," added David Hodgins, professor of psychology at the University of Calgary. "It's also recognized as a potential precipitant of relapse. In the 12-step community, there's a little saying that describes the risk factors for relapse; it's called HALT. People who are Hungry, Angry, Lonely or Tired are at an increased risk of relapse. Certainly, one way a person can be tired is through sleep disruptions."
For this study, researchers examined 63 alcoholics in recovery (44 men, 19 women) who were experiencing insomnia. All underwent a multimodal sleep assessment that included a structured interview, daily sleep diaries, questionnaires, and sleep monitoring via actigraph recordings (an actigraph is a small, lightweight monitor that is worn on the non-dominant wrist, providing continuous recording of movement in the participant's natural sleep environment). Participants were further divided into two groups: those with short-term (less than 12 months) and long-term (more than 12 months) abstinence.
Researchers found that alcoholics with both short- and long-term abstinence can experience sleep problems for many months after they quit drinking.
"This study provides important, further validation of the significance of sleep problems in recovering alcoholics," said Currie. "Insomnia is a highly variable disorder; most insomniacs experience both good and bad nights of sleep in a typical week, so it is important to obtain several nights of data to get an accurate picture of how severe the problem is. Just as physicians like to obtain several readings of blood pressure before diagnosing hypertension, it is likewise important to obtain several nights of sleep information to diagnose a sleep disorder. The monitor that we used, in conjunction with participants' detailed sleep diaries, confirmed that alcoholics did indeed have persistent sleep disruptions that could not be attributed to a single bad night of sleep in a lab."
The study also found that, in general, problems with sleep onset were worse than with sleep maintenance.
"Most insomniacs have a combination of problems getting to sleep and problems staying asleep," said Currie. "Our results indicate that most recovering alcoholics have both types of insomnia but the onset problem is generally worse."
More than half of the participants reported sleep problems that predated the onset of alcohol dependence.
"The rate of chronic insomnia in the general adult population is about 10 to 15 percent," said Currie. "In our study, more than 50 percent of the alcoholics reported having sleep problems for many years before their drinking reached dependence levels. Although we cannot infer any causal connection between insomnia and alcoholism from this data, it is hard to ignore such a high rate of pre-existing sleep problems in the sample."
In addition, poor sleep hygiene was evident among the recovering alcoholics. "Sleep hygiene refers to behaviors that constitute good sleep habits, such as keeping a regular rising time, avoiding napping, and refraining from stimulants like caffeine in the evening," said Currie.
"Many people believe that having a drink will help their sleep," noted Hodgins. "In fact, many physicians will informally suggest the use of alcohol as a sleep aid. However, these findings warn against developing the habit of having, for example, a glass of wine to help go to sleep. More importantly, these findings lead to the idea of targeted interventions with alcoholics. Despite the very comprehensive and broad-based nature of most treatment programs, very, very few of them tackle sleep as an issue. But sleep is obviously a problem for some people and a relevant area of intervention. Trying to refrain from drinking can take a lot of vigilance, self-control and self-worth; it would be even more difficult for someone if they were exhausted."
Currie is currently wrapping up a study that involves a non-pharmaceutical treatment (cognitive-behavioural therapy) for sleep problems in recovering alcoholics. "It may be that sleep can be improved in recovering alcoholics through using an approach that emphasizes good sleep habits, relaxation and stress management," he said.
Alcoholism: Clinical & Experimental Research (ACER) is the official journal of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism. Co-authors of the ACER paper included: Stewart Clark and Sonya Malhotra of the Addiction Centre in the Calgary Health Region; and Stephen Rimac of the University of Calgary. The study was funded by the Alberta Heritage Foundation for Medical Research.
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