Addiction and sleep share a problematic bidirectional relationship where each influences the other. Many people treat sleep problems with drugs and alcohol, which can lead to addiction. People who are already addicted to drugs and alcohol undergo changes in their sleep architecture and sleep needs, forcing them to increasingly rely on their addiction in order to sleep. Once in recovery, one of the main reasons many people relapse is the discomfort and insomnia they experience, compounded by the long period of time it takes for the body to adjust back to normal sleep without drugs and alcohol.
Individuals with addiction experience sleep deprivation in two ways: they get less sleep than normal, but they also experience lower sleep quality, since they don’t spend the same amount of time in the various stages of sleep as a healthy individual would.
Unfortunately, sleep deprivation itself can lead to drug use, dependence and abuse. Only a quarter of adolescents, for instance, get the recommended 8 or more hours of sleep per night (adolescents need slightly more sleep than the recommended 7 to 8 hours for adults). Research shows these sleep-deprived teens are more likely to engage in risky behaviors, perform worse in school, and use drugs. Worse, those who regularly slept less than 6 hours per night were three times likelier to start using drugs than those who got sufficient sleep on a consistent basis. Experts believe this is due to the reduced ability to regulate your emotions and make good decisions when you’re sleep- deprived. Sleep-deprived people also have lower levels of dopamine, drawing adolescents towards drugs that can boost those reduced levels.
People who abuse drugs and alcohol often suffer from the following substance-induced sleep disorders during their addiction or into recovery. Such disorders are labeled as “substance-induced” because the substance abuse causes the sleeping problem and interferes severely enough with the individual’s normal life, often to the point of requiring medical intervention:
Insomnia describes difficulty falling or staying asleep. Because of the way drugs and alcohol affect the brain and body, nearly all individuals (97 percent) who abuse these substances experience poor sleep quality. Numbers vary, but severe insomnia is experienced by 17 percent of individuals with addiction, and moderate insomnia by 40 percent. While alcohol and drugs like cannabis can aid in initial sleep onset, they result in less restful sleep and an increasing dependence on the addictive substance.
Hypersomnia or excessive daytime sleepiness is the opposite of insomnia, although the two are often linked. Hypersomniacs sleep too much or too late, and they don’t feel refreshed upon waking. To counteract these effects, they try to sleep more, interfering with their life, or to induce sleep by relying on certain addictive substances.
Parasomnias such as sleepwalking, nightmares, or night terrors are more prevalent in individuals who abuse drugs, especially hallucinogens. Fear of these activities can create bedtime anxiety and insomnia, further lessening the individual’s overall amount of sleep.
Obstructive sleep apnea (OSA) describes a condition where the individual literally stops breathing during sleep because their airways have been blocked, whether due to obesity, the muscles relaxing in the back of the throat, or another factor. The brain briefly wakes them up to get them to start breathing again, disrupting sleep and lessening sleep efficiency. More than half of individuals with addiction also have sleep apnea. Alcohol causes the throat muscles to relax, worsening symptoms of sleep apnea, and the resulting lower levels of oxygen in the bloodstream worsen hangovers.
Restless legs syndrome (RLS) occurs when individuals are in a supine position, such as when they’re in bed. People with RLS experience an uncomfortable tingling or numbing sensation in their legs, accompanied by an uncontrollable, irresistible urge to move them in order to find relief. These symptoms are painful and disruptive when the individual is trying to fall asleep. RLS affects one- third of individuals with addiction.
Substance abuse is on the rise, and disrupted sleep, poor sleep, and sleep disorders are along for the ride Some people may rely on depressants like cannabis or alcohol to fall asleep, and eventually they can’t sleep without these substances. Others, who abuse stimulants like cocaine or amphetamines, experience such a boost in alertness that they feel like they don’t need sleep, and end up sleep deprived without realizing it. Once they come down, they may feel so fatigued that they take more drugs in order to stay awake.
This roller coaster of a sleep-wake cycle gets worse when you take into account that chronic drug and alcohol abuse disrupts sleep architecture and the way the brain experiences sleep. Below we’ll review how different drugs interfere with sleep.
Cocaine interferes with the brain’s ability to absorb dopamine, so it gets flooded with it and the individual experiences euphoria. Chronic cocaine use may increase the circadian rhythm and permanently damage the body’s ability to sleep well Even low doses of cocaine can increase wakefulness, decrease restorative slow wave sleep, and alter the amount of REM sleep, critical to cognitive processing. The energizing effect of cocaine causes insomnia, while withdrawal causes hypersomnia.
Amphetamines boost energy and can produce effects similar to cocaine. Amphetamine users share similar sleep problems to those who abuse cocaine, experiencing insomnia when they’re high, and hypersomnia during periods of withdrawal. Over time, chronic amphetamine abuse can disrupt the circadian rhythm.
MDMA (Ecstasy) is another energizing drug that reduces the serotonin nerve endings in the brain over time. Serotonin is involved in melatonin production, the hormone responsible for regulating sleep. Because of this interference with serotonin, MDMA abusers experience the effects of sleep deprivation sooner and more severely than others, especially in regards to cognitive functioning.
Hallucinogens mimic serotonin and stimulate brain activity, the opposite of what is supposed to happen when your body prepares for sleep. As a result, hallucinogen use can result in insomnia or delayed sleep.
While alcohol helps people fall asleep, their sleep isn’t as restful and they are more prone to nightmares, snoring and sleep apnea (because the throat muscles collapse), enuresis (nighttime urination), and night sweats. Alcohol also causes early waking – the alcohol makes your body temperature drop, inducing sleep, but once the alcohol wears off, your body responds with a rise in temperature, making you wake up. Alcoholics experience more alpha and delta brain waves than normal sleepers, interfering with their ability to sleep. They spend less time in REM sleep too, a stage of sleep critical for mood, motor skills, and concentration. Up to 20 percent of people use alcohol as a sleep aid, which over time can lead to dependence. The poor sleep from alcohol withdrawal can last as long as several months or even years, depending on the severity of the addiction.
Marijuana is another sedative like alcohol. It doesn’t impact total sleep quantity, but it does reduce REM sleep (especially THC strains) and users experience insomnia at double the rate of the general population. Less REM sleep means less quality sleep, and when users stop chronic use, they experience a REM rebound effect with especially vivid dreams for up to 2 months after quitting.
While behavioral addictions such as gambling, internet and smartphone addiction don’t have the same physical symptoms of drug addiction, they share many similarities, including negative symptoms such as sleep problems. Gamblers often experience poor and/or disrupted sleep as well as many mood or anxiety disorders that are comorbid with sleep disorders like insomnia. Addictive gamblers in particular have higher rates of daytime sleepiness to recreational gamblers. Sleep deprivation in turn reduces focus and makes gamblers more prone to mistakes and poor bets, which can result in negative behaviors or emotions. Smartphone addiction is correlated with higher rates of depression and anxiety, which often go hand in hand sleep problems. Finally, internet addiction is associated with higher rates of suicide, difficulty falling and staying asleep, daytime sleepiness, and hypersomnia.
Opioid Addiction and Sleep
About 2 million Americans are addicted to prescription opioids, according to the CDC, and overdose deaths from opioids have more than quadrupled in the past 2 decades. The most common opioids involved in death from overdose are methadone, oxycodone, and hydrocodone. 25 percent of people who receive opioids for non-cancer long-term therapy purposes end up becoming addicted.
Opioids are prescribed to help individuals with severe or chronic pain, since the body doesn’t create enough opioids naturally on its own to block intense pain. Opioids are depressants that attach to receptors in your brain to block pain, slow breathing, and create an overall sense of calm. They share a similar structure with the natural neurotransmitters in your brain, allowing them to attach to dopamine receptors, but because they are artificial and not quite the same, they can lead to negative outcomes when a person becomes addicted.
Opioids are addictive because, like cocaine, they flood the brain’s dopamine receptors and create a sense of euphoria when they’re not used as directed. The more a person abuses opioids, the worse their body becomes at producing opioids naturally, so their body becomes dependent on the opioids to block out lesser amounts of pain.
When a person is using opioids, they experience up to 30 to 50 percent reduction in REM and slow-wave deep sleep. REM, the dream state of sleep, is essential for memory consolidation and cognitive processing, while slow-wave deep sleep is what restores the body. Without sufficient amounts of either of these, an individual has trouble focusing, regulating their mood, and remembering things. Even individuals taking opioid medications as prescribed experience these adverse changes in sleep architecture so taking them in the long term can result in chronic fatigue.
Additionally, opioid addicts spend less time asleep overall, experience a higher number of transitions between sleep stages, and spend more time in light sleep. 30 percent of people with chronic opioid use also have central sleep apnea, which further disrupts their sleep, and some studies have linked RLS with opioid dependence.
For opioid addicts in recovery, withdrawal is especially intense. Their nervous system goes haywire, resulting in symptoms like anxiety, sweating, vomiting, diarrhea, muscle aches, and insomnia. Because their body and mind are weakened emotionally, energetically, and physically, it is even tougher for them to cope with the insomnia, and lack of sleep only exacerbates all the other symptoms. Yet sleep is critical for regulating mood, rebalancing the body’s hormones, and strengthening the immune system and restoring energy. Opiate withdrawal can last a week or longer, and symptoms such as these explain why relapse is so common.
Sleep Medication and Overuse
Prescription sleep aids use has increased significantly in the past 20 years, with 4 percent of Americans reporting having used them within the last month. These sedative- hypnotics, or “z-drugs,” include benzodiazepines, barbiturates, and hypnotics, and they all induce sleep. Benzodiazepines are anti-anxiety medications that increase drowsiness, while barbiturates cause a sedative effect by depressing the nervous system. The three most prescribed sleep medications are Ambien, Sonata, and Lunesta. Between 2006 and 2011, 38 million prescriptions were written for Ambien alone.
Most sleep medications aren’t approved for long-term use, because of how they interact with the brain and the dangerous side effects that can occur, such as driving while asleep. Scarily, even prescribed amounts as low as 18 doses per year result in a threefold increase of mortality rates.
Like opioids, prescription sleep medications are easy to become addicted to, in part because they work so well. Once the individual stops using them, they often have trouble falling asleep, so they start to use them again or increase their dose. They may even begin craving the medication, experience memory loss, or start seeking out prescriptions from multiple doctors in order to meet their higher dosage needs.
Recovering from sleep medication addiction requires tapering down the dose slowly and should be done under guidance from a doctor. Withdrawal can cause seizures.
Recovery brings drastic changes to all aspects of an individual’s life, including their emotions, their focus, their behaviors, their routines, and their sleep. Their brain and body have developed a tolerance to the substance which resulted in adjusted sleep patterns or problems, and the sudden withdrawal wreaks havoc on the system as the body learns to adjust to a normal sleep cycle again. Meanwhile, the physical symptoms of withdrawal can be extremely painful or uncomfortable, and anxious thoughts often accompany the road to recovery.
Unfortunately, the lack of sleep associated with recovery worsens mood, increases depression and irritability, and makes it tougher to focus and make sound decisions. Life is suddenly and considerably more challenging. The individual feels terrible physically and emotionally, and their decision-making is impaired from the sleep deprivation. They may start to think they were better off with the substance, increasing their risk of relapse.
This is why it is important to include sleep as part of the overall treatment plan in the following sections we’ll discuss options for facilitating good sleep during recovery. Research shows that getting sufficient sleep aids recovery. Individuals who sleep well during recovery feel better overall and experience fewer cravings. Insomnia and recovery.
For most individuals in recovery, however, insomnia is a constant challenge. Insomnia is 5 times more prevalent in individuals in recovery than the general population, making it that much harder to return to sober life.
Alcoholics in recovery experience higher rates of insomnia, and have difficulty establishing a regular sleep cycle. As many as 75 percent of alcoholics’ experience insomnia during detox, and those with a sleep disorder are twice as likely to relapse than those getting restful sleep. Even if they sleep through the night, it doesn’t feel as restorative. The exhaustion is one of the main reasons for release. Insomnia is such a persistent problem for recovery that it’s included one of the acronyms for the 12-step program, HALT. HALT is the acronym for relapse risk factors, and stands for Hungry, Angry, Lonely or Tired.
Some addicts, such as cannabis smokers, used the drug specifically to help them fall asleep They’ve trained their mind to associate falling asleep with using marijuana, so they have trouble falling asleep without it. The resulting poor sleep during withdrawal causes 65 percent to relapse.
The bad news is that consistently good sleep is often one of the last things to return to an individual in recovery. Of course, that means the good news is that when you do find yourself sleeping better, that’s often one of the first signs you’re adjusted to sober life.
Treatments for Sleep during Recovery
Sleep is critical to a successful recovery. If you’re having trouble sleeping, you’re not alone. Fortunately, there are many behavioral changes and therapies you can try to get better sleep as you adjust to sobriety.
Natural Sleep Aids during Recovery
Cognitive behavioral therapy (CBT) helps patients learn to recognize their problematic or harmful thoughts and habits, and replace them with better thoughts and coping strategies. It’s often used to help individuals with a range of problems from anxiety and eating disorders to insomnia. CBT-I focuses specifically on helping individuals with insomnia adjust the thoughts and behaviors that prevent them from getting restful sleep.
Stimulus control therapy focuses on stimuli your brain has associated with not falling asleep, and retrains the mind to view them differently. For example, someone who works from their bed or watches a lot of TV may be encouraged to only use the bed for sleep and sex, or to stay out of the bedroom altogether except when engaging in those activities.
Sleep restriction therapy sets strict bed and wake times for an individual, and they’re only allowed to stay in bed during those prescribed times, regardless of how much sleep they get. The idea is the body and brain eventually learn to sleep during the appropriate schedule.
Sleep hygiene is about promoting sleep-healthy behaviors, such as avoiding caffeine later in the day, exercising regularly, eating healthier foods, and avoiding blue light in the hours before bed from electronics like TV or computers.
Sleep environment improvement focuses on making the bedroom conducive to sleep, such as keeping it dark with blackout curtains or eye masks, cooling the temperature to somewhere in the mid-60 degrees Fahrenheit, and removing stimulating electronics.
Relaxation training techniques include meditation, deep breathing exercises, muscle relaxation, and visualization strategies to calm the mind and body to prepare for sleep.
Remaining passively awake helps the mind stave off anxiety or stress about not being able to fall asleep, and instead become comfortable just lying in the bed, allowing sleep to come naturally instead of worrying about it.
Biofeedback monitors the patient’s heart rate and muscle tensions so they and their therapist can observe biological reactions that may be inhibiting sleep.
Because of the tendency towards addiction, over-the-counter sleep aids are not recommended for individuals in recovery. Both over-the-counter and prescription sleep aids can create side effects and dependency that interfere with recovery or adjusting back to sober sleep.
Melatonin can be helpful as a sleep aid and is generally considered safe, but individuals should still consult their medical professional first, just to ensure they experience no adverse effects based on their individual addiction. The side effects of melatonin on teens in puberty also hasn’t been fully evaluated.
Thom Kessler, LMFT, RAS
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Marriage & Family Therapist and Registered Addiction Specialist