Addiction, Sleep Disorders Go Hand-in-Hand

Saturday's symposium about links between sleep disorders and addiction drew a standing-room-only crowd, as well as many questions during a discussion period.

Saturday’s symposium about links between sleep disorders and addiction drew a standing-room-only crowd, as well as many questions during a discussion period.

Addiction and sleep disorders form an uneasy partnership, an observation shared by of one of the speakers during symposium “Sleep and Addiction: Understanding the Problem and the Need to Act.”

“It is almost unheard of for us to see patients who come in for addiction treatment who do not have sleep problems,” said Michael Varenbut, M.D., FASAM, Assistant Clinical Professor of Sleep Medicine, University of Toronto. “We all as a group do a fairly poor job of diagnosing and treating sleep problems.”

He recommended adhering to a plan of action when patients present with a complaint of insomnia, rather than just writing a prescription for a drug. A study conducted 10 years ago showed that primary care physicians asked only 2.2 questions of their patients before prescribing a sedative narcotic, in contrast to the 45 minutes it takes to perform a proper sleep assessment.

Dr. Varenbut suggested a sleep assessment package that would involve such things as intake questionnaires, sleep diaries, and screenings. The first take-home pearl he suggested is not to prescribe medications for insomnia, followed by another pearl that insomnia is not a diagnosis but rather a symptom. A particularly important pearl is to screen everyone for sleep apnea.

“When patients are referred to us in the sleep disorder center with substance disorders, the No. 1 diagnosis that comes back is sleep apnea,” he said.

It’s equally important to get to the bottom of insomnia: What are the insomnia symptoms? What is causing it? Which type is it? Dr. Varenbut said that the International Classification of Sleep Disorders shows more than 100 sleep diagnoses. At least 50 percent have insomnia as a cardinal feature.

An insomnia diagnosis requires associated daytime dysfunction. If the patient is not suffering during the daytime because of their sleep, there’s no need to treat it, he said. Insomnia is primarily diagnosed through clinical evaluation, not sleep studies. A sleep history should include specific insomnia complaints: initiation insomnia (getting to sleep), maintenance insomnia (staying asleep) or terminal insomnia (waking early).

At least 50 percent of those who come to the sleep disorders lab with a diagnosis of insomnia will have another co-morbid condition, most often another psychiatric diagnosis, such as anxiety or depression. It’s also important to learn about sleep-wake patterns and other sleep symptoms like snoring. Furthermore, all substances of abuse affect sleep.

“There’s no point in us trying to fix their sleep problem while they are actively using,” Dr. Varenbut said.

Conrad Iber, M.D., Director of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, reported on substances and sleep interactions. One interaction that might be over-rated is central sleep apnea and opiates, he noted.

“The population I see more commonly as a burden is an intersection between obesity, sleep apnea, and narcotic use, which I see as a major problem,” Dr. Iber said. “There are tremendous interactions between insomnia and alcohol, narcotics, and benzodiazepenes. The interaction between the diagnosis of hypersomnias and stimulant abuse is something I see commonly as well.”