1. Sleep problems in addicts: a
behavioral approach
Ahmed Eid el-Aghoury
MBChB MScMed, Board-certified ATP Director

2. Why?
 A strong hypothesis: “persons who are
recovering from an addiction to any
psychoactive substance and have a sleep
disturbance are at an increased risk of
relapse compared to those without a sleep
disturbance”
Brower KJ, Perron BE. Sleep disturbance as a universal risk factor for relapse in addictions to psychoactive ubstances.
Med Hypotheses. 2010 May;74(5):928-33. Epub 2009 Nov 11. PubMed PMID: 19910125; PubMed Central PMCID:
PMC2850945.
 The treatment of sleep disturbance is a
potential target for the management of SUD,
esp in protracted withdrawal.
2 Abbassia Training Program, ATP Cairo, July 2011

3. Range of sleep problems
 Sleep disturbance can include both
objectively measured and subjectively
reported problems involved with falling
asleep, staying at sleep, distressing dreams,
or inability to progress through normal stages
of sleep
 A universal withdrawal symptom
3 Abbassia Training Program, ATP Cairo, July 2011

4. Range of sleep problems
 Withdrawal-related insomnia: should be
ROUTINELY considered
 Nocturnal sleep-disturbing nicotine craving:
Patients who awoke most days or daily had the
lowest chance to quit smoking and the lowest
compliance with the program, “special group”
 OSA: opioids & MDMA
 RLS: tramadol
Brower KJ, Perron BE. Prevalence and correlates of withdrawal-related insomnia among adults with alcohol dependence: results
from a national survey. Am J Addict. 2010 May-Jun;19(3):238-44. PubMed PMID: 20525030; PubMed Central PMCID: PMC2998536.
Riemerth A, Kunze U, Groman E. Nocturnal sleep-disturbing nicotine craving and accomplishment with a smoking cessation
program. Wien Med Wochenschr. 2009;159(1-2):47-52. PubMed PMID: 19225735.
Ramar K. Reversal of sleep-disordered breathing with opioid withdrawal. Pain Pract. 2009 Sep-Oct;9(5):394-8. Epub 2009 Jun 22.
PubMed PMID: 19549061.
4 Abbassia Training Program, ATP Cairo, July 2011

5. In children and adolescents
 Trouble sleeping in childhood were twice as
likely to have the same problem in
adolescence.
 Childhood overtiredness predicted poor
response inhibition in adolescence.
 Both: early onset of substance abuse
Wong MM, Brower KJ, Nigg JT, Zucker RA. Childhood sleep problems, response inhibition, and alcohol and drug
outcomes in adolescence and young adulthood. Alcohol Clin Exp Res. 2010 Jun;34(6):1033-44. Epub 2010 Apr 5. PubMed
PMID: 20374209.
Wong MM, Brower KJ, Zucker RA. Childhood sleep problems, early onset of substance use and behavioral problems in
adolescence. Sleep Med. 2009 Aug;10(7):787-96. Epub 2009 Jan 12. Erratum in: Sleep Med. 2010 Jan;11(1):110-1. PubMed
PMID: 19138880; PubMed Central PMCID: PMC2716423.
Roane BM, Taylor DJ. Adolescent insomnia as a risk factor for early adult depression and substance abuse. Sleep. 2008
Oct;31(10):1351-6. PubMed PMID: 18853932; PubMed Central PMCID: PMC2572740.
5 Abbassia Training Program, ATP Cairo, July 2011

6. Even prenatal !
 Prenatal cocaine, opiate, marijuana,
alcohol, and/or nicotine exposure: was
associated with sleep problems till early
adolescence!
Stone KC, LaGasse LL, Lester BM, Shankaran S, Bada HS, Bauer CR, Hammond JA. Sleep problems in children with prenatal substance
exposure: the Maternal Lifestyle study. Arch Pediatr Adolesc Med. 2010 May;164(5):452-6. PubMed PMID: 20439796; PubMed Central
PMCID: PMC2917192.
6 Abbassia Training Program, ATP Cairo, July 2011

7. College students
 College students with insufficient sleep:
frequently use medications and alcohol as
sleep aids, use stimulants as alertness aids,
and fall asleep at the wheel, or have motor
vehicle accidents due to sleepiness.
Taylor DJ, Bramoweth AD. Patterns and consequences of inadequate sleep in college students: substance use and motor
vehicle accidents. J Adolesc Health. 2010 Jun;46(6):610-2. Epub 2010 Feb 25. PubMed PMID: 20472221.
7 Abbassia Training Program, ATP Cairo, July 2011

8. Sleep System
SLEEP WAKE
Thalamus
GABA ACh
VLPO
HIST
5-HT NE
8 Abbassia Training Program, ATP Cairo, July 2011
Saper CB, et al. Trends Neurosci. 2001.

9. The Sleep Switch
9 Abbassia Training Program, ATP Cairo, July 2011
Adapted from Saper CB, et al. Trends Neurosci. 2001.

10. Sleep Architecture: NREM & REM Sleep
10 Abbassia Training Program, ATP Cairo, July 2011
Pace-Schott EF, Hobson JA. Nat Rev Neurosci. 2002.

11. Nomenclature of sleep states and
stages
 NREM
 Quiet sleep (infants)
 Orthodox sleep
 Synchronized sleep
 NREM stages 1 and 2
 Light sleep
 NREM stages 3 and 4
 Deep sleep
 Slow-wave sleep (SWS)
 Delta sleep
 REM sleep
 Active sleep (infants)
 Paradoxical sleep
 Desynchronized sleep
11 Abbassia Training Program, ATP Cairo, July 2011

12. Patterns of sleep: somnotype &
chronotype
Shneerson JM, (2005): Sleep Medicine: a guide to sleep and its disorders. 2nd ed.
12 Abbassia Training Program, ATP
Oxford, Blackwell Publishing Ltd. Cairo, July 2011

13. Sleep Latency and Efficiency
 Sleep Latency  Sleep Efficiency
 It takes most people  Most people sleep
10-20 minutes to fall approximately 90% of
asleep. the time that they are
 Average sleep in bed.
latency  Average sleep
 Less than this may be efficiency
sign of excessive
sleepiness
13 Abbassia Training Program, ATP Cairo, July 2011

14. Non drug management of
insomnia
 CBTi
 Sleep restriction
 Stimulus control
Siebern AT, Manber R. Insomnia and its effective non-pharmacologic treatment. Med Clin North Am. 2010
May;94(3):581-91. Review. PubMed PMID: 20451034.
14 Abbassia Training Program, ATP Cairo, July 2011

15. Sleep restriction
 Increases process S
 According to chronotype & somnotype
 Manage medical conditions before
15 Abbassia Training Program, ATP Cairo, July 2011

16. Stimulus control
 Got to bed when sleepy & Get out of bed if
unsleepy
 Set a regular morning wake time
 Avoid napping
16 Abbassia Training Program, ATP Cairo, July 2011

17. Mindfulness meditation (MM)
 Useful in treating the distress and emotional
reactivity associated with chronic insomnia
 A group program that integrates mindfulness
principles with behavior therapy: 2 hrs / session ×
8 wks + one all-day retreat
 Cognitive components: Beginners mind / non
striving/ letting go / non judging / acceptance /
trust / patience
 Behavioral components: stimulus control , sleep
restriction, and sleep hygiene.
Britton WB, Bootzin RR, Cousins JC, Hasler BP, Peck T, Shapiro SL. The contribution of mindfulness practice to a multicomponent
behavioral sleep intervention following substance abuse treatment in adolescents: a treatment-development study. Subst
Abus. 2010 Apr;31(2):86-97. PubMed PMID: 20408060.
17 Abbassia Training Program, ATP Cairo, July 2011

18. After sunset at Abbassia
Email: atpbox@gmail.com
18 Abbassia Training Program, ATP Cairo, July 2011