Insomnia: Sleepless in Recovery – what really helps
By Carola De Souza
Insomnia and addiction recovery go hand in hand. Research shows that between 70-90 % of individuals in recovery from alcohol or drug use experience difficulties achieving restful sleep. As if recovery wasn’t already difficult on its own, insomnia adds to the mix by leaving us grumpy, irritable and unable to focus. But what exactly is insomnia, and what is insomnia’s relationship to substance use and recovery? Most importantly, what helps?
What is insomnia?
The term insomnia is Latin in origin and also related to the Greek word ‘hypnos’, the god of sleep and son of Nyx (Night) in Greek mythology. In modern terms, insomnia describes sleep difficulties involving some of the following:
Although not all of us in recovery will experience all of the aforementioned problems. Sleep difficulties can leave us unmotivated and too tired to face the uphill battle that recovery really is. Some individuals in recovery also experience the opposite of insomnia, sometimes referred to as hypersomnia, or the tendency to sleep much more than usual. In this case, we can experience great difficulties getting out of bed, and we feel plagued by consistent physical fatigue that leaves our bodies feeling as if filled with lead.
What does sleep actually look like in a healthy person?
Healthy sleep is divided into REM and Non-Rem sleep, and we cycle through distinct stages approximately 4 – 5 times per night. Non-Rem sleep is sometimes called ‘slow wave’ sleep based on the slower brain wave activity during this part of our nightly rest.
Non-Rem sleep has three distinct phases: N1, N2, and N3, each phase gradually and gently transporting us deeper into the realm of rest and rejuvenation. Brain activity, heart rate, and blood pressure decrease, and eye movement slows down and eventually stops completely. During N3, we finally reach our deepest sleep phase, and our brain shows delta waves often associated with deep rejuvenation and healing. We do need this type of sleep in order to feel rested; if we wake from this sleep phase, we tend to feel ‘out of it’, and getting up and starting the day is harder.
Common misconceptions around REM sleep
In contrast, and contrary to popular belief, REM sleep is fairly light sleep. Our eye movements are fast, and our brain can show more activity than during waking hours. Most of our dreams take place in this sleeping phase, although nightmares and night terrors also appear to occur during N3 sleeping phases.
REM sleep typically last only approximately 10-15 minutes in each sleep cycle, typically starting when we are about 90 minutes into our sleep. If you wake up during this phase, you are likely to remember your dreams. REM sleep is important, as we tend to process emotions experienced throughout the day during this phase. REM sleep is also associated with transferring new learning into short-term memory.
What is the link between sleep and alcohol and illicit drugs?
Most individuals in recovery can easily relate to some sort of sleep problems during withdrawal and early recovery from alcohol or substance abuse. However, this is not the only link between substance use and sleep.
Fact is, insomnia is often a contributor if not a major cause of escalating alcohol or drug use. What may start as an innocent ‘night cap’ to induce much-wanted rest and deep sleep can often very gradually and thus barely noticed lead us into the depth of addiction. The initial glass of wine or beer is soon not enough, and we increase our use over time to achieve the same sedating effects.
This pattern of using first cautiously and sparingly before descending into increased use and eventually the abyss of psychological or physical dependency can also be true for marijuana or prescription sleeping pills such as benzodiazepines. In these instances, insomnia kick-starts, maintains and escalates alcohol or substance abuse.
Different substances appear to impact our ability to sleep in diverse ways; alcohol tends to help us fall asleep but makes our bodies hyper sensitive to stimuli once metabolized, thus rendering us more prone to waking up in the middle of the night.
Opioids are said to disrupt both REM and Non-Rem sleep cycles, and there are suggestions that it can cause sleep apnea.
Cocaine causes disruptions in our biological circadian rhythm, which in turn may increase the risk of heart disease and cancer.
Long-term cannabis use is linked to troubles falling asleep and impacts our deep sleep phase (N3) negatively, often lasting well into recovery. Contrary to popular belief, marijuana users are twice as likely to suffer from insomnia compared to non-users.
Common to withdrawal from most illegal substances is an impact on sleep quality due to very vivid and sometimes violent dreams.
Sleep problems are often linked to mental health problems, including depression, anxiety and trauma. These mental health problems also often overlap with alcohol or substance abuse, as individuals suffering from mental health problems try to achieve relief from symptoms by reaching for mood altering substances.
Insomnia is a major risk factor for relapse, as many individuals in recovery suffer from insomnia well past the initial withdrawal phase. Over time, such lasting difficulties achieving restful sleep can have a severe impact on a person’s ability to function: in addition to leaving us with a foul mood, short-tempered and unmotivated to do anything, insomnia can have a significantly negative impact on our ability to concentrate, problem solve and control impulses. As with insomnia that precedes and kick-starts substance, alcohol or prescription drug misuse, lasting insomnia during recovery can grind us down, wear us out and eventually make us more vulnerable and prone to press the ‘F…… It’ button that leads to relapse.
‘The Switch’: What do Pavlovian Dogs have to do with my Sleep?
Remember Russian scientist Ivan Pavlov, who trained his dogs to salivate at the ring of a bell? Pavlov paired the ring of the bell with the dog’s feeding times, and over time, the dogs started salivating at the sound of the bell, as if it was feeding time even if no food was presented. What does this have to do with sleeping, or problems sleeping you ask?
How do you feel when you toss and turn in your bed, yet again unable to fall or stay asleep? Frustrated? Irritated? Desperate? Angry? Hopeless? Exhausted? All of the above? Many insomniacs, after tossing and turning night after night, experience what is called ‘The Switch’: they may feel extremely tired when it is time to go to bed, but as soon as they lay down, they are all of a sudden wide awake. As if someone switched an ‘on’ button in their brain and their entire system.
Why? When we repeatedly toss and turn in bed, our subconscious mind will eventually associate the bed with the aforementioned negative emotional states, and with restlessness and being awake – pretty much the same way that the Pavlovian dogs started to associate the bell with food. Consequently, the moment your body touches the bed, your entire system reacts in the way insomnia has trained it to: with frustration and irritation, fully awake and yet again unable to come to rest.
Treatment: What helps?
There is good news and bad news: Insomnia is complicated, and finding the right treatment may take time and patience. That’s the bad news. The good news is that effective treatment exists. For example, insomnia due to substance use and/or mental health issues will require addressing these underlying issues in order to achieve long lasting improvement in our sleep. Also, insomnia due to circadian rhythm problems or sleep apnoea may require a thorough assessment in the sleep lab, followed by specialist intervention and/or equipment (e.g. sleep mask).
One of the most effective treatments for insomnia remains CBTi, cognitive behavioural therapy, and many strategies recommended can be applied without specialist help.
Cognitive Behavioural Therapy for Insomnia (CBT-i): An effective alternative to Medication
CBT-I (cognitive behavioural therapy for insomnia) is an effective treatment for insomnia. Contrary to pharmaceutical sleep aids (more to that later…), CBTi has no negative side effects, and it provides us with ample opportunities to strengthen internal resources and coping skills.
CBT-i typically involves:
6 techniques that will help you with insomnia
CBT-I typically includes stimulus control techniques. These are things you can do to break the aforementioned association between bed and restlessness, including:
In addition to these behavioural interventions focused on breaking our subconscious mind’s association of the bed with restlessness and frustration, you can increase your chances of a good night’s sleep by establishing a solid bedtime routine filled with rituals that nourish your body, spirits and soul. Following such a routine daily will gradually work to signal your body and mind that it is time to transition from wakeful activity to peaceful rest.
What does a healthy bedtime routine look like?
Consider starting your bedtime routine by taking care of your worries, particularly if your worries tend to keep you up. Write your worries in a worry book, so you know you can come back to them the next day and problem solve. Journaling about the events of the day, including left over thoughts, images and feelings, may help to leave the day behind and set the stage for bedtime. Next, think about things you experience as soothing and calming: for some of us, this may involve a warm bath with aroma oil and candlelight. Others may feel nurtured by some camomile tea and a good book, a short meditation, a gratitude list or prayer. A short gentle yoga practice focused on deep calm breathing may prove a final helpful step in preparing the body and the mind to enter the realm of dreams and rest. Find what works for you!
A word of caution about Sleep Aids
Our sleepless nights make some others apparently rather happy, their treasure chests fully stocked. In 2012, the earnings from the sale of pharmaceutical sleep aids had risen to a whopping $32 billion dollars in the US, following a steady 9% increase in sales year after year.
Significant side effects and habit forming potential
If you suffer from insomnia, doctors are often all too eager to reach for their prescription pad, suggesting one of the following medications: Antidepressants, Benzodiazepines, Gabapentin or Seroquel, all of which can have significant side effects if used long-term and/or in higher doses. Among these options, the prescription of benzodiazepines for sleep problems has become particularly controversial given their habit forming potential, and especially when given to an individual struggling with alcohol or substance abuse.
Long-term use of benzodiazepines does not only create psychological and physical dependencies, they also tend to increase anxiety- one of the problems they are often originally prescribed for. Furthermore, withdrawal from benzodiazepines is potentially dangerous, described as more painful than withdrawal from heroin, and thus requires careful and gradual tapering under professional supervision. Serious concerns have been raised for sleep medications like Ambien or Lunesta, including the possibility of increased risk for fatality.
Over the counter sleep aids are not completely harmless either
Over the Counter (OTC) sleep aids such as melatonin or herbal supplements such as Valerian root have also been suggested as potentially helpful. While there is research confirming melatonin as potentially helpful for some individuals in recovery, the efficacy of Valerian root for insomnia in the context of recovery from substance abuse is yet to be proven. It is important to remember that OTC medications or sleep aid are not necessarily completely harmless, as they can interact with prescription medications in unforeseen ways. A consultation with a physician or pharmacist is therefore highly recommendable before commencing any sleep aid.
The downside of using any sleep aids in recovery
Apart from potential interaction with other medications or significant side effects, reaching for a quick external ‘fix it’ represents an all too familiar pattern for any addicted person. As addicts, we are experts in avoiding, denying, suppressing any discomfort or any problem by reaching for the quick relieve that external ‘fix its’ promise us.
Treating insomnia with medication has therefore perhaps another undesired and not readily visible side effect: it reinforces old unhelpful patterns of behaviour that will not serve us in the long run. Reaching for the quick ‘fix it’ strongly reinforces the idea that we cannot help ourselves, and it interferes with an opportunity to strengthen newly learned coping skills and tools.
In conclusion, while behavioural tools and strategies may take time and patience, they are effective and have no negative side effects. Most importantly, succeeding without the usual ‘external quick fix’ will foster confidence that we can deal with life’s difficulties skillfully and successfully.
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