Subjective sleep–wake parameters in treatment-seeking opiate addicts
Introduction
In general, sleep difficulties are common features of many psychiatric disorders (Ford and Kamerow, 1989, Soldatos, 1994). Hence distinct sleep profiles of different psychiatric populations have been identified. Generalised anxiety disorders are associated with inadequate sleep quantity, persistent sleep onset latency, and high number of nocturnal awakenings (Gelder et al., 1996). Patients with panic disorder are known to have lower sleep efficiency, a higher percentage of wakefulness, and a reduction in the amounts of slow wave sleep (Hauri et al., 1989, Arriaga et al., 1996). Patients with major depression are known to experience a high number of nocturnal awakenings, short sleep duration, decreased deep sleep (stages 3 and 4), decreased latency to the onset of rapid eye movement (REM) sleep, and an increase in the percentage of REM sleep in the early part of the night (Rush et al., 1991).
Although there are many studies of sleep and psychoactive drugs in general, the majority of which focus on the therapeutic and non-therapeutic effects of sedatives, including alcohol (Mellinger et al., 1985, McClusky et al., 1991, Weyerer and Dilling, 1991, Shorr and Bauwens, 1992), very few (Kay et al., 1981) have investigated the effects of opiates on sleep pattern. There are reports of reduced total sleep time, sleep efficiency, slow wave sleep, and REM sleep resulting from acute administration of opiates among non-dependent subjects (Kay et al., 1981; Gillin, 1994). On the other hand, chronic administration of opiates, especially methadone, is not known to result in sleep difficulties (Kay, 1975). As these and similar studies examined only the effects of opiates on sleep, they could not provide information on the sleep profile of opiate dependent patients in similar details as those reported in other psychiatric populations.
The main aim of the present study, therefore, was to identify a distinct sleep profile of opiate addicts by comparing their sleep parameters with those of a sample of non-addicts. Our reasons for undertaking this study were as follows:
Firstly, people with sleep difficulties often report a higher prevalence of psychiatric disorders than those without (Ford and Kamerow, 1989). Thus, the manifestation of sleep difficulties among opiate addicts seeking treatment may in fact indicate the existence of comorbid psychiatric disorders. Early recognition of these disorders, therefore, may provide useful information for appropriate care plan, including a halt to their development through early case finding and intervention.
Secondly, in our clinical experience, opiate addicts often complain of sleep difficulties during the reduction phase of methadone detoxification. Some of them, in fact, attribute their premature exit from treatment to sleep difficulties, which become more manifest during this phase than in the observation and stabilisation phases. What has not been well documented is the addicts' sleep–wake pattern prior to experiencing the acute withdrawal effects of methadone.
Thirdly, as there were no published clinical studies in the UK that document the extent to which the sleep–wake schedules of treatment-seeking opiate addicts differ from those of non-addicts, it was necessary to identify a sleep–wake profile among opiate addicts that can provide a framework for developing appropriate sleep enhancement protocols as an adjunct to methadone treatment.
We have been able to identify four categories of sleep difficulties commonly expressed by opiate addicts undergoing methadone detoxification. These are difficulty initiating sleep (DIS), difficulty maintaining sleep (DMS), inadequate sleep quantity (ISQn), inadequate sleep quality (ISQI), low sleep efficiency (LSE) and sleep at inappropriate times (SIT). As SIT appears to be a disturbance of circadian rhythms commonly associated with the nocturnal lifestyle of addicts in general, it was excluded from this study.
Section snippets
Methods
This study was designed to investigate the subjective sleep–wake schedule and sleep difficulties of opiate addicts at the time of admission into methadone detoxification programme. The main study objectives were: (i) to examine sleep–wake parameters among treatment-seeking opiate addicts and compare these to those of a drug-free group; (ii) to estimate the likelihood of the following sleep difficulties among opiate addicts, difficulty initiating sleep; difficulty maintaining sleep; inadequate
Comparison between subjects and controls on subjective sleep parameters
Subjects reported significantly shorter nocturnal sleep (S=123.0 P=0.0001) and shorter total sleep time (S=130.0, P=0.0002) than controls. They also reported a significantly longer SOL (S=144.5, P=0.0016); and lower (but not statistically significant) sleep efficiency (S=200.0, P=0.07) None of the controls and only one subject reported any daytime sleep, hence the average duration of nocturnal sleep and total sleep time were identical (Table 1).
Subjects also reported significantly lighter sleep
Discussion
Generally, reported sleep–wake schedules of patients and controls are quantitatively and qualitatively different. Total and nocturnal sleep (420 min or 7 h) reported by the controls falls within the range widely reported in the sleep literature for normal healthy adults (Carskadon and Dement, 1994, Janson et al., 1995). Also, the average SOL (15 min) reported by the controls is similar to that commonly observed among normal healthy adults (Ohayon, 1996). In this respect, the findings of this
Acknowledgements
We are grateful to Steve Mootoo, Ken Umanee, and other clinical members of the Regional In-patient Treatment and Research Unit at Springfield University Hospital, London, for their support.
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