Sleep Quality and Risk of Alcohol Misuse

Chapter 36

Sleep Quality and Risk of Alcohol Misuse Shannon R. Kenney Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA

Chapter Outline Sleep and Alcohol Use: Acute Effects 329 Alcohol Use and Sleep Physiology 329 Poor Sleep and Cognitive–Behavioral Functioning 329 Sleep and Alcohol Use: Behavioral Risks 330 Adolescents330 College Students 331 Insomnia and Alcohol Use in the General Population 331

SLEEP AND ALCOHOL USE: ACUTE EFFECTS Alcohol Use and Sleep Physiology Sleep problems and alcohol misuse co-occur and exhibit a bidirectional causal relationship. Studies conclude that although the sedating properties of moderate to excessive alcohol intake initially help to reduce sleep onset latency (SOL), once metabolized it results in fragmented and deficient sleep. In the latter half of sleep the effects of intoxication result in inefficient sleep, stimulating wake after sleep onset, decreasing slow-wave sleep, and causing abnormalities in rapid eye movement (REM) periods (suppression of REM in the first half of sleep and rebounding in the second half of sleep) (Landolt, Roth, Dijk, & Borbély, 1996; MacLean & Cairns, 1982; Roehrs, Zwyghuizen-Doorenbos, Timms, Zorick, & Roth, 1989). At blood alcohol levels of 0.06–0.08, for example, sleep is disrupted once alcohol is eliminated from the body, roughly 4–5 h into the sleep cycle (Roehrs & Roth, 2001). Recent evidence indicates that the effects of alcohol consumption on sleep may be modified by developmental age. In contrast to the current findings, Chan, Trinder, Andrewes, Colrain, and Nicholas (2013) found that alcohol did not result in reduced SOL or increased REM in the latter half of sleep in a sample of 18- to 21-year-old women. The authors contend that developmental changes in sleep cycles (e.g., delayed circadian timing and reduction in delta sleep) among late adolescents may result in a relationship between nightly alcohol consumption and sleep that is unique to this

Alcohol-Dependent Adults 331 Treating Sleep Problems in Alcohol Dependents 332 Considerations for Future Research 332 Longitudinal Studies 332 Measuring Sleep and Alcohol Use Problems 332 Mental Health 333 References333

age group. Although more research is needed to investigate the unique processes by which alcohol directly affects sleeping cycles in nonadult age groups, the research specific to adults is conclusive: even at moderate levels of drinking, consuming alcohol prior to bedtime has adverse effects on sleep quality in adults. Other studies have also found that alcohol use prior to sleep suppresses growth hormone secretion, although the clinical consequences are not yet known (Ekman et al., 1996; Prinz, Roehrs, Vitaliano, Linnoila, & Weitzman, 1980).

Poor Sleep and Cognitive–Behavioral Functioning Laboratory studies have also assessed the impact of sleep restriction and deprivation on human subjects’ psychosocial and cognitive functioning after consuming alcohol. Relative to control participants, sleep-deprived participants exhibit diminished attention, increased risk-taking behaviors, and impairment of motor response from alcohol intake (Roehrs, Beare, Zorick, & Roth, 1994; Roehrs & Roth, 1998). In a study of young adult pilots, blood alcohol concentrations of 0.10–0.12 prior to sleep impaired performance, relative to a placebo, on a flight simulator 14 h later (Yesavage & Leirer, 1986). These findings are consistent with studies in which sleep deprivation impaired participants’ executive functioning, including problem-solving, inhibitory functioning, and divergent thinking capacity (Linde & Bergström, 1992; Nilsson et al., 2005; Wimmer, Hoffmann, Bonato, & Moffitt, 1992).

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Further, brain studies link sleep deprivation with reductions in neural activity in the prefrontal cortex region of the brain, an area essential for higher-order executive functioning (e.g., decision making, self-monitoring, and conflict resolution; Thomas et al., 2000, 2003). Inadequate sleep may thus deprive people of important physical and cognitive capacities that are needed to evade potential harms and make rational and informed decisions while drinking. These laboratory-based findings raise awareness of the hazards of relying on alcohol to promote sleep as well as the risks associated with drinking while sleep-deprived, and inform the research and treatment of comorbid alcohol use and sleep disorders. Daytime sleepiness combined with alcohol consumption appears to intensify the physiological effects of alcohol. Roehrs and Roth (1998) manipulated participants’ nocturnal sleep durations and then administered alcohol the following day. Sleepiness and psychomotor performance assessments over 8 h supported the relationship between increased sleepiness at alcohol intake with poorer psychomotor functioning. Overall, a significant body of laboratory-based sleep research using simulated and computerized tasks as well as electrophysiological measures has shed light on the acute causal effects of the relationship (i.e., alcohol consumption on sleep quality and sleep quality on drinking impairment).

SLEEP AND ALCOHOL USE: BEHAVIORAL RISKS Poor sleep is associated with alcohol misuse and problems among adolescents (Johnson & Breslau, 2001; Tynjälä, Kannas, & Levälahti, 1997), college students (Kenney, Lac, LaBrie, Hummer, & Pham, 2013), and adults (Chaput, McNeil, Després, Bouchard, & Tremblay, 2012). Furthermore, sleep problems have prospectively predicted alcohol misuse in community samples (e.g., Crum, Storr, Ya-Fen, & Ford, 2004; Weissman, Greenwald, Niño-Murcia, & Dement, 1997), relapse among alcoholics (e.g., Brower, Aldrich, & Hall, 1998; Brower, Aldrich, Robinson, Zucker, & Greden, 2001), and alcohol use among adolescents (sleep problems at age 3–5 years predicted early onset of alcohol use at age 12–14 years; Wong, Brower, Fitzgerald, & Zucker, 2004).

Adolescents Sleep and alcohol problems are prevalent public health concerns in adolescent populations. Among elementary and high school students in the United States, more than one half report feeling tired or sleepy and more than one third reported problems staying asleep within the prior 2 weeks (National Sleep Foundation, 2006). Further, it appears that insufficient and inconsistent sleep patterns persist into college and emerging adulthood (Lund, Reider, Whiting, & Prichard, 2010).

Underage alcohol misuse is also common in adolescents: 7 in 10 U.S. high school students report ever consuming alcohol, with about 1 in 5 reporting binge drinking (5+ drinks in a row) in the prior 2 weeks (Johnston, O’Malley, Bachman, & Schulenberg, 2011). Addressing heavy drinking is central to risk prevention; approximately 90% of all underage alcohol consumed is consumed while binge drinking, and bingeing increases exponentially risks for experiencing negative consequences (Office of Juvenile Justice and Delinquency Prevention, 2005). In large studies of adolescents, those reporting higher levels of sleep problems also reported higher levels of risktaking behaviors, particularly in late adolescence (Bailly, Bailly-Lambin, Querleu, Beuscart, & Collinet, 2004; O’Brien & Mindell, 2005; Taylor & Bramoweth, 2010). Among the most prevalent risk behaviors associated with poor sleep in this population is heavy drinking. Sleep disturbance is associated with alcohol problems, including drinking frequency, drinking quantity, and inebriation (Johnson & Breslau, 2001; Morioka et al., 2013; Vignau et al., 1997). In a recent nationally representative study of 98,867 Japanese adolescents, difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening were associated with number of drinking days as well as amount of alcohol consumption per drinking occasion (Morioka et al., 2013). Moreover, adolescents report significantly greater prevalence of sleep problems even at moderate levels of drinking (i.e., less than 5 drinking days per month or less than a glass of alcohol per occasion compared to abstainers). The relationship between sleep and alcohol problems among adolescents is particularly important in light of the change in central neuroendocrine regulation and neural maturation that occurs during this developmental age. These biological changes affect physiological, cognitive, and psychological functioning. Thus, at a time when sufficient sleep is critical to developmentally appropriate brain reorganization and recuperation (Feinberg & Campbell, 2013), adolescents tend to experience biological and social changes that counteract healthy sleep schedules. Puberty is associated with insomnia symptoms among adolescents (Bailly et al., 2004). In a study of 431 adolescents, Pieters, Van Der Vorst, Burk, Wiers, and Engels (2010) found that pubertal development was associated with sleep disturbance and preferences for later bedtimes, which in turn were predictive of alcohol use. Therefore, the pubertal development that occurs during adolescence may heighten risks for cooccurring sleep and alcohol problems, such that puberty predicts problematic alcohol use through altered sleep regulation and patterns. Overall, sleepiness is associated with impaired executive functioning and cognitive control (e.g., impulsivity and attention control; Anderson, Storfer-Isser, Taylor, Rosen, & Redline, 2009; Beebe et al., 2008; Dahl, 1996), and excessive drinking during adolescence is linked to

Sleep Quality and Risk of Alcohol Misuse Chapter | 36  331

deficits in neural and cognitive functioning, such as memory impairment (Acheson, Stein, & Swartzwelder, 1998; Brown, Tapert, Granholm, & Delis, 2000; Zeigler et al., 2005). More research examining the potential interaction or synergistic relationship between poor sleep and drinking on adolescent brain development is warranted.

facilitate sleep (McCabe, 2008). An estimated 10% of student drinkers in another survey reported using alcohol as a sleep aid in just the previous week (Taylor & Bramoweth, 2010). More large-scale epidemiological studies that assess students’ reliance on sleeping medications or alcohol to fall asleep are warranted.

College Students

Insomnia and Alcohol Use in the General Population

In a nationally representative survey of 123,078 U.S. college students, over one quarter reported sleep difficulties as “traumatic or difficult to handle” in the prior 12 months, and 60% of students reported feeling “tired, dragged out, or sleepy” during the majority of days during a week (ACHA, 2013). Consistent with these reports, in other studies, 60–68% of students reported sleep problems (Hicks, Fernandez, & Pellegrini, 2001; Lund et al., 2010). Among young adults, sleep problems are linked to a range of negative consequences, including risk-taking behaviors (e.g., drowsy driving, violence, unsafe sex, substance use; O’Brien & Mindell, 2005; Taylor & Bramoweth, 2010; Wolfson & Carskadon, 1998) and poor academic performance (Buboltz et al., 2006; Gaultney, 2010; O’Brien & Mindell, 2005; Singleton & Wolfson, 2009). As many as 1 in 5 students report that sleep difficulties have a negative impact on their individual academic performance (e.g., lower grades, dropped courses; ACHA, 2013). During the college years, students are especially vulnerable to sleep problems (Tsai & Li, 2004) and risky alcohol use (Gaultney, 2010; Kenney et al., 2013; Thompson, Leinfelt, & Smyth, 2006). Social and academic demands, for instance, increase students’ likelihood to manifest delayed sleep phase disorder (Kloss, Nash, Horsey, & Taylor, 2011). In a 2012 study of college students (Kenney, LaBrie, Hummer, & Pham, 2012), poorer global sleep quality moderated the relationship between drinking and alcohol risk such that among heavier drinkers, participants reporting poorer (as compared to better) sleep quality experienced considerably greater levels of alcohol-related negative consequences. Especially in risky college drinking contexts, insufficient sleep may increase alcohol risk through its depletion of cognitive functioning (O’Brien & Mindell, 2005; Taylor & Bramoweth, 2010; Wolfson & Carskadon, 1998). Thus, drinking excessively when sleepdeprived appears to have a synergistic effect on exacerbating risks for alcohol-related negative outcomes. In this way, although intoxication itself weakens cognitive functioning, decision making, and self-protective abilities, co-occurring sleep deficiency may make arriving at safe decisions and warding off negative consequences all the more difficult. In contrast, lighter drinkers, even if deprived of quality sleep, may have less compromised cognitive functioning when drinking. Studies examining the use of sleeping medication to induce sleep demonstrate that 10% of college students use prescribed and nonprescribed sleeping medication to

Among people with persistent insomnia—typically defined as having significant difficulties initiating or maintaining sleep for more than 3 or 4 consecutive weeks (Stein & Friedmann, 2005)—nearly 1 in 3 report using alcohol as a sleep aid and, of those, 2 in 3 perceive alcohol as an effective means for inducing sleep (Ancoli-Israel & Roth, 1999). Among individuals with sleep problems, using alcohol to induce sleep is associated with higher levels of daytime sleepiness, over and above insomnia symptoms; total sleep time; and sociodemographics (Costa e Silva, Chase, Sartorius, & Roth, 1996). Paradoxically, despite alcohol’s adverse effects on sleep overall, its ability to reduce SOL is a powerful mechanism by which individuals with sleep problems may become reliant on consuming moderate to excessive doses of alcohol as a sedative (Johnson & Breslau, 2001; Roane & Taylor, 2008; Roehrs & Roth, 2001). Risks associated with habitual alcoholinduced sleep include the need for higher doses of alcohol, as individuals build up tolerance within as short a period as 1 week. In a general sample of non-alcohol-dependent individuals (N = 1537), those reporting sleep disturbances because of worry had double the risk for developing an alcohol use disorder one decade later (Crum et al., 2004). In a study of over 1000 young adults, those with (versus without) insomnia were significantly more likely to have an alcohol use disorder 3 years later (Breslau, Roth, Rosenthal, & Andreski, 1996). Large epidemiological community samples support the prospective relationship between insomnia and onset of alcohol abuse (Weissman et al., 1997).

Alcohol-Dependent Adults Alcohol and sleep disorders are highly comorbid (Teplin, Raz, Daiter, Varenbut, & Tyrrell, 2006; Weissman et al., 1997). In general samples of adults, rates of alcohol abuse are twice as high among individuals with, relative to without, insomnia (7% vs 3.8%; Ford & Kamerow, 1989). In their examination of 11 studies, Zhabenko, Krentzman, Robinson, and Brower (2013) calculated that, on average, 59.4% of 3027 alcohol-dependent patients experienced symptoms of insomnia. These prevalence rates are nearly twice that of general population samples (Calem et al., 2012; Roth et al., 2006).

332  PART | VII  Alcohol and Sleep Dysfunction

For alcohol dependents, alcohol withdrawal is associated with severe disturbances in sleep, including longer sleep latency, increased nighttime disruptions, poor sleep efficiency, and reductions in REM rebound in the latter half of sleep (Gillin, Smith, Irwin, Kripke, & Schuckit, 1990; Thompson, Gillin, Golshan, & Irwin, 1995). Among patients in remission from alcohol use disorders, self-reports indicate that serious sleep problems may endure for up to 6 months (Brower, Krentzman, & Robinson, 2011; Currie, Clark, Rimac, & Malhotra, 2003), and abnormal polysomnography (PSG) readings may persist for years in abstainers (Drummond, Gillin, Smith, & DeModena, 1998). Reasons for this persistence may include cumulative alcohol toxicity, mental health comorbidities, or a sleep disorder (e.g., insomnia) that preceded alcohol dependence (Zhabenko et al., 2013). Particularly concerning is that sleep problems are a common risk factor for relapse among alcohol dependents (Teplin et al., 2006). Whether assessed using PSG techniques in laboratory settings (Drummond et al., 1998; Gillin et al., 1994; Teplin et al., 2006) or subjective self-reports (Brower et al., 1998; Brower et al., 2001; Conroy et al., 2006), difficulty or increased time needed to fall asleep and sleep disturbances (e.g., frequent awakenings or movements during sleep) consistently predict relapse in alcohol-dependent patients. Alcoholdependent patients who report insomnia or difficulty falling asleep are up to twice as likely to relapse within 6 months compared with patients without sleep difficulties (Brower, 2003; Brower et al., 1998). In samples of alcohol dependents, 58–91% report serious sleep problems or insomnia during the first week of detoxification (Cohn, Foster, & Peters, 2003; Foster, Marshall, & Peters, 2000; Mello & Mendelson, 1970). Although the specific causal mechanisms leading to relapse are not fully established, many alcohol-dependent patients admit to drinking as a sleep aid despite recognizing that it disturbs their sleep (Mackenzie, Funderburk, & Allen, 1994). In all, given that sleep problems are a strong predictor of relapse, successful recovery from alcohol dependence may require careful monitoring, and appropriate treatment of sleep disturbances should be monitored.

Treating Sleep Problems in Alcohol Dependents Untreated sleep problems pose a primary impediment to healthy recovery among alcohol dependents, particularly in the first several months of withdrawal (Brower et al., 1998; Brower et al., 2001). To date, a number of pharmacological and nonpharmacological behavioral treatments aimed at managing severe sleep problems have demonstrated efficacy in this population. Given patients’ susceptibility to substance abuse and the risk for overdose when hypnotic medications are mixed with alcohol, clinicians must use caution when prescribing treatment. In a recent survey, 64%

of addiction treatment specialists reported treating alcoholdependent insomniac patients with pharmacological agents and less than one quarter did so with the majority of these patients (Friedmann et al., 2003). Nonpharmacological cognitive behavioral treatments for insomnia (CBT-I) have demonstrated efficacy in non-­alcoholdependent patients (Irwin, Cole, & Nicassio, 2006; Smith et al., 2002). Moreover, CBT-I is found to be more beneficial than pharmacological treatments over 6–8 weeks (Jacobs, Pace-Schott, Stickgold, & Otto, 2004; Sivertsen, 2006; Smith et al., 2002). The efficacy of CBT-I may be explained, in part, by the robust role of sleep-related cognitions in remission. Sleep cognitions are strongly tied to sleep disturbance onset and maintenance (Harvey, 2002) and appear more influential on sleep problems than physiological arousal (Lichstein & Rosenthal, 1980). Cognitive beliefs may include the inability to calm a racing mind (Espie, Brooks, & Lindsay, 1989). Overall, CBT-I interventions targeting alcohol-dependent insomniacs have been effective in improving sleep, but have not yielded consistent reductions, relative to controls, in rates of relapse (Arnedt et al., 2007; Arnedt, Conroy, Armitage, & Brower, 2011; Currie, Clark, Hodgins, & El-Guebaly, 2004). More research is needed to determine if CBT-I can be effectively tailored to recovering alcohol-dependent patients to reduce the risk for relapse.

CONSIDERATIONS FOR FUTURE RESEARCH Longitudinal Studies Methods that enable researchers to better assess the causal relationship between sleep and alcohol risk are needed to better inform clinical practice. Daily diary data collection minimizes retrospective self-report and allows for daily prospective data reports. Ecological Momentary Assessment (EMA; Stone & Shiffman, 1994) is an example of an innovative data collection application that enables participants to provide data on their current drinking behaviors, in real time and in natural drinking environments, using cell phones or other mobile devices. EMA may be a convenient and reliable way for participants to provide daily information on the prior night’s sleeping as well as drinking behaviors that following day. In addition to explicating the causal relationship between sleep and alcohol problems, prospective and longitudinal studies enable researchers to best identify predictors and moderators of sleep and alcohol disorders in order to shed light on how co-occurring disorders evolve over time.

Measuring Sleep and Alcohol Use Problems Existing studies examining the relationship between sleep and alcohol behaviors use a variety of measures to assess

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sleep and alcohol-related behaviors and diagnoses. With respect to both collection (e.g., subjective self-report, objective PSG) and variable operationalization (definitions and time frames), there is a lack of standardized measurement. In order to gain a consistent understanding of the relationship between sleep and alcohol risk and enable the comparison across populations, coordinated and consistent assessment techniques using established and validated instruments are needed.

Mental Health To fully disentangle the risks associated with sleep and drinking behaviors, it is important for researchers to examine potential moderating or confounding variables. Poor sleep (Benca, Obermeyer, Thisted, & Gillin, 1992; Kenney et al., 2013; Taylor, Bramoweth, Grieser, Tatum, & Roane, 2013; Taylor, Lichstein, Durrence, Reidel, & Bush, 2005) and problematic alcohol use (Bellos et al., 2013; Davidson, 1995; Merikangas, Angst, Eaton, & Canino, 1996; Murray et al., 2012) are strongly correlated with depression and anxiety symptoms. Sleep disturbances prospectively predict the development of psychological disorders (e.g., major depression) 1–3 years later in general adult samples (Breslau et al., 1996; Ford & Kamerow, 1989) and up to 7 years later in adolescent samples (Roane & Taylor, 2008; Roberts, Roberts, & Chen, 2002). Therefore, it is important for research to account for coexisting mental health problems when examining the influence of sleep deprivation on alcohol risk.

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