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Subjective sleep–wake parameters in treatment-seeking opiate addicts
Drug and Alcohol Dependence 48 (1997) 9 – 16
Subjective sleep – wake parameters in treatment-seeking opiate addicts Adenekan Oyefeso *, Philip Sedgwick, Hamid Ghodse Department of Psychiatry of Addicti6e Beha6iour, St. George’s Hospital Medical School, London SW17 ORE, UK Received 16 October 1996; received in revised form 13 May 1997; accepted 24 June 1997
Abstract We investigated subjective sleep parameters and sleep difficulties of opiate addicts undertaking methadone detoxification and identified their sleep profile. Using the St Mary’s Sleep Questionnaire, we compared the subjective sleep parameters of 27 consecutively consenting patients (16 males, 11 females) with a mean age of 33 years (S.D. =7.5) undertaking in-patient methadone detoxification with those of 26 drug-free controls (9 males, 17 females) with a mean age of 35 years (S.D.= 8.0). Our findings reveal that subjective sleep parameters of opiate addicts and controls are quantitatively and qualitatively different. The patients are more likely than controls to report difficulty initiating sleep (OR = 5.42; 95%CI =1.43, 20.47); difficulty maintaining sleep (OR = 16.50; 95%CI = 3.81, 71.47); inadequate sleep quality (OR = 8.56; 95%CI = 2.04, 35.81); and inadequate sleep quantity (OR =9.00; 95%CI =2.49, 32.57). © 1997 Elsevier Science Ireland Ltd. Keywords: Methadone detoxification; Opiate addicts; Sleep difficulties; Subjective sleep parameters
1. 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 Abbre6iations: DIS, difficulty initiating sleep; DMS, difficulty maintaining sleep; ISQI, inadequate sleep quality; ISQn, inadequate sleep quantity; LSE, low sleep efficiency; NA, number of nocturnal awakenings; NS, nocturnal sleep; SOL, sleep onset latency; TST, total sleep time. * Corresponding author. Tel.: + 44 181 6729944; fax: + 44 181 7252914.
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.
0376-8716/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 3 7 6 - 8 7 1 6 ( 9 7 ) 0 0 0 9 7 - 5
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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.
2. 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 sleep quality and quantity; and low sleep efficiency; (iii) to identify the predominate sleep –wake
difficulties among the addicts; and (iv) to examine any relationship between sleep difficulties, patients’ demographics and treatment variables Subjects consisted of 27 consecutively consenting patients admitted into a specialist in-patient methadone detoxification programme and 26 drug-free controls. The patients’ ages ranged between 20 and 53 years (mean= 33.0; S.D.= 7.5), and they comprised of 16 men and 11 women. The majority (22/27) were unemployed. All the patients have been receiving daily oral methadone prescriptions prior to admission (median dose= 50 mg; semi-interquartile range= 20) over a period of time (median= 4 months; semi-interquartile range= 2) in an out-patient or community setting. They all met DSM-111-R (American Psychiatric Association, 1987) diagnosis for opiate dependence with no comorbid psychiatric diagnosis and were urine positive for opiates. The standard methadone detoxification regimen which they undertook has been fully described by Ghodse (1995). Following admission, the patients were taken off their pre-admission methadone for a period ranging between 24 and 48 h. During this period, they were then carefully monitored for features of opiate withdrawal using a symptom checklist based on commonly described signs and symptoms (Ghodse, 1995). Oral methadone was administered once withdrawal was apparent, and this continued whenever withdrawal reemerged, until a stable dose was achieved. Once the patients were satisfactorily stabilised for an average period of 2–5 days, gradual reduction of methadone began. The methadone reduction phase usually lasts between 5 and 21 days for patients completing treatment, depending on the stabilisation dose. The drug-free control group consisted of 9 men, 17 women, who were clinical and academic members of staff of a specialist substance misuse service, and were on permanent daytime shift. Their ages ranged from 23 to 56 years (mean= 34.8 years, S.D.= 8.0). Participants in the control group did not have any kind of psychiatric disorder, past psychiatric history; or problematic substance use, and currently were not on psychotropic medications. They reported a regular sleep–wake schedule of at least 1 month prior to the study. All subjects and controls completed the St Mary’s Hospital (SMH) Sleep Questionnaire (Ellis et al., 1981), a self-reported questionnaire with accepted reliability and validity (Leigh et al., 1988). It measured the following subjective sleep parameters in relation to the previous day: Nocturnal sleep (NS), total sleep time (TST), number of nocturnal awakenings (NA); sleep onset latency (SOL: i.e. time between settling down for the night and falling asleep); depth of sleep (an 8-point ordered categorical scale that ranges from ‘very light’ to ‘very deep’); sleep quality (a 6-point ordered categorical scale ranging from ‘very badly’ to ‘very well’); alertness
A. Oyefeso et al. / Drug and Alcohol Dependence 48 (1997) 9–16
on waking (a 6-point ordered categorical scale ranging from ‘still very drowsy’ to ‘very alert’); sleep satisfaction (a 5-point ordered categorical scale ranging from ‘very unsatisfied’ to ‘completely satisfied’); and difficulty falling asleep (a 4-point ordered categorical scale ranging from ’none or very little’ to ‘extremely difficult’). Other measures obtained from the questionnaire were time of settling down for the night, time of sleep, time of wakening and time of rising from bed. From these, sleep efficiency, i.e. the ratio of time asleep to time in bed, expressed as a percentage was calculated. The following treatment variables were recorded for each patient: number of days of stabilisation, average stabilisation dose, number of days of methadone reduction, and whether treatment was completed or not. The SMH Sleep Questionnaire was administered to the patients, within 1 h of waking, on the first and second mornings following their admission for treatment, in order to estimate the first night effect and rebound sleep following the first night effect, if any. The first night effect, which is characterised, among other things, by sleep onset latency and lower sleep efficiency, is said to be mainly determined by unfamiliar surroundings (Toussaint et al., 1995), such as that provided in residential treatment programmes. First night effect was examined by comparing sleep parameters reported by the subjects on the first and second nights of admission. For the control group, questionnaire administration took place cross-sectionally and individually in the morning of a weekday.
2.1. Hypotheses The main study hypotheses were as follows: When compared to the control group, opiate addicts would report significantly shorter nocturnal sleep; higher number of nocturnal awakenings; longer SOL; lighter sleep; poorer sleep; poorer sleep satisfaction; greater difficulty falling asleep; and lower sleep efficiency.
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Other analyses involved the use of the Wilcoxon Signed Rank Test, with the test statistic indicated by W, to examine the presence of first night effect, by comparing the subjects’ sleep quantity and efficiency between the first and second nights of admission. Spearman’s Correlation Coefficient, with the test statistic indicated by r, was used to determine the relationship of age with sleep quantity and sleep efficiency. The Fisher’s Exact Test was applied to examine gender differences in sleep difficulties. All statistical analyses were undertaken using SPSS for Windows (Norussis, 1993).
3. Results
3.1. Comparison between subjects and controls on subjecti6e 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 (S= 119.5, P =0.0001); poorer sleep (S= 127.5, P= 0.0001); less satisfaction with sleep (S=159.5, P= 0.001); and greater difficulty falling asleep (S= 107.5, P= 0.00001). There was no significant difference in the two groups on alertness arising (S= 325.0, P= 0.9) Although there was a difference in the number of nocturnal awakenings between subjects and controls (S= 188.5, P= 0.008), the level of significance was higher than the adjusted P-value (0.005) (Table 1).
3.2. Pre6alence and likelihood of sleep difficulties
2.2. Statistical analysis The Mann-Whitney U test, with the test statistic indicated by S, was used to examine the difference in all subjective sleep parameters between subjects and controls. Bonferroni’s correction factor was applied to adjust for multiple testing. In total, 10 tests were applied to the main hypotheses, and consequently, the new level of significance was set at 0.005. Using a case-control design odds ratios and their 95% confidence intervals were calculated for the likelihood of each sleep difficulty among opiate addicts when compared to the control group. The Mann-Whitney U test was used to examine the relationship between sleep difficulties and treatment variables.
The following indices were derived from the subjective sleep parameters to identify the types and prevalence of sleep difficulties reported by the patients: Difficulty initiating sleep (DIS), difficulty maintaining sleep (DMS); inadequate sleep quantity (ISQn); inadequate sleep quality (ISQI) and low sleep efficiency (LSE).
3.2.1. DIS index This was obtained by recoding sleep onset latency (SOL of 15 min or less = 1; SOL\ 15 min = 2); and difficulty falling asleep (None or very little = 1; Some, A lot or Extreme difficulty= 2) and adding the total score on the recoded variables. (Coefficient a=0.81) (DIS scores ranged between 2 and 6 (2= ‘absence of
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Table 1 Subjective sleep-wake parameters reported by opiate addicts and controls Parameter
Nocturnal sleep (min) Total sleep time (min) Sleep efficiency (%) SOL (min) Alertness arising Depth of sleep Difficulty falling asleep Sleep quality Satisfaction with sleep Number of nocturnal awakenings
Opiate addicts
Controls
n
Median
Semi inter-quartile range
n
Median
Semi inter-quartile range
25 25 23 24 25 25 25 25 25 25
320.0 320.0 86.4 45.0 3.0 2.5 2.0 3.0 2.0 2.0
75.0 82.5 14.0 15.0 1.0 1.9 0.5 1.0 1.4 1.9
26 26 25 25 26 26 26 26 26 26
420.0 420.0 90.0 15.0 4.0 5.0 1.0 4.0 4.0 1.0
33.8 33.8 4.6 12.5 1.0 1.0 0.0 1.0 0.8 1.0
Mann-Whitney U value
P*
123.0 130.0 200.0 144.5 325.0 119.5 107.5 127.5 159.5 188.5
0.0001 0.0002 0.07 0.0016 0.9 0.0001 0.00001 0.0001 0.0013 0.008
* Due to multiple testing, the level of significance was adjusted and set at 0.005 using Bonferroni’s adjustment factor.
difficulty’; 3, 4, 5 and 6=‘varying degree of difficulty’). The cut-off point of 15 min for SOL was the median SOL reported by controls.
ratios were 9.0 (ISQn), 8.56 (ISQI), 5.42 (DIS) and 1.69 (LSE) (Table 2).
3.3. Sleep difficulties and patient characteristics 3.2.2. DMS Index This was obtained by recoding number of awakenings after sleep onset (0 and 1=1 or ‘absence of difficulty’; 2 or more=2 or ‘presence of difficulty’). 3.2.3. ISQI index This was obtained by recoding depth of sleep (deep average, fairly deep, deep, or very deep= 1 (‘deep’); light average, fairly light, light, or very light= 2 (‘light’); sleep wellness (fairly well, well, or very well= 1 (good); fairly badly, badly, or very badly= 2 (bad); and satisfaction (fairly satisfied or completely satisfied= 1 (satisfactory); slightly unsatisfied, moderately unsatisfied and very unsatisfied= 2 (unsatisfactory) and summing the scores on the recoded variables. (Coefficient a =0.79) ISQI scores ranged between 3 and 6 (3= ‘adequate sleep quality’; 4 or more = ‘varying degree of inadequate sleep quality’). ISQn index was obtained by recoding nocturnal sleep (sleep 420 min or more =1 or ‘adequate’; sleep less than 420 min= 2 or ‘inadequate’). The 420 min cut-off point was the median nocturnal sleep reported by the controls. Sleep efficiency was recoded into two categories (efficiency of 90% or more= 1 or ‘high efficiency’; efficiency of less than 90%=2 or ‘low efficiency’). The 90% cut-off point was the median sleep efficiency for the controls. The likelihood of reported sleep difficulties, calculated as odds ratios, among subjects, compared with controls, ranged between 1.69 and 16.50. The highest odds ratio (16.50) was reported for DMS. Other odds
3.3.1. Gender and age The only statistically significant gender difference in reported sleep difficulties was observed in ISQI. Male patients were more likely to report inadequate sleep quality than females (Fisher’s Exact P=0.05). There was no relationship between age and sleep difficulties. In general, average nocturnal sleep patterns for all patients were as follows: Time of settling down, 01:15; time of sleep, 02:00; time of wakening, 07:45; and time of rising, 08:00. 3.4. Sleep difficulties and treatment 6ariables Engagement in treatment ranged between 7 and 27 days (median= 18 days, semi-interquartile range= 4.5). The average number of days required for stabilisation was 4 (semi-interquartile range=0.125). Individual patient’s average stabilisation dose, dose of methadone at the beginning of the reduction and the last dose before treatment termination are summarised in Table 3. A total of 15 (56%) completed detoxification, and there were no significant differences in the prevalence rates of sleep difficulties between treatment completers and non-completers. Among all patients, difficulty initiating sleep predicted duration of stabilisation. Patients with difficulty initiating sleep required a longer period of stabilisation on methadone than those without (Mann-Whitney U= 17.0, P= 0.05). Furthermore, non-completers reporting low sleep efficiency required a longer period of stabilisation than those reporting high sleep efficiency (Mann-Whitney U= 2.50, P= 0.04).
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Table 2 Comparison of the likelihood of sleep difficulties between subjects and controls Parameter
Difficulty initiating sleep Difficulty maintaining sleep Inadequate sleep quality Inadequate sleep quantity Low sleep efficiency
Subjects
Controls
Number reporting
Prevalence rate (%)
Number reporting
Prevalence rate (%)
20 22 22 20 14
83.3 88.0 88.0 80.0 60.9
12 8 12 8 12
48.0 30.8 46.2 30.8 48.0
(n= 24) (n= 25) (n= 25) (n= 25) (n =23)
3.4.1. First night effects There were no significant differences (all P \ 0.1) in all sleep parameters relating to the first and second nights of admission. 4. 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 study can be said to be valid. Using subjective sleep – wake schedules of controls as a norm, therefore, the patients have reported, on the average, total and nocturnal sleep that is about one-quarter (23.8%) shorter than normal; sleep efficiency of about 4% below normal; and sleep onset latency of 45 min, that is three times the average for controls. They also have a tendency to wake up more often during the night than controls. The patients, however, did not differ significantly from controls in self-reported alertness arising. This observation is consistent with the syndrome described by Berrios and Shapiro (1993) as secondary insomnia, which, in this case, may be attributed to prolonged administration of methadone. Taken together, the patients’ sleep – wake parameters also reveal higher prevalence rates of DMS (OR= 16.50); ISQn (OR = 9.00); ISQI (OR =8.56); and DIS (OR=5.42) than controls. Among opiate addicts the risk for sleep difficulty is highest for DMS. The profile of sleep difficulties that emerges is somewhat similar to those of patients with major depression and generalised anxiety disorder. DMS, DIS and ISQn are characteristic of patients with major depression (Rush et al., 1991) and generalised anxiety disorders (Gelder et al., 1996). Unlike these disorders, however, the opiate addicts reported high levels of ISQI that have not
(n =25) (n = 26) (n = 26) (n =25) (n = 25)
Odds Ratio (95% CI)
P
5.42 16.50 8.56 9.00 1.69
0.01 0.00003 0.0017 0.00047 0.27
(1.43, (3.81, (2.04, (2.49, (0.53,
20.47) 71.47) 35.81) 32.57) 5.31)
been previously reported in other psychiatric populations. The similarities in the sleep profile of opiate addicts, as revealed in this study, and those of depression and anxiety patients suggest that (i) opiate dependence, depression and anxiety may share a common etiology; (ii) depression and anxiety may coexist in opiate addicts; and (iii) the presence of depression and/or anxiety among opiate addicts may predispose them to sleep difficulties. Although there is evidence that opiate addicts have elevated rates of depression and anxiety (Kosten et al., 1992; Kokkevi and Stefanis, 1995) it is difficult in this study to establish which of the three explanations prevail as we did not control for the influence of depression and anxiety on sleep difficulties. Further investigation of this interaction is, therefore, necessary. Furthermore, since psychopathology is a risk factor for sleep difficulties (Soldatos, 1994), it could be argued that the high prevalence of sleep difficulties in our sample indicates a high prevalence of underlying psychopathology. This is evident in the high prevalence rate (82%) of lifetime diagnosis of any psychiatric disorder among opiate addicts in treatment (Rounsaville et al., 1986). Our observation that patients reporting difficulty initiating sleep also experienced longer periods of stabilisation on methadone during treatment strongly suggests that they were possibly self-medicating, either for their sleep difficulty, or for the underlying psychopathology, or for both. The screening of opiate addicts reporting sleep difficulties at the time of admission for underlying psychopathology, therefore, may prove to be of immense clinical utility. There are other plausible explanations for the elevated rates of sleep difficulties in our sample. Firstly, opiate addicts in this study can be said to exhibit delayed circadian rhythm in relation to the ‘sociallyacceptable’ sleep–wake schedule on the ward when in treatment. This delayed sleep/wake rhythm may have accounted for the reported inadequate sleep quantity (Waterhouse, 1993). However, the absence of a first night effect weakens this assumption.
Mean stabilisation dose
24 20 40 49 58 27 40 50 50 68 64 50 25 45 55
Patient
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
20 15 35 40 50 20 35 45 45 65 65 45 20 40 45
Dose of methadone on day 1 of reduction
Table 3 Dosing pattern of patients during methadone detoxification
0 5 0 0 0 0 0 14 25 30 35 0 0 0 10
Last dose
16 17 18 19 20 21 22 23 24 25 26 27
Patient number
61 30 50 26 40 60 35 60 60 40 70 40
Mean stabilisation dose 60 25 45 25 35 55 30 55 55 35 65 35
Dose of methadone on Day 1 of reduction
40 0 0 0 10 30 0 15 25 25 0 0
Last dose
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Furthermore, in the absence of polysomnography, the reported inadequate sleep quantity may be a manifestation of sleep state misperception as patients who complain of sleep difficulties generally provide sleep estimates that are significantly lower than actual sleep times (Edinger and Fins, 1995). Given that our findings suggest a mixed etiology of sleep difficulties among methadone patients at admission into an inpatient detoxification programme, the framework of any intervention programme developed to alleviate sleep problems in this population should be eclectic. A combination of behavioural techniques (Espie et al., 1989; Morin et al., 1990; Lacks and Morin, 1992; Morin et al., 1994), sleep hygiene (Espie et al., 1989; Morin et al., 1994) and sleep hygiene with bright light therapy (Guilleminault et al., 1995) known to be effective, can be incorporated into methadone detoxification protocols. Sleep hygiene counselling can include training the patients to: avoid naps, get regular exercise, take a hot bath within 2 h before bedtime; keep a regular time out of bed everyday; avoid smoking after 19:00; avoid caffeine entirely or limit it to no more than three cups, no later than 10:00; and to avoid heavy use of alcohol. Other sleep hygiene instructions may include training the patients to avoid strenuous exercise after 18:00; and to avoid eating or drinking heavily 3 h before bedtime (Zarcone, 1994). Completion of sleep diaries by patients will also help clinical staff to identify any unusual sleep pattern, thereby facilitating prompt therapeutic response. The findings of this study have not been affected by first night effect and gender. Although there are no gender differences, the influence of the female luteal phase on sleep – wake schedules was not controlled for in this study. This limitation, however should not affect the validity of the findings as the potential error attributable to luteal phase was common in both groups. This study has investigated the subjective sleep– wake schedule and sleep difficulties of opiate addicts at the time of admission into a methadone detoxification programme. The emerging profile can not be said to apply to the other stages of methadone detoxification (i.e. stabilisation and reduction). It is also possible that the sleep – wake schedule described by polysmonography may be different. These issues are being addressed in on-going research.
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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Subjective sleep – wake parameters in treatment-seeking opiate addicts Adenekan Oyefeso *, Philip Sedgwick, Hamid Ghodse Department of Psychiatry of Addicti6e Beha6iour, St. George’s Hospital Medical School, London SW17 ORE, UK Received 16 October 1996; received in revised form 13 May 1997; accepted 24 June 1997
Abstract We investigated subjective sleep parameters and sleep difficulties of opiate addicts undertaking methadone detoxification and identified their sleep profile. Using the St Mary’s Sleep Questionnaire, we compared the subjective sleep parameters of 27 consecutively consenting patients (16 males, 11 females) with a mean age of 33 years (S.D. =7.5) undertaking in-patient methadone detoxification with those of 26 drug-free controls (9 males, 17 females) with a mean age of 35 years (S.D.= 8.0). Our findings reveal that subjective sleep parameters of opiate addicts and controls are quantitatively and qualitatively different. The patients are more likely than controls to report difficulty initiating sleep (OR = 5.42; 95%CI =1.43, 20.47); difficulty maintaining sleep (OR = 16.50; 95%CI = 3.81, 71.47); inadequate sleep quality (OR = 8.56; 95%CI = 2.04, 35.81); and inadequate sleep quantity (OR =9.00; 95%CI =2.49, 32.57). © 1997 Elsevier Science Ireland Ltd. Keywords: Methadone detoxification; Opiate addicts; Sleep difficulties; Subjective sleep parameters
1. 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 Abbre6iations: DIS, difficulty initiating sleep; DMS, difficulty maintaining sleep; ISQI, inadequate sleep quality; ISQn, inadequate sleep quantity; LSE, low sleep efficiency; NA, number of nocturnal awakenings; NS, nocturnal sleep; SOL, sleep onset latency; TST, total sleep time. * Corresponding author. Tel.: + 44 181 6729944; fax: + 44 181 7252914.
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.
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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.
2. 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 sleep quality and quantity; and low sleep efficiency; (iii) to identify the predominate sleep –wake
difficulties among the addicts; and (iv) to examine any relationship between sleep difficulties, patients’ demographics and treatment variables Subjects consisted of 27 consecutively consenting patients admitted into a specialist in-patient methadone detoxification programme and 26 drug-free controls. The patients’ ages ranged between 20 and 53 years (mean= 33.0; S.D.= 7.5), and they comprised of 16 men and 11 women. The majority (22/27) were unemployed. All the patients have been receiving daily oral methadone prescriptions prior to admission (median dose= 50 mg; semi-interquartile range= 20) over a period of time (median= 4 months; semi-interquartile range= 2) in an out-patient or community setting. They all met DSM-111-R (American Psychiatric Association, 1987) diagnosis for opiate dependence with no comorbid psychiatric diagnosis and were urine positive for opiates. The standard methadone detoxification regimen which they undertook has been fully described by Ghodse (1995). Following admission, the patients were taken off their pre-admission methadone for a period ranging between 24 and 48 h. During this period, they were then carefully monitored for features of opiate withdrawal using a symptom checklist based on commonly described signs and symptoms (Ghodse, 1995). Oral methadone was administered once withdrawal was apparent, and this continued whenever withdrawal reemerged, until a stable dose was achieved. Once the patients were satisfactorily stabilised for an average period of 2–5 days, gradual reduction of methadone began. The methadone reduction phase usually lasts between 5 and 21 days for patients completing treatment, depending on the stabilisation dose. The drug-free control group consisted of 9 men, 17 women, who were clinical and academic members of staff of a specialist substance misuse service, and were on permanent daytime shift. Their ages ranged from 23 to 56 years (mean= 34.8 years, S.D.= 8.0). Participants in the control group did not have any kind of psychiatric disorder, past psychiatric history; or problematic substance use, and currently were not on psychotropic medications. They reported a regular sleep–wake schedule of at least 1 month prior to the study. All subjects and controls completed the St Mary’s Hospital (SMH) Sleep Questionnaire (Ellis et al., 1981), a self-reported questionnaire with accepted reliability and validity (Leigh et al., 1988). It measured the following subjective sleep parameters in relation to the previous day: Nocturnal sleep (NS), total sleep time (TST), number of nocturnal awakenings (NA); sleep onset latency (SOL: i.e. time between settling down for the night and falling asleep); depth of sleep (an 8-point ordered categorical scale that ranges from ‘very light’ to ‘very deep’); sleep quality (a 6-point ordered categorical scale ranging from ‘very badly’ to ‘very well’); alertness
A. Oyefeso et al. / Drug and Alcohol Dependence 48 (1997) 9–16
on waking (a 6-point ordered categorical scale ranging from ‘still very drowsy’ to ‘very alert’); sleep satisfaction (a 5-point ordered categorical scale ranging from ‘very unsatisfied’ to ‘completely satisfied’); and difficulty falling asleep (a 4-point ordered categorical scale ranging from ’none or very little’ to ‘extremely difficult’). Other measures obtained from the questionnaire were time of settling down for the night, time of sleep, time of wakening and time of rising from bed. From these, sleep efficiency, i.e. the ratio of time asleep to time in bed, expressed as a percentage was calculated. The following treatment variables were recorded for each patient: number of days of stabilisation, average stabilisation dose, number of days of methadone reduction, and whether treatment was completed or not. The SMH Sleep Questionnaire was administered to the patients, within 1 h of waking, on the first and second mornings following their admission for treatment, in order to estimate the first night effect and rebound sleep following the first night effect, if any. The first night effect, which is characterised, among other things, by sleep onset latency and lower sleep efficiency, is said to be mainly determined by unfamiliar surroundings (Toussaint et al., 1995), such as that provided in residential treatment programmes. First night effect was examined by comparing sleep parameters reported by the subjects on the first and second nights of admission. For the control group, questionnaire administration took place cross-sectionally and individually in the morning of a weekday.
2.1. Hypotheses The main study hypotheses were as follows: When compared to the control group, opiate addicts would report significantly shorter nocturnal sleep; higher number of nocturnal awakenings; longer SOL; lighter sleep; poorer sleep; poorer sleep satisfaction; greater difficulty falling asleep; and lower sleep efficiency.
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Other analyses involved the use of the Wilcoxon Signed Rank Test, with the test statistic indicated by W, to examine the presence of first night effect, by comparing the subjects’ sleep quantity and efficiency between the first and second nights of admission. Spearman’s Correlation Coefficient, with the test statistic indicated by r, was used to determine the relationship of age with sleep quantity and sleep efficiency. The Fisher’s Exact Test was applied to examine gender differences in sleep difficulties. All statistical analyses were undertaken using SPSS for Windows (Norussis, 1993).
3. Results
3.1. Comparison between subjects and controls on subjecti6e 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 (S= 119.5, P =0.0001); poorer sleep (S= 127.5, P= 0.0001); less satisfaction with sleep (S=159.5, P= 0.001); and greater difficulty falling asleep (S= 107.5, P= 0.00001). There was no significant difference in the two groups on alertness arising (S= 325.0, P= 0.9) Although there was a difference in the number of nocturnal awakenings between subjects and controls (S= 188.5, P= 0.008), the level of significance was higher than the adjusted P-value (0.005) (Table 1).
3.2. Pre6alence and likelihood of sleep difficulties
2.2. Statistical analysis The Mann-Whitney U test, with the test statistic indicated by S, was used to examine the difference in all subjective sleep parameters between subjects and controls. Bonferroni’s correction factor was applied to adjust for multiple testing. In total, 10 tests were applied to the main hypotheses, and consequently, the new level of significance was set at 0.005. Using a case-control design odds ratios and their 95% confidence intervals were calculated for the likelihood of each sleep difficulty among opiate addicts when compared to the control group. The Mann-Whitney U test was used to examine the relationship between sleep difficulties and treatment variables.
The following indices were derived from the subjective sleep parameters to identify the types and prevalence of sleep difficulties reported by the patients: Difficulty initiating sleep (DIS), difficulty maintaining sleep (DMS); inadequate sleep quantity (ISQn); inadequate sleep quality (ISQI) and low sleep efficiency (LSE).
3.2.1. DIS index This was obtained by recoding sleep onset latency (SOL of 15 min or less = 1; SOL\ 15 min = 2); and difficulty falling asleep (None or very little = 1; Some, A lot or Extreme difficulty= 2) and adding the total score on the recoded variables. (Coefficient a=0.81) (DIS scores ranged between 2 and 6 (2= ‘absence of
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Table 1 Subjective sleep-wake parameters reported by opiate addicts and controls Parameter
Nocturnal sleep (min) Total sleep time (min) Sleep efficiency (%) SOL (min) Alertness arising Depth of sleep Difficulty falling asleep Sleep quality Satisfaction with sleep Number of nocturnal awakenings
Opiate addicts
Controls
n
Median
Semi inter-quartile range
n
Median
Semi inter-quartile range
25 25 23 24 25 25 25 25 25 25
320.0 320.0 86.4 45.0 3.0 2.5 2.0 3.0 2.0 2.0
75.0 82.5 14.0 15.0 1.0 1.9 0.5 1.0 1.4 1.9
26 26 25 25 26 26 26 26 26 26
420.0 420.0 90.0 15.0 4.0 5.0 1.0 4.0 4.0 1.0
33.8 33.8 4.6 12.5 1.0 1.0 0.0 1.0 0.8 1.0
Mann-Whitney U value
P*
123.0 130.0 200.0 144.5 325.0 119.5 107.5 127.5 159.5 188.5
0.0001 0.0002 0.07 0.0016 0.9 0.0001 0.00001 0.0001 0.0013 0.008
* Due to multiple testing, the level of significance was adjusted and set at 0.005 using Bonferroni’s adjustment factor.
difficulty’; 3, 4, 5 and 6=‘varying degree of difficulty’). The cut-off point of 15 min for SOL was the median SOL reported by controls.
ratios were 9.0 (ISQn), 8.56 (ISQI), 5.42 (DIS) and 1.69 (LSE) (Table 2).
3.3. Sleep difficulties and patient characteristics 3.2.2. DMS Index This was obtained by recoding number of awakenings after sleep onset (0 and 1=1 or ‘absence of difficulty’; 2 or more=2 or ‘presence of difficulty’). 3.2.3. ISQI index This was obtained by recoding depth of sleep (deep average, fairly deep, deep, or very deep= 1 (‘deep’); light average, fairly light, light, or very light= 2 (‘light’); sleep wellness (fairly well, well, or very well= 1 (good); fairly badly, badly, or very badly= 2 (bad); and satisfaction (fairly satisfied or completely satisfied= 1 (satisfactory); slightly unsatisfied, moderately unsatisfied and very unsatisfied= 2 (unsatisfactory) and summing the scores on the recoded variables. (Coefficient a =0.79) ISQI scores ranged between 3 and 6 (3= ‘adequate sleep quality’; 4 or more = ‘varying degree of inadequate sleep quality’). ISQn index was obtained by recoding nocturnal sleep (sleep 420 min or more =1 or ‘adequate’; sleep less than 420 min= 2 or ‘inadequate’). The 420 min cut-off point was the median nocturnal sleep reported by the controls. Sleep efficiency was recoded into two categories (efficiency of 90% or more= 1 or ‘high efficiency’; efficiency of less than 90%=2 or ‘low efficiency’). The 90% cut-off point was the median sleep efficiency for the controls. The likelihood of reported sleep difficulties, calculated as odds ratios, among subjects, compared with controls, ranged between 1.69 and 16.50. The highest odds ratio (16.50) was reported for DMS. Other odds
3.3.1. Gender and age The only statistically significant gender difference in reported sleep difficulties was observed in ISQI. Male patients were more likely to report inadequate sleep quality than females (Fisher’s Exact P=0.05). There was no relationship between age and sleep difficulties. In general, average nocturnal sleep patterns for all patients were as follows: Time of settling down, 01:15; time of sleep, 02:00; time of wakening, 07:45; and time of rising, 08:00. 3.4. Sleep difficulties and treatment 6ariables Engagement in treatment ranged between 7 and 27 days (median= 18 days, semi-interquartile range= 4.5). The average number of days required for stabilisation was 4 (semi-interquartile range=0.125). Individual patient’s average stabilisation dose, dose of methadone at the beginning of the reduction and the last dose before treatment termination are summarised in Table 3. A total of 15 (56%) completed detoxification, and there were no significant differences in the prevalence rates of sleep difficulties between treatment completers and non-completers. Among all patients, difficulty initiating sleep predicted duration of stabilisation. Patients with difficulty initiating sleep required a longer period of stabilisation on methadone than those without (Mann-Whitney U= 17.0, P= 0.05). Furthermore, non-completers reporting low sleep efficiency required a longer period of stabilisation than those reporting high sleep efficiency (Mann-Whitney U= 2.50, P= 0.04).
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Table 2 Comparison of the likelihood of sleep difficulties between subjects and controls Parameter
Difficulty initiating sleep Difficulty maintaining sleep Inadequate sleep quality Inadequate sleep quantity Low sleep efficiency
Subjects
Controls
Number reporting
Prevalence rate (%)
Number reporting
Prevalence rate (%)
20 22 22 20 14
83.3 88.0 88.0 80.0 60.9
12 8 12 8 12
48.0 30.8 46.2 30.8 48.0
(n= 24) (n= 25) (n= 25) (n= 25) (n =23)
3.4.1. First night effects There were no significant differences (all P \ 0.1) in all sleep parameters relating to the first and second nights of admission. 4. 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 study can be said to be valid. Using subjective sleep – wake schedules of controls as a norm, therefore, the patients have reported, on the average, total and nocturnal sleep that is about one-quarter (23.8%) shorter than normal; sleep efficiency of about 4% below normal; and sleep onset latency of 45 min, that is three times the average for controls. They also have a tendency to wake up more often during the night than controls. The patients, however, did not differ significantly from controls in self-reported alertness arising. This observation is consistent with the syndrome described by Berrios and Shapiro (1993) as secondary insomnia, which, in this case, may be attributed to prolonged administration of methadone. Taken together, the patients’ sleep – wake parameters also reveal higher prevalence rates of DMS (OR= 16.50); ISQn (OR = 9.00); ISQI (OR =8.56); and DIS (OR=5.42) than controls. Among opiate addicts the risk for sleep difficulty is highest for DMS. The profile of sleep difficulties that emerges is somewhat similar to those of patients with major depression and generalised anxiety disorder. DMS, DIS and ISQn are characteristic of patients with major depression (Rush et al., 1991) and generalised anxiety disorders (Gelder et al., 1996). Unlike these disorders, however, the opiate addicts reported high levels of ISQI that have not
(n =25) (n = 26) (n = 26) (n =25) (n = 25)
Odds Ratio (95% CI)
P
5.42 16.50 8.56 9.00 1.69
0.01 0.00003 0.0017 0.00047 0.27
(1.43, (3.81, (2.04, (2.49, (0.53,
20.47) 71.47) 35.81) 32.57) 5.31)
been previously reported in other psychiatric populations. The similarities in the sleep profile of opiate addicts, as revealed in this study, and those of depression and anxiety patients suggest that (i) opiate dependence, depression and anxiety may share a common etiology; (ii) depression and anxiety may coexist in opiate addicts; and (iii) the presence of depression and/or anxiety among opiate addicts may predispose them to sleep difficulties. Although there is evidence that opiate addicts have elevated rates of depression and anxiety (Kosten et al., 1992; Kokkevi and Stefanis, 1995) it is difficult in this study to establish which of the three explanations prevail as we did not control for the influence of depression and anxiety on sleep difficulties. Further investigation of this interaction is, therefore, necessary. Furthermore, since psychopathology is a risk factor for sleep difficulties (Soldatos, 1994), it could be argued that the high prevalence of sleep difficulties in our sample indicates a high prevalence of underlying psychopathology. This is evident in the high prevalence rate (82%) of lifetime diagnosis of any psychiatric disorder among opiate addicts in treatment (Rounsaville et al., 1986). Our observation that patients reporting difficulty initiating sleep also experienced longer periods of stabilisation on methadone during treatment strongly suggests that they were possibly self-medicating, either for their sleep difficulty, or for the underlying psychopathology, or for both. The screening of opiate addicts reporting sleep difficulties at the time of admission for underlying psychopathology, therefore, may prove to be of immense clinical utility. There are other plausible explanations for the elevated rates of sleep difficulties in our sample. Firstly, opiate addicts in this study can be said to exhibit delayed circadian rhythm in relation to the ‘sociallyacceptable’ sleep–wake schedule on the ward when in treatment. This delayed sleep/wake rhythm may have accounted for the reported inadequate sleep quantity (Waterhouse, 1993). However, the absence of a first night effect weakens this assumption.
Mean stabilisation dose
24 20 40 49 58 27 40 50 50 68 64 50 25 45 55
Patient
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
20 15 35 40 50 20 35 45 45 65 65 45 20 40 45
Dose of methadone on day 1 of reduction
Table 3 Dosing pattern of patients during methadone detoxification
0 5 0 0 0 0 0 14 25 30 35 0 0 0 10
Last dose
16 17 18 19 20 21 22 23 24 25 26 27
Patient number
61 30 50 26 40 60 35 60 60 40 70 40
Mean stabilisation dose 60 25 45 25 35 55 30 55 55 35 65 35
Dose of methadone on Day 1 of reduction
40 0 0 0 10 30 0 15 25 25 0 0
Last dose
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Furthermore, in the absence of polysomnography, the reported inadequate sleep quantity may be a manifestation of sleep state misperception as patients who complain of sleep difficulties generally provide sleep estimates that are significantly lower than actual sleep times (Edinger and Fins, 1995). Given that our findings suggest a mixed etiology of sleep difficulties among methadone patients at admission into an inpatient detoxification programme, the framework of any intervention programme developed to alleviate sleep problems in this population should be eclectic. A combination of behavioural techniques (Espie et al., 1989; Morin et al., 1990; Lacks and Morin, 1992; Morin et al., 1994), sleep hygiene (Espie et al., 1989; Morin et al., 1994) and sleep hygiene with bright light therapy (Guilleminault et al., 1995) known to be effective, can be incorporated into methadone detoxification protocols. Sleep hygiene counselling can include training the patients to: avoid naps, get regular exercise, take a hot bath within 2 h before bedtime; keep a regular time out of bed everyday; avoid smoking after 19:00; avoid caffeine entirely or limit it to no more than three cups, no later than 10:00; and to avoid heavy use of alcohol. Other sleep hygiene instructions may include training the patients to avoid strenuous exercise after 18:00; and to avoid eating or drinking heavily 3 h before bedtime (Zarcone, 1994). Completion of sleep diaries by patients will also help clinical staff to identify any unusual sleep pattern, thereby facilitating prompt therapeutic response. The findings of this study have not been affected by first night effect and gender. Although there are no gender differences, the influence of the female luteal phase on sleep – wake schedules was not controlled for in this study. This limitation, however should not affect the validity of the findings as the potential error attributable to luteal phase was common in both groups. This study has investigated the subjective sleep– wake schedule and sleep difficulties of opiate addicts at the time of admission into a methadone detoxification programme. The emerging profile can not be said to apply to the other stages of methadone detoxification (i.e. stabilisation and reduction). It is also possible that the sleep – wake schedule described by polysmonography may be different. These issues are being addressed in on-going research.
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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