Sleep disturbance as a universal risk factor for relapse in addictions to psychoactive substances
Introduction
Relapse to uncontrolled use of a psychoactive substance is arguably the single most defining characteristic of an addiction, a source of immense frustration that is accompanied by tragic consequences for patients and society, and a primary target for addiction treatment research. Unfortunately, relapse following addiction treatment is very common and, therefore, predictors of relapse are a highly significant area of study. Before the turn of the century, most of the addiction treatment outcome literature focused on psychosocial predictors of relapse, which includes the long list of variables in Table 1. The underlying premise for studying these variables is that some might be modifiable, such as increasing self-efficacy, while other variables might respond optimally to specifically targeted treatment programs (e.g., gender, age).
More recently, investigating biological predictors of treatment outcome has gained momentum. Human studies in this area have shown relationships between relapse and (a) genetic variants [1], [2], [3], [4], [5], (b) size of specific brain structures [6], (c) functioning of various neurotransmitters and neuroendocrine systems [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], (d) activation of specific neuroanatomical regions as measured with functional brain imaging [18], [19], [20], and (e) patterns of electrophysiological brain patterns [21], [22], [23], [24], [25], [26], including neurophysiological correlates of sleep [27], [28], [29]. The investigation of biological predictors—which for the most part are neurobiological predictors—is consistent with the currently dominant paradigm in addiction research, namely that addiction is a brain disease. According to this paradigm, if we can delineate how the brain is altered in affected individuals, then we can improve upon treatment strategies by targeting these specific neurobiological alterations, for example, with pharmacotherapy agents. Not surprisingly for a dominant paradigm, a proliferation of scholarly reviews of the neurobiology of addiction has recently been published [30], [31], [32], [33].
Of course, most experts would agree that addiction is not simply a brain disease, but rather a disorder that is strongly influenced by psychological, social, and cultural factors in addition to genetic, epigenetic, and neurobiological ones. While agreeing to the importance of non-biological factors in the etiology and course of substance use disorders, we will focus on a biological one, specifically sleep, which is also influenced strongly by psychosocial and cultural factors. Sleep disturbance offers a number of advantages when investigating predictors of addiction treatment outcome. For example, it is a common symptom across all substance-related withdrawal disorders recognized in the DSM-IV [34]. Psychological and pharmacological treatments are available to address sleep disturbances among persons with substance-related disorders [35], [36]. Thus, with proper assessment and targeted sleep-related interventions, treatment providers can increase the likelihood of successful outcomes for this at-risk population. Finally, systematic investigation of the relationship between sleep disturbance and relapse can advance our knowledge on the basic science of addiction and treatments.
Section snippets
Hypothesis
Current research suggests that sleep disturbances among persons who are recovering from an alcohol addiction and have a sleep disturbance are at an elevated risk of relapse compared to those without a sleep disturbance. Given common neurobiological and psychosocial processes in sleep and addictive behaviors, we believe this sleep-related relapse risk for alcohol generalizes to all other types of psychoactive substances. In formalized terms, we hypothesize that persons who are recovering from an
Alcohol
The largest body of evidence relating sleep disturbance to relapse involves studies of alcohol dependence, for which both subjective and objective measures of sleep at baseline have predicted subsequent relapse [27], [37]. A 2003 review of the literature cited 12 publications from 1975 to 2001 by six different research groups demonstrating a relationship between sleep disturbance and relapse [38]. Since that time, at least three other reports have appeared which extend the evidence [39], [40],
Conceptual framework for the sleep disturbance-relapse hypothesis
The evidence that sleep disturbance is linked to relapse is strongest for alcohol dependence. Two sets of arguments for generalizing the link between sleep disturbance and relapse to other psychoactive substances are provided below. The first of these arguments is based on the commonality of sleep disturbances across psychoactive substances, while the second of these sections is based on the unique advantages of sleep disturbances as a predictor of treatment outcome.
Research
Despite over 30 years of evidence that addiction-related sleep disturbances are predictors of relapse, this area of research is still in its infancy. While details of a comprehensive research agenda are beyond the scope of this article, a few next steps for studying sleep as a predictor of relapse are offered. As discussed above, the current evidence for linking sleep and relapse is strongest for alcohol dependence, because it is the best studied. Additional studies on the potential relationship
Summary
Measures of sleep disturbance in substance-dependent patients are common across different drugs of abuse and persist following the course of acute withdrawal into the period of protracted abstinence. Sleep disturbances are theorized to reflect neurobiological dysfunction, increase relapse risk, and be amenable to pharmacotherapy when the mechanisms underlying addiction and sleep disturbance are better understood. Although the current evidence is strongest for alcohol addiction, we have
Conflict of interest
None declared.
Acknowledgments
The authors acknowledge funding from NIH Grants K24 AA00304 and R03 DA027832.
The sources that provided funding had no role in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to suit the manuscript for publication.
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