The Association Between Sleep Disturbances and Perceived Stress in Substance Use Disorder Treatment

Martin Hochheimer, PhD; Jennifer D. Ellis, PhD; Brion Maher, PhD; Justin C. Strickland, PhD; Jill A. Rabinowitz, PhD; David Wolinsky, MD; Andrew S. Huhn, PhD

J Clin Psychiatry. 2024;85(3):23m15220

Abstract

Introduction: Sleep disturbances and elevated stress levels are commonly reported among individuals seeking treatment for substance use disorders (SUDs). However, it remains unclear whether the relationship between sleep and stress differs based on the primary substance of use or if there are commonalities across different substances. This study aimed to investigate the association between sleep disturbances and perceived stress among individuals in SUD treatment and examine whether primary substance influences this relationship.

Method: A sample of 4,201 individuals from 59 SUD treatment programs completed assessments including the Insomnia Severity Index and Perceived Stress Scale in 2021. Cross-sectional and longitudinal analyses were conducted to evaluate the relationship between sleep and stress across different primary substances during treatment.

Results: The results demonstrated that higher stress was associated with more severe insomnia, and vice versa, both at treatment intake and over the course of treatment, regardless of primary substance. Persons using heroin/ fentanyl evidenced a stronger association of sleep on stress, and persons using cocaine evidenced a stronger relationship of stress on sleep.

Discussion: The findings suggest that sleep/stress associations are ubiquitous across different classes of drugs, although sleep might have more influence on stress in persons primarily using heroin/ fentanyl, and stress might have more influence on sleep in persons primarily using cocaine, relative to other substances. Interventions targeting either sleep or stress could have positive effects on SUD outcomes, but further research is needed to investigate the underlying neurobiological mechanisms and inform the development of effective interventions for sleep and stress in SUD populations.

J Clin Psychiatry 2024;85(3):23m15220

Author affiliations are listed at the end of this article.

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References (67)

Babson KA, Boden MT, Harris AH, et al. Poor sleep quality as a risk factor for lapse following a cannabis quit attempt. J Subst Abuse Treat. 2013;44(4):438–443. PubMed CrossRef
Bolla KI, Lesage SR, Gamaldo CE, et al. Sleep disturbance in heavy marijuana users. Sleep. 2008;31(6):901–908. PubMed CrossRef
Brower KJ, Aldrich MS, Robinson EA, et al. Insomnia, self-medication, and relapse to alcoholism. Am J Psychiatry. 2001;158(3):399–404. PubMed CrossRef
Brower KJ, Perron BE. Prevalence and correlates of withdrawal-related insomnia among adults with alcohol dependence: results from a national survey. Am J Addict. 2010;19(3):238–244. PubMed CrossRef
Chakravorty S, Chaudhary NS, Brower KJ. Alcohol dependence and its relationship with insomnia and other sleep disorders. Alcohol Clin Exp Res. 2016;40(11):2271–2282. PubMed CrossRef
Hu N, Ma Y, He J, et al. Alcohol consumption and incidence of sleep disorder: a systematic review and meta-analysis of cohort studies. Drug Alcohol Depend. 2020;217:108259. PubMed CrossRef
Huhn AS, Finan PH. Sleep disturbance as a therapeutic target to improve opioid use disorder treatment. Exp Clin Psychopharmacol. 2022;30(6):1024–1035. PubMed CrossRef
Vrajová M, Šlamberová R, Hoschl C, et al. Methamphetamine and sleep impairments: neurobehavioral correlates and molecular mechanisms. Sleep. 2021;44(6):zsab001. PubMed
Rady A, Mekky J, Moulokheya T, et al. Polysomnographic correlates for the risk of relapse in detoxified opiate-misuse patients. Neuropsychiatr Dis Treat. 2020;16:3187–3196. PubMed
Mukherjee D, Stankoski DM, Tilden SE, et al. Reregulation of cortisol levels and sleep in patients with prescription opioid use disorder during long-term residential treatment. Drug Alcohol Depend. 2021;227:108931. PubMed CrossRef
Erga AH, Nesvåg S, Dahlberg IE, et al. Persistent sleep problems among people in recovery from substance use disorders: a mixed methods study. Addict Res Theor. 2022;30(6):422–430.
Koob GF, Colrain IM. Alcohol use disorder and sleep disturbances: a feed forward allostatic framework. Neuropsychopharmacology. 2020;45(1):141–165. PubMed CrossRef
Dunn KE, Huhn AS, Bergeria CL, et al. Non-opioid neurotransmitter systems that contribute to the opioid withdrawal syndrome: a review of preclinical and human evidence. J Pharmacol Exp Ther. 2019;371(2):422–452. PubMed
Gates P, Albertella L, Copeland J. Cannabis withdrawal and sleep: a systematic review of human studies. Subst Abus. 2016;37(1):255–269. PubMed CrossRef
Plazzi G, Montagna P, Meletti S, et al. Polysomnographic study of sleeplessness and oneiricisms in the alcohol withdrawal syndrome. Sleep Med. 2002;3(3):279–282. PubMed CrossRef
Angarita GA, Emadi N, Hodges S, et al. Sleep abnormalities associated with alcohol, cannabis, cocaine, and opiate use: a comprehensive review. Addict Sci Clin Pract. 2016;11(1):9. PubMed CrossRef
Yi CM, Huhn AS, Hobelmann JG, et al. Integration of patient-reported outcomes assessment into routine care for patients receiving residential treatment for alcohol and/or substance use disorder. J Addict Med. 2022;16:e240–e247. PubMed CrossRef
Ek J, Jacobs W, Kaylor B, et al. Addiction and sleep disorders. Adv Exp Med Biol. 2021;1297:163–171. PubMed CrossRef
Brower KJ, Perron BE. Sleep disturbance as a universal risk factor for relapse in addictions to psychoactive substances. Med Hypotheses. 2010;74(5):928–933. PubMed CrossRef
Conroy DA, Arnedt JT. Sleep and substance use disorders: an update. Curr Psychiatry Rep. 2014;16(10):487. PubMed CrossRef
Álvarez RP, Daigre C, Ros-Cucurull E, et al. Insomnia at the onset of addiction treatment may be related to earlier relapses: a one-year follow-up study. Eur Psychiatry. 2021;64(suppl 1):S561–S562.
Wilkerson AK, Sahlem GL, Bentzley BS, et al. Insomnia severity during early abstinence is related to substance use treatment completion in adults enrolled in an intensive outpatient program. J Subst Abuse Treat. 2019;104:97–103. PubMed CrossRef
McEwen BS, Karatsoreos IN. Sleep deprivation and circadian disruption: stress, allostasis, and allostatic load. Sleep Med Clin. 2015;10(1):1–10. PubMed
Lo Martire V, Caruso D, Palagini L, et al. Stress & sleep: a relationship lasting a lifetime. Neurosci Biobehav Rev. 2020;117:65–77. PubMed CrossRef
Yap Y, Slavish DC, Taylor DJ, et al. Bi-directional relations between stress and self-reported and actigraphy-assessed sleep: a daily intensive longitudinal study. Sleep. 2020;43(3):zsz250. PubMed CrossRef
Ruisoto P, Contador I. The role of stress in drug addiction. An integrative review. Physiol Behav. 2019;202:62–68. PubMed CrossRef
Goeders NE. The impact of stress on addiction. Eur Neuropsychopharmacol. 2003;13(6):435–441. PubMed CrossRef
MacLean RR, Armstrong JL, Sofuoglu M. Stress and opioid use disorder: a systematic review. Addict Behav. 2019;98:106010. PubMed CrossRef
Koob GF, Buck CL, Cohen A, et al. Addiction as a stress surfeit disorder. Neuropharmacology. 2014;76 Pt B(0 0):370–382. PubMed CrossRef
Brower KJ. Assessment and treatment of insomnia in adult patients with alcohol use disorders. Alcohol. 2015;49(4):417–427. PubMed CrossRef
Zhang R, Tomasi D, Manza P, et al. Sleep disturbances are associated with cortical and subcortical atrophy in alcohol use disorder. Transl Psychiatry. 2021;11(1):428. PubMed CrossRef
Brower KJ, Krentzman A, Robinson EAR. Persistent insomnia, abstinence, and moderate drinking in alcohol-dependent individuals. Am J Addict. 2011;20(5):435–440. PubMed CrossRef
Hartwell EE, Pfeifer JG, McCauley JL, et al. Sleep disturbances and pain among individuals with prescription opioid dependence. Addict Behav. 2014;39(10):1537–1542. PubMed CrossRef
Morin CM. Insomnia: Psychological assessment and management. Guilford Press; 1993.
Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307. PubMed CrossRef
Chiu HY, Chang LY, Hsieh YJ, et al. A meta-analysis of diagnostic accuracy of three screening tools for insomnia. J Psychosom Res. 2016;87:85–92. PubMed CrossRef
Cohen S. Perceived stress in a probability sample of the United States. In: Spacapan S, Oskamp S, eds. The Social Psychology of Health. Sage Publications, Inc; 1988:31–67.
Lesage FX, Berjot S, Deschamps F. Psychometric properties of the French versions of the perceived stress scale. Int J Occup Med Environ Health. 2012;25(2):178–184. PubMed CrossRef
Taylor JM. Psychometric analysis of the ten-item perceived stress scale. Psychol Assess. 2015;27(1):90–101. PubMed
Cohen S, Janicki-Deverts D. Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009. J Appl Social Psychol. 2012;42(6):1320–1334.
Dzaja A, Arber S, Hislop J, et al. Women’s sleep in health and disease. J Psychiatr Res. 2005;39(1):55–76. PubMed
Baker FC, Driver HS. Circadian rhythms, sleep, and the menstrual cycle. Sleep Med. 2007;8(6):613–622. PubMed CrossRef
Ohayon MM, Carskadon MA, Guilleminault C, et al. Meta-Analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Sleep. 2004;27(7):1255–1273. PubMed CrossRef
Vitiello MV. Sleep in normal aging. Sleep Med Clin. 2006;1(2):171–176.
Varga AW, Ducca EL, Kishi A, et al. Effects of aging on slow-wave sleep dynamics and human spatial navigational memory consolidation. Neurobiol Aging. 2016;42:142–149. PubMed CrossRef
Matud MP. Gender differences in stress and coping styles. Personal Individ Differ. 2004;37(7):1401–1415.
Stefaniak AR, Blaxton JM, Bergeman CS. Age differences in types and perceptions of daily stress. Int J Aging Hum Dev. 2022;94(2):215–233. PubMed CrossRef
Wang LP, Maxwell SE. On disaggregating between-person and within-person effects with longitudinal data using multilevel models. Psychol Methods. 2015;20(1):63–83. PubMed CrossRef
Kleiman E. Understanding and analyzing multilevel data from real-time monitoring studies: an easily-accessible tutorial using R. 2017.
R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing; 2023.
Bates D, Mächler M, Bolker B, et al. Fitting linear mixed-effects models using lme4. Journal of statistical software. J Stat Softw. 2015;67(1):1–48.
Acock A. A Gentle Introduction to Stata. Stata Press; 2014.
Nieminen P. Application of standardized regression coefficient in meta-analysis. BioMedInformatics. 2022;2(3):434–458.
Cohen J. Statistical power analysis for the behavioral sciences. Academic Press; 2013.
Koob GF. The role of CRF and CRF-related peptides in the dark side of addiction. Brain Res. 2010;1314:3–14. PubMed CrossRef
Thorne HB, Rockloff MJ, Ferguson SA, et al. Gambling problems are associated with alcohol misuse and insomnia: results from a representative national telephone survey. Int J Environ Res Public Health. 2021;18(13):6683. PubMed
Liu H, Zhou Z, Huang L, et al. Prevalence of smartphone addiction and its effects on subhealth and insomnia: a cross-sectional study among medical students. BMC Psychiatry. 2022;22(1):305. PubMed
Wei Q, Zhang S, Pan Y, et al. Epidemiology of gaming disorder and its effect on anxiety and insomnia in Chinese ethnic minority adolescents. BMC Psychiatry. 2022;22(1):260–269. PubMed
Fazeli S, Mohammadi Zeidi I, Lin CY, et al. Depression, anxiety, and stress mediate the associations between internet gaming disorder, insomnia, and quality of life during the COVID-19 outbreak. Addict Behav Rep. 2020;12:100307. PubMed CrossRef
Van Wijk M. An examination of the relationship between insomnia symptoms and treatment outcome in binge eating disorder. Memorial University of Newfoundland; 2019.
Reid MJ, Gamaldo CE, Dunn KE, et al. Effects of Suvorexant on sleep-EEG power spectrum in patients undergoing buprenorphine tapered opioid withdrawal. Sleep Med. 2022;100:S210–S211.
Arnedt JT, Conroy DA, Brower KJ. Treatment options for sleep disturbances during alcohol recovery. J Addict Dis. 2007;26(4):41–54. PubMed CrossRef
Speed TJ, Hanks L, Turner G, et al. A comparison of cognitive behavioral therapy for insomnia to standard of care in an outpatient substance use disorder clinic embedded within a therapeutic community: a RE-AIM framework evaluation. Trials. 2022;23(1):965. PubMed CrossRef
Chakravorty S, Vandrey RG, He S, et al. Sleep management among patients with substance use disorders. Med Clin North Am. 2018;102(4):733–743. PubMed CrossRef
Geoffroy PA, Lejoyeux M, Rolland B. Management of insomnia in alcohol use disorder. Expert Opin Pharmacother. 2020;21(3):297–306. PubMed CrossRef
Fragale JE, James MH, Avila JA, et al. The insomnia-addiction positive feedback loop: role of the orexin system. Front Neurol Neurosci. 2021;45:117–127. PubMed CrossRef
James MH, Fragale JE, Aurora RN, et al. Repurposing the dual orexin receptor antagonist suvorexant for the treatment of opioid use disorder: why sleep on this any longer? Neuropsychopharmacology. 2020;45(5):717–719. PubMed CrossRef