Ever since I quit drinking I cant sleep at night. What should I do?

Lack of sleep is probably the single most unsettling symptom that former alcoholics have to struggle with, sometimes on a chronic basis. Even after months or years of sobriety, many alcoholics continue to complain of a lack of restful sleep and excessive daytime sleepiness. Lack of sleep can have serious implications, including breathing difficulties and heart and mood problems. Additionally, excess daytime sleepiness can affect the ability to focus and concentrate and to remember and perform normal daytime functions, the most serious being automobile driving.

Sleep Architecture

Sleep has a characteristic pattern in adults, known as sleep architecture, as measured by an electroencephalogram. The two most prominent components include slow-wave sleep and rapid eye movement (REM) sleep. Alcohol has an initial stimulant effect among nonalcoholics, followed by a decrease in sleep onset. This prompts many to use alcohol as a sleep inducer. The sedative effects of alcohol wear off after about 6 hours, usually leading to a rebound effect causing people to wake up. Chronic consumption of alcohol over time only magnifies this problem, prompting ever further increasing amounts of alcohol to "chase" this problem. In alcoholics, the general sleep pattern becomes a decreased sleep onset, frequent awakenings, and excessive daytime sleepiness. In this instance, if alcohol is stopped, withdrawal symptoms lead to a worsening of the pattern. Often there is no restful sleep. Even after withdrawal has ended, slow wave, or restful sleep, can only return after a bout of heavy drinking, further reinforcing dependency.

Lack of sleep is probably the single most unsettling symptom that former alcoholics have to struggle with, sometimes on a chronic basis.

Sleep architecture a predictable pattern during a night's sleep that includes the timing, amount, and distribution of rapid eye movement (REM) sleep and non REM.

Slow-wave sleep a state of deep sleep that occurs regularly during a normal period of sleep with intervening periods of rapid eye movement (REM) sleep.

Rapid eye movement (REM) rapid eye movements that occur during a stage of sleep that appears on EEG as if the subject is awake. Dream sleep.

Chronic Insomnia

Alcoholics who suffer from chronic insomnia are twice as likely to turn back to alcohol in order to sleep as those who don't report insomnia. They therefore suffer from more severe alcohol dependence and depression. One study demonstrated that alcoholics who had higher levels of REM or dream sleep after cessation of alcohol predicted relapse within 3 months after hospital discharge in 80% of patients. Sleep problems, whether verbalized by patients or documented in a sleep lab, clearly predict higher rates of relapse.

Treatment for Insomnia

The need to treat insomnia therefore is paramount in preventing relapse. Three options are available: (1) behavioral treatments, (2) over-the-counter medications, or (3) prescription medications. No particular behavioral treatment has been found to be superior over another, although all are useful. These include progressive muscle relaxation, guided imagery, and word and imagination games (e.g., counting sheep). Behavioral treatment tends to improve sleep onset more than medication, although overall improvement in sleep is no different between the three options. The most common over-the-counter medication is any of the variety that contains diphenhydramine (Benadryl).

This is not a good medication for sleep because of its tendency to disrupt all stages of sleep, and it can cause a hangover effect along with other side effects, including dry mouth, constipation, and increased appetite.

The final option for insomnia is prescription medication. The ideal medication would be one that has a quick onset of action, a short half-life (body eliminates it rapidly), does not interact with other medications, is not metabolized by the fiver, and finally, does not lead to another problem with addiction. As mentioned in Question 57, benzodiazepines are a poor but ever present choice in the battle against insomnia. Recent focus has been on the use of a new class of sleeping agents that allegedly meet these criteria. These agents are specific to the benzodiazepine receptor, which affects only sedation and not memory or anxiety, and therefore are allegedly not addictive. One cannot miss the ads for zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). Unfortunately, there are growing case reports of multiple problems with these medications, including addiction as well as sleep walking, making these potentially problematic for insomnia related to alcoholism. Other possibilities exist for treating insomnia, including trazadone (Desyrel), mirtazepine (Remeron), doxepine (Sinequan), gabapentin (Neurontin), and quetiapine (Seroquel). Each medication can induce and sustain sleep. Each has the potential for significant adverse effects (Table 14 shows a fist of medications for insomnia). At least one study has been conducted using gabapentin for alcoholism-induced insomnia. It probably has the fewest adverse effects associated with it, and 300 to 1,800 mg have been found to be superior to either placebo or trazadone.

Zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta) these are all sleep-enhancing or sleep-inducing medications that are not benzodiazepines but do act on one of the GABA receptors in a manner similar to benzodiazepines.

Finally, the FDA has recently approved a novel sleep medication called ramelteon (Rozerem). This medication uniquely acts on the receptor involved with melatonin, a long-standing natural sleep remedy used for the treatment of insomnia. Melatonin is thought to assist in regulating the body's sleep/wake cycle. Ramelteon is a different molecule than melatonin. Because of that, its attachment to the melatonin receptors involved in regulating sleep and circadian rhythms is three to five times greater than for melatonin. Additionally, ramelteon is up to 17 times more potent at those receptors than melatonin. It is not addictive; however, neither does it cause drowsiness. It must be taken regularly for it to be effective. This often leads to frustration among people suffering from insomnia who have tried other sleep medications because they are looking for the feeling of sedation that usually comes with a sleeping pill and they do not get this with ramelteon. As a result, they often discontinue the drug prematurely. This is unfortunate, as studies demonstrate that ramelteon is safe and effective in treating chronic insomnia. Whether ramelteon has a place in treating insomnia associated with alcoholism remains to be seen, but it is certainly an option to be considered.

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