8:  CAFFEINE, ALCOHOL, TOBACCO, AND RECREATIONAL DRUGS                                   [Rev 1-16-2019]

This is one of the general issues addressed in Step C

For most patients, these substances are not recommended treatments for insomnia. Rather, they are substances that the person is already using regularly and that can be possible sources of insomnia for them, or they are already being used by patients as ways to get to sleep.

8a. Assessment

Perhaps we should go through a list of common substances that could be related to sleep issues and for each one, ask whether the person uses it. If so then we could ask when, how much, and what the consequences are.

A Partial List

• Caffeinated beverages, such as coffee, tea or soft drinks.
• Alcoholic drinks – beer, wine, mixed drinks, etc.
• Tobacco – cigarettes, other forms
• Marijuana
• Cocaine
• Opioids
• Amphetamines
• See also: Section 9

People use drugs for a variety of reasons – social, habitual, or mood management – and loss of sleep is often an unintended and unexamined consequence of that use. Here, it might pay to treat the substance abuse as an issue in itself, supporting that treatment with prospects of sleeping better.

There can also be interactions – for example, a patient uses marijuana to manage chronic pain, and both the pain and the marijuana have impacts on his/her ability to sleep.

Other people use substances specifically to manage sleep – marijuana or alcohol to go to sleep at night, coffee or caffeinated soft drinks to stay awake all day.

If the person is using one of these substances, the next step is to determine whether it is affecting sleep. There are two possibilities. If the person is using the substance regularly, it may have long-term effects on sleep, and the best indicator would be to be abstinent from that substance for a long enough period of time that the effect would be reduced. Then after the chosen time lapse, ask about sleep again.

If the person uses the substance to go to sleep, you can give a sleep log with usage of that substance as one of the entries, and recommend an experiment. The person uses it some nights and not others and records its effects on sleep.

The issues of this section overlap with some of the issues of Section 9 (Diet).

8b.  The effects of specific substances

CAFFEINE

Caffeine is the substance most commonly used to manage the experience of sleepiness (Conroy, D.A., Arnedt, J. T. , and Brower, 169) and because of its effects, a likely part of the daytime diet of people who have insomnia.

However, caffeine can also contribute directly to a person’s insomnia. It can cause a person to take longer to get to sleep, cause more awakenings in the night, and interfere with the overall quality of sleep (Friedman, Zeitzer and Mumenthaler, p.262; Hauri and Linde, p. 58). This can be happening even if the person is unaware of it. Even small amounts of caffeine can affect a person’s sleep.

Caffeine has a half-life of 3-7 hours (Morin, 147) and can interfere with sleep up to 10 hours later (National Sleep Foundation). This is the reason for the common recommendation that people with sleep issues not have coffee or tea after early afternoon.

People can also develop a tolerance to the effect of caffeine on daytime arousal (Friedman, Zeitzer and Mumenthaler, 262). They may continually increase their coffee or tea intake over time, leading to a greater impact on insomnia and greater experience of daytime sleepiness.

According to Hauri and Linde (p.54) people with insomnia tend to have higher metabolic rate than people who don’t have this problem, and caffeine can increase their overall arousal level (Conroy, D.A., Arnedt, J. T. , and Brower, 169). This can make it even more difficult for them to fall asleep and stay asleep than without caffeine. Unfortunately, their lack of sleep makes them drowsy during the following day, leading to a potential for dependence to stay alert.

Coffee is an obvious source of caffeine, but caffeine is also in chocolate, tea, soft drinks and other food preparations. Headache medications often contain caffeine.

A cup of coffee has about 80 mg of caffeine. A cup of Tea has about 40 mg. Hauri and Linde (pp. 55-56) note that more than 200 mg of caffeine a day ( two cups of coffee or 2-3 cans of cola) can both affect a person’s sleep and lead to a possible caffeine dependency.

However, there is no consensus on what a reasonable amount of caffeine is. For a person with insomnia, even smaller amounts could have an impact on sleep, and treatment may involve eliminating caffeine entirely from the person’s diet (Hauri and Linde, p.59).

However, caffeine withdrawal can produce symptoms of sleepiness, lethargy, depression, impaired functioning, mental fogginess, irritability and headaches. (Conroy, D.A., Arnedt, J. T. , and Brower,170) Withdrawal symptoms commonly last for 3-5 days but may continue for a week or more (Conroy, D.A., Arnedt, J. T. , and Brower, 170)

Some people may have tried to withdraw and found the experience so unpleasant that they believe they are unable to.

 

ALCOHOL

The apparent advantages of having a drink or two to get to sleep is that it often works. The person falls asleep easily and quickly. However there often are problems. Alcohol suppresses REM sleep for the first few hours. Then the alcohol is metabolized and the person can go into withdrawal, with shallow sleep, nightmares and vivid dreams, several awakenings, and general arousal (Friedman, Zeitzer and Mumenthaler p. 261, Reite, Weissberg and Ruddy, p. 57).

As a result, sleep may be impaired in the second half of the night, with fatigue the following day. Early awakenings may be the result of lighter sleep, increased REM activity, and nightmares (Morin, 149).

Using alcohol as a sleep aid can lead to tolerance within a few days, and a need for more to achieve the same effect (Conroy, Arnedt, and Brower, p.168, Roehrs and Roth, p.392). Social drinkers should keep track of their sleep on nights when they have and have not had something to drink, and consider not having any alcohol for 4-6 hours before bedtime (Morin, 150).

Long-term alcohol dependence commonly leads to complaints of delay in falling asleep, sleep related breathing disorders, and multiple awakenings. For some people, sleep can improve within a couple of weeks after beginning abstinence. For others, some disruptions may continue for months after the person stops drinking Friedman, Zeitzer and Mumenthaler p. 261.

 

TOBACCO

There appear to be two different effects of smoking on a person’s sleep – one depending on the overall amount of daily tobacco usage and the other on the timing of the last cigarette of the day.

1. How much does the person smoke each day?

The overall amount of a person’s smoking affects both the time it takes a person to fall asleep and the person’s sleep efficiency.

If a person is a regular smoker, there are many well-known health risks, some of which have a direct impact on the person’s sleep. Smoking raises a person’s blood pressure, increases heart rate, and stimulates brain activity (Hauri and Linde, p.63).

Breathing can be affected, as tissues in the nose and throat are irritated. Swollen tissues partially obstruct breathing, and can lead to snoring and sleep apnea. This and restlessness can wake a partner, who may be inclined to return the favor. Swelling of tissues in the back of the throat can also lead to an increased risk of obstructive sleep apnea.

Smoking leads to light sleep, sleep fragmentation and restlessness. Regular smokers are more likely to report feeling unrested after a night’s sleep. They also spend less time in deep sleep, when the body normally recovers from daily life.

2. Does the person smoke to relax?

A person may believe that a cigarette relieves tension, but on average, smokers take longer than nonsmokers to fall asleep. In low blood concentrations, nicotine may be relaxing, but in larger concentrations, it is a stimulant, and early sleep is lighter than for nonsmokers. It is also possible that the attributing of relaxation to a cigarette is a placebo effect or a consequence of taking a break from other activities.

3. Does the person smoke at night?

If the person smokes within two hours of bedtime or during the night, there are other implications for sleep. Nicotine wears off during the night, which can lead to withdrawal, waking, and possible craving. Some people awaken in the middle of the night and have another cigarette, thus extending its interference with sleep (Morin, 148). For alternatives to a bedtime cigarette, see Section 17  (Part D1)

4. Treatment

The natural recommendation is to stop smoking. This is difficult for most people, because of daytime withdrawal symptoms. However Morin (p.149) reports that sleep can benefit within the first three days, and patients commonly fall asleep more quickly and sleep more soundly after 3-5 nights..

 

MARIJUANA

Marijuana has different effects on sleep, depending on several factors.

Most users smoke it, and the effects are relatively unpredictable, because they tend to use haphazard resources. In states where marijuana is legalized, quality control is better and so is predictability of its effect on sleep.

Traditional accounts report that heavy users tend to have trouble falling and staying asleep and not feeling rested during the day. For these circumstances, a plausible recommendation might be to cut back or eliminate pot smoking and see whether that helps with sleep.

More recent accounts (Colorado Pot Guide and others) divide marijuana into two broad strains. At the energizing end of the spectrum are the Sativa-dominant strains; and at the relaxing end are the Indicas. If the person has a choice and wants to continue using marijuana, an obvious recommendation would be to choose a strain that is more relaxing.

A person who is experiencing pain or stress at bedtime may find some pain relief from using marijuana, thus taking less time to get to sleep. It may increase the amount of time a person spends in deep sleep, when the body is restoring itself, and less time in REM sleep. People who use marijuana to sleep may not remember dreams.

The effect of the drug may depend on the delivery system the person uses. Recent legalization of marijuana use in some states has led to development of alternate delivery forms, such as liquid, candy, sub-linguals and gummy-bears. These deliver different amounts of the drug to the person’s system and have different effect latencies See Colorado Pot Guide for more.

Greater dose control may allow a person to use a minimum-effective amount and possibly reduce side effects. This possibility has not yet been systematically studied.

 

Reference: Reite, Weissberg and Ruddy, 57-59,