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Abstract
Substance use disorder is one of the most complicated problems that face not only medical professionals but the whole community. Problems of substance abuse produce dramatic costs for all societies in the term of low productivity, medical complications, family and social troubles as well as crimes.
Regarding physical complications, studies indicate that psychoactive substances have acute and chronic effects on sleep architecture. Sleep disturbances occurs in various forms and stages of substance use and related nearly all the psychoactive substances. Sleep pattern of patients differ with time and most of the patients are not aware of these changes. Moreover, the co-occurrence of other psychiatric disorders with psychoactive substance use increases the difficulty of identifying and treating the sleep disturbances.
Scientific data as well as clinical experience highlight opioids as one of the main psychoactive substances of abuse affecting sleep. Such an effect occurs in various stages of opioid abuse: drug induction phase, drug maintenance phase, acute abstinence phase and protracted abstinence phase. For some, sleep disturbance can be so severe as to reverse treatment success and precipitate a relapse to addiction or dependence. Inspite of these important facts and their significant clinical implications, a very little number of studies were done exploring this phenomenon.
Based on that, this study was conducted aiming to study the profile of sleep in opioid abuse patients following the period of detoxification , determining the nature of the sleep disturbance in them if present and highlighting the factors related to this disturbance.
Accordingly, all opioid dependant male patients admitted in the substance abuse department at the Institute of Psychiatry, Ain Shams University and approving to participate in this study were included as the case group. Their age ranges between 18-45 years and they had history of regular opioid abuse for at least one year. Patients with Axis I psychiatric disorders according to DSM IV, co-morbid major physical illness or history of neurological diseases were excluded from the study. A control group of 10 individuals of volunteers was formed for the case control comparison. They were matched with the patient group for age and sex and with no apparent physical or psychiatric morbidity.
The study took place from the 1st of June 2006 till 31st of May 2008.
All the inpatients in the substance abuse department were examined to determine eligibility for participation in the study.
Screening was conducted through clinical psychiatric interview according to inpatient psychiatric sheet of Ain Shams University Institute of Psychiatry, which examined demographic data, psychiatric history and examination as well as medical history information.
Patients were examined 3 weeks following admission, after resolution of most of the symptoms of withdrawal.
Patients who agreed on participation were subjected to full medical history and examination (general, cardiological, chest and neurological examination) to detect any neurological or chronic medical condition that would lead to exclusion from the study.
Routine laboratory investigation including liver and kidney function, complete blood picture tests as well as ECG will be performed to confirm exclusion of major physical illness.
All subjects of the study were assessed by using
Tools to diagnose case group:
• Structured Clinical Interview for DSM-IV (SCID I) diagnostic tool to diagnose opioid dependence and to exclude other Axis I diagnosis according to DSM VI classification.
• Addiction Severity Index (ASI) to ensure that the study will include patients who have opioids as the main substance of abuse and study the pattern of opioids abuse over the life time of the patients and in the last 30 days before admission.
Tools to assess the psychological status of the cases:
• Beck Depression Inventory (BDI): to assess the severity of depression state.
• Taylor Manifest Anxiety Scale: to assess the anxiety state.
• The Structured Clinical Interview for DSM Axis II Disorders (SCID II): to evaluate an axis II diagnosis.
Tools to study Sleep Profile (applied for cases and control subjects):
• Comprehensive Sleep Disorder Questionnaire: To assess Personal sleep rituals as well as Sleep disorders which are insomnia, hypersomnia, parasomnias, or dyssomnias.
• All Night Polysomnography (PSG): to analyze the sleep architecture of the subjects including General sleep aspects NREM and REM sleep characteristics as well as assessment of respiratory variables during sleep.
Sleep assessment was performed when the participants were medication free for at least 7 days prior to study to exclude the effect of any psychotropic medication on their polysomnography.
Moreover, urine test for substances of abuse was performed to guarantee abstinence during the assessment period.
The results of the study were obtained using the statistical package of the SPSS- 15th version. The statistical processes performed were Student’s t test, Spearman Correlation test, ANOVA test as well as Chi Square test.
The Main Findings in the Study were:
As regard the demographic and clinical profile of the sample:
The current study showed that the socio-demographic characteristics of the sample pointed that all patients were males with mean age group 27 years. The majority of the subjects were single (n=29, 87%) while 9% (n=3) were married and 3% (n=1) divorced. 45.5% sample were college graduate (n=15), whereas 27% (n=9) graduated from secondary and 24% (n=8) from technical school while the rest 9% (n=3) from preparatory school.
As regard the level of occupation, 42% (n=14) of the sample were unemployed, 27% (n=9) were students, 18% were working in professional jobs while 12% (n=4) were skilled workers.
Assessment of the substance abuse pattern showed that 79% (n=26) of the patients sample abused Heroine by intra venous injection while 21% (n=7) of them abused Tramadol orally.
The duration of lifetime opioid abuse ranged from 3 years to 20 years with mean 7 years. On the other hand, the duration of opioid abuse in the last 30 days before abstinence ranged from 22 days to 30 days with mean 28 days. Regarding abstinence, the mean last abstinence period of the cases in our study was 5.3 months and the time lapsed from last abstinence was of mean 7.2 months. The patients mean trials of treatment was 2.5 times.
Examining the medical condition of the cases revealed that 61% (n=20) case was Hepatitis C Positive, 3% (n= 1) was Hepatitis B positive and 36% (n=12) had no medical conditions.
Regarding the depressive state of the patients according to Beck Depression Inventory, 48% of cases (n=16) had moderate state, 42% (n=14) had mild state, 6% Severe state and 3 (n=1) was normal.
As for the severity of anxiety state, both mild and moderate anxiety states counted for 48% of cases (n=16) where as only 3% of the cases (n=1) had severe anxiety state. Examining the cases of the study for personality disorder using SCTDII showed that 45% of the cases had no personality disorder. According to DSM-IV classification the most frequent personality cluster among cases group was cluster C (24.24%) followed by cluster B (18.18%), while the mixed personality disorders represented (9%) and multiple personality disorders 3%.
As regard the Clinical Sleep Complaints of the sample:
81% of the studied group showed initial insomnia, 57% of the studied group had interrupted sleep and 48% of them had late insomnia. Also in the patients group, 67% suffered from day time somnolence, 42% suffered from sleep talking and 33% of them suffered from sleep acid reflux. All these complaints showed statistically significant difference from the control group.
On the other hand, comparing case group to control subjects showed no statistical significance regarding snoring, experiencing nightmares as well as nocturnal enuresis.
The mean night sleeping hours of cases was 6.6 hours SD ± 1.45 and the subjective sleep onset latency was 47.5 minutes SD ± 13.97. Both values were of statistical significant difference when compared to those of control.
As regard the sleep laboratory findings of the sample according to polysomnography:
Regarding sleep latency, sleep efficiency and arousal index, there were marked affection in cases. That is to say that there was significant lengthening of sleep latency, significant diminish of sleep efficiency, and significant rise of arousal index in opioid dependant patients as compared to healthy controls.
Comparing NREM parameters of cases and control subjects showed that there is a significant increase in both stage 1 and stage 2 of NREM sleep in opioid dependence patients as compared to healthy controls, while stages 3 and 4 as well as SWS% are significantly reduced . On the other hand, comparing REM sleep components of opioid dependent patients to control subjects showed no statistically significant difference regarding REM % of total sleep time, REM density as well as REM latency. The same finding was related to respiratory variables after studying these variables respiratory variables in opioid dependence patients as compared with healthy controls. There was no statistically significant difference regarding sleep apnea parameters whether central, obstructive or mixed.
Periodic leg movements during sleep in opioid dependence patients also showed no statistically significant difference when compared with healthy controls.
Analysis of factors affecting Clinical Sleep Complaints of the sample:
In the current study, various factors related to substance abuse were analyzed in relation to sleep complaints of the sample group. This analysis showed that sleep talking was significantly correlated to the frequency of abuse in the last 30 days before abstinence. Moreover, late insomnia in the form of early morning awakening and sleep acid reflux showed statistically significant correlation with the number of treatment trials. Other than that, factors related to opioid abuse including type of opioid , route of abuse, lifetime abuse duration and duration of last abstinence period were not correlated to sleep complaints of case group in the current study.
Similarly, no statistically significant correlation was detected between the sleep complaints of the cases and the tested psychological parameters in the study including depressive and anxiety status as well as the presence of personality disorder.
Analysis of factors affecting sleep laboratory findings of the sample:
Regarding factors affecting polysomnography findings of the patients in the case group, the current study failed to find any statistically significant correlation between sleep laboratory findings detected by polysomnography and various variables of opioid dependence of the case group. These variables included type of opioid, route of abuse, lifetime abuse duration, frequency of abuse in last 30 days, treatment trials and duration of last abstinence period.
This was different to the study findings regarding correlation between the sleep laboratory findings and psychological status of the cases. There was statistically significant correlation between depressive state of the cases and SWS especially stage III of NREM sleep. This stage was found to be significantly lower in opioid dependant patients with moderate depressive state compared to those with mild depressive state. On the other hand, polysomnography findings of the case group in the study could not be correlated to the anxiety state of the cases.
The study carried some limitations including being conducted on males only, not matching body mass index between case and control groups and the presence of some confounding factors such as the use of caffeine and nicotine by the patients as well as environmental change as a factor affecting sleep.
The study concludes that patients with opioid abuse disorders suffer from sleep disturbance that continues for a period of time even after discontinuation of abuse. Sleep laboratory studies shows that the nature of this disturbance is related to NREM sleep parameters and with no marked correlation to abuse variables such as duration of abuse and type of opioids.