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Assessing sleep in opioid dependence: A comparison of subjective ratings, sleep diaries, and home polysomnography in methadone maintenance patients

https://doi.org/10.1016/j.drugalcdep.2010.08.007Get rights and content

Abstract

Objectives: Comparisons of subjective and objective sleep measures have shown discrepancies between reported sleep and polysomnography (PSG) in non-drug dependent individuals with and without insomnia. Sleep may affect behavioral and physiologic aspects of drug abuse and dependence; patients in methadone maintenance therapy (MMT) for opioid dependence frequently report sleep problems. Whether subjective sleep reflects objective sleep in MMT patients is unknown. We undertook these analyses to establish the correlations among subjective and objective sleep measures in MMT patients. Methods: We compared one week of daily sleep diaries, one night of home PSG, a questionnaire completed the morning after PSG, and the Pittsburgh Sleep Quality Inventory (PSQI) as well as demographics and drug use measures in 62 MMT patients with disturbed sleep (PSQI score > 5). Results: Subjective and objective sleep durations were similar in this sample; average sleep times for the diary, morning questionnaire, and PSG were 340, 323, and 332 min, respectively. Average diary sleep time, subjective ratings of feeling rested, and PSG sleep efficiency were correlated significantly with PSQI score. Age was inversely correlated with PSG sleep time. Participants whose urine toxicology showed benzodiazapine use reported significantly longer sleep times on the morning questionnaire. Conclusions: Objective sleep measures confirm subjective measures in MMT patients with disturbed sleep. The high prevalence of sleep complaints in this population likely reflects pathology rather than sleep misperception. Both objective and subjective measures are useful in research and clinical settings for assessing sleep in opioid-dependent patients.

Introduction

Sleep may impact drug use, treatment compliance, intervention efficacy, and relapse risk through behavioral and physiologic mechanisms. A role for sleep disturbance in addiction has been found in cocaine users (Morgan et al., 2006, Morgan et al., 2010), methadone patients (Stein et al., 2004, Peles et al., 2006, Kurth et al., 2009, Sharkey et al., 2009, Trksak et al., 2010), and alcohol-dependent patients (Brower et al., 1998, Conroy et al., 2006). Among alcohol-dependent patients in early recovery, for example, sleep disturbances and perceived sleep disruption are related to future alcohol use (Brower et al., 1998, Conroy et al., 2006).

Patients in methadone maintenance therapy (MMT) for opioid dependence frequently report sleep complaints (Oyefeso et al., 1997, Stein et al., 2004, Peles et al., 2006). One potential pathway to sleep disruption in MMT patients is opioid-induced reduction of the nucleoside adenosine in the basal forebrain (Nelson et al., 2009). The notion that reduced adenosine – a neurochemical modulator of the homeostatic drive for sleep – may be responsible for sleep disturbances in MMT patients is further supported by the observation that MMT patients fail to show typical recovery responses after a sleep-deprivation challenge (Trksak et al., 2010). Comorbid psychiatric disorders, chronic pain, and other drug use may also contribute to sleep complaints in MMT patients (Stein et al., 2004, Peles et al., 2006).

Comparisons of subjective and objective sleep measures in non-drug dependent individuals with and without insomnia have shown that self-reported sleep can differ substantially from physiologic recordings (Carskadon et al., 1976, Spinweber et al., 1985, Hauri and Wisbey, 1992, Silva et al., 2007). Whether subjective sleep complaints reflect objective sleep measures in MMT patients is unknown. In order to establish associations between subjective and objective sleep measures in MMT patients, we compared one week of sleep diaries to one night of polysomnography (PSG), a morning questionnaire following PSG, and the Pittsburgh Sleep Quality Inventory (PSQI).

Section snippets

Participants

As part of a clinical trial of a pharmacological insomnia treatment, we recruited 137 patients from 8 MMT clinics in Rhode Island from 2006 to 2009 (see Kurth et al. (2009) for details).

Inclusion criteria were: insomnia (PSQI > 5 at screening; Buysse et al., 1989), intent to continue MMT for 6 months, fluency in English, and stable housing. Exclusion criteria were: psychotic symptoms, diagnosis of bipolar disorder, schizophrenia, schizoaffective or schizophreniform disorder, trazodone use in the

Results

The 62 participants had a mean age of 39.2 ± 8.3 years (range 21–56), and included 38 women and 54 non-Hispanic Caucasian participants. Median MMT enrollment duration was 13 months. Methadone dose ranged from 21 mg to 285 mg with a mean of 107.9 ± 51.7 mg (median = 100 mg). Of those with valid urine drug tests on the PSG night (n = 55), we observed the following rates of drug use: benzodiazepines: 41.8% (n = 23); cocaine: 27.8% (n = 15); tetrahydrocannabinoids: 20.0% (n = 11), and opiates: 14.8% (n = 8).

Average

Discussion

Most patients in MMT for opioid dependence report sleep difficulties, but no previous study has assessed whether subjective complaints of sleep disruption in MMT patients are correlated with objective sleep disturbance. Our data comparing PSG sleep with a morning sleep questionnaire demonstrate that MMT patients are reliable in reporting their sleep duration within a short time frame. In addition, this short-term consistency is reflected in sleep reported at other time points. Subjective sleep

Role of funding source

This work was funded by NIH R01 DA 020479 to MDS. Dr. Stein is the recipient of a NIDA Mid-Career Award K24-DA00512. NIH/NIDA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Contributors

Michael D. Stein designed the study. Michael D. Stein and Richard P. Millman wrote the protocol. Megan E. Kurth managed participant recruitment and data collection. Richard P. Corso recruited participants and collected data. Authors Stein, Millman, Kurth, Anderson, and Sharkey planned the data analyses. Bradley J. Anderson performed the statistical analyses. Katherine M. Sharkey wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of interest

No conflict declared.

Acknowledgements

The authors thank Raynald Joseph, Jill MacCormack, Roberta Fish, Braulio Lopez, Laura DiMaio, Celeste Caviness, Meredith Sims, John Murray, and Carol Carlisle for assistance with this project.

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