Insomnia and substance abuse

Francesca is a 18-year-old university student referred because of daytime tiredness and inability to fall asleep and stay asleep. The history is going back at least 4 years when at the age of 14 she was diagnosed with depression and anorexia. At the time she was treated with antidepressants with a partial improvement in her mood. However, her sleep pattern remained quite disturbed. Currently Francesca is attending university and she lives away from home with other university students.

Her current sleep pattern is characterized by going to bed between midnight-1am and not being able to fall asleep until 3-4 am. Once she has fallen asleep her sleep is quite fragmented with recurrent awakenings. If left undisturbed she would wake up around midday but on university days she has to get up at 8am. According to her family Francesca has been a ‘poor sleeper’ since she was a toddler. She suffered from frequent night terrors.

Initially Francesca attended with her father at the first interview. She was seen again on her own and on that occasion she admitted being a current smoker of marijuana in the last 6 months (4 cones a day, usually in the evening). Her caffeinated beverage intake was very high with 500ml of Coke first thing in the morning and at least 3 litres during the day. She felt that in the evening she would not be able to fall asleep without having some cannabis. She also admitted to once every 10 days or so of staying awake all night without being able to fall asleep.

Although her current sleep pattern was causing significant problem with the university lectures and exams, she did not display symptoms of morbid depression.

We had a good discussion about her sleep pattern and, similar to the previous case discussed, Francesca has evidence of delayed sleep phase (her inability to fall asleep before midnight). However, there was also significant fragmentation of sleep. We explained to Francesca that the use of cannabis to any level, but certainly to the level that she was smoking, would be an important contribution to her inability to fall asleep. The use of caffeine to the extreme amount she was taking would also be a reason for fragmentation of sleep through the night.

The insomnia in this case is a symptom of substance abuse (cannabis and caffeine) resulting in fragmentation of sleep and delayed sleep phase.

A major difficult for Francesca was to readjust her body clock and slowly withdraw from the amount of substances she was using.

She was willing to modify her behaviour and over a period of 6 months she was taken through a slow withdrawal from both cannabis and caffeinated beverages with the help of the Drug and Alcohol unit at the local health service.

She started readjusting her sleep and wake pattern to a regular bedtime between 11pm-midnight and getting up between 6-7am irrespective of the amount of sleep achieved.

She was made aware that initially this strategy could actually worsen her overall sense of poor daytime functioning. She was provided with a letter for the university to explain her current situation.

She also had a reassessment by a psychiatrist for both the substance use as well as depression, which have been an issue since at least the age of 14.

Six months after the first encounter her sleep pattern was improved as well as her daytime functioning.

This is an example of insomnia due to at least 3 important issues. The first is a typical example of how substances that are in common use such as caffeine, other caffeinated soft drinks, heavy use of chocolate, tea and similar, can affect sleep. Different people respond differently to the effect of caffeine. However, caffeine in the amount as described in Francesca’s case invariably disturbs the continuity of sleep with recurrent awakenings through the night. The effect of caffeine can last up to 12 hours and in some predisposed individuals even coffee at midday can affect sleep. It is also true that there are people who can safely take caffeine in the evening with no apparent significant effect on their sleep.

The use of recreational drugs such as cannabis is also a major problem. Chronic daily cannabis (two or more cones per day) tends to reduce the total amount of sleep and also reduce a certain stage of sleep such as REM (rapid eye movement). Importantly cannabis effect can last up to 6 hours after consumption. Sleep is even more disturbed upon withdrawal from cannabis. Similar considerations can be applied to people who regularly use amphetamine or cocaine.

Alcohol intake also causes significant fragmentation of sleep. Alcohol can promote sleep onset, but because its action is limited to 2-3 hours, the person experiences a “rebound effect” in the second part of the night with increase sleep fragmentation and overall poor sleep quality. In the case of heavy alcohol intake with alcohol dependency sleep disruption with insomnia can persists for months-years even after alcohol intake is stopped. In these cases specialist advice and team effort by dedicated health professionals is needed to provide treatment and support long term.