SLEEP PROBLEMS
Complicated by alcohol and tobacco
https://wildninja.files.wordpress.com/2010/10/sleep2.jpg
Disclaimer
The views expressed in this presentation are those of the author
and do not reflect the official policy of the Department of the Army/Navy/Air Force
or the Department of Defense The identification of specific products or scientific
instrumentation does not constitute an endorsement or implied endorsement
on the part of the authors, DoD, or any component agency. While we generally
excise references to products, companies, manufacturers, organizations, etc. in
government produced works, the abstracts produced and other similarly situated
researchers presents a special circumstance when such product inclusions become
an integral part of the scientific endeavor. Identification of specific
products or scientific instrumentation does not constitute endorsement or
implied endorsement on the part of the author, DoD, or any component agency.
While we generally excise references to products, companies, manufacturers,
organizations, etc. in government produced works, the abstracts produced
and other similarly situated researcher presents a special circumstance when
such product inclusions become an integral part of the scientific endeavor.”
Sleep Problems
Among the many factors
complicating substance use
treatment is the
unshakeable persistence of
insomnia
Normal Sleep Cycle
REM
Rebound
https://i.ytimg.com/vi/fmQGJWoArOU/hqdefault.jpg
Alcohol and OSA
Increased risk of alcohol related breathing problems while asleep
The consumption of alcohol worsens OSA by relaxing upper airway
muscles.
The heightened risk of OSA among individuals with an alcohol use
disorders is further complicated with the addition of co-occurring
psychiatric disorders
The highest prevalence of sleep related breathing problems occurs
among individuals with PTSD
WRNMMC Research Study:
Alcohol and Sleep Problems
Three home sleep studies over a one month period.
Wrist worn device includes an actigraph, peripheral arterial
tonometer, a pulse oximeter, and an integrated body
position and snoring sensor.
In terms of the respiratory sleep parameters, investigators
comparing PSG/Wrist Device report nearly comparable
results
WRNMMC Research Study:
Alcohol and Sleep Problems
AUDIT - used 8 or greater for men and 5 or greater for
women to screen at risk drinking.
Alcohol Biomarkers
• EtG values equal to or greater than 250ng/ml
• EtS values equal to or greater than 50ng/ml
• GGT values equal to or greater than 71 u/l for men, GGT values
equal to or greater than 41 u/l for women
• CDT% values equal to or greater than 1.4
EtG = Ethyl Glucuronide, EtS = Ethyl Sulfate, GGT = gamma
Relationships between Alcohol Biomarkers, AUDIT scores and Sleep
Measures
Variable
Sleep time/minutes
EtG*
EtS
GGT
CDT%
AUDIT
Mean Change
95% CI
Effect Size
-49.1
-52.3
-41.1
7.3
1.1
-100.2, 2
-110.3, 5.7
-89.1, 7
-36.9, 51.4
-58.6, 60.8
0.59*
0.63*
0.48
0.08
0.01
Respiratory Disturbance Index
EtG
EtS
GGT
CDT%
AUDIT
5.9
5.7
2.3
2.5
0.9
-1.1, 12.9
-2.7, 14.2
-3.3, 7.9
-3.8, 8.8
-2.6, 4.4
0.70*
0.67*
0.26
0.28
0.16
Apnea Hypopnea Index
EtG
EtS
GGT
CDT%
AUDIT
6.8
7.5
1.9
2.1
0.7
-0.6, 14.1
-1.5, 16.5
-4, 7.8
-4.5, 8.8
-2.6, 4
0.79*
0.88**
0.21
0.23
0.13
Oxygen Desaturation Index
EtG
EtS
GGT
CDT%
AUDIT
5.1
5.9
1.5
1.4
-0.3
-0.8, 11
-1.4, 13.2
-3.1, 6.1
-3.9, 6.6
-2.9, 2.4
0.76*
0.88**
0.21
0.19
0.07
First Deep Sleep/minutes
EtG
EtS
GGT
CDT%
AUDIT
50.4
43.4
27.3
13.1
6.7
5.0, 95.7
-6.4, 93.2
-29, 83.7
-29.1, 55.3
-27.5, 40.9
0.80*
0.67*
0.41
0.20
0.12
Number Awakenings
EtG
EtS
GGT
CDT%
AUDIT
2.4
2.7
1.2
0.2
-0.2
0.2, 4.6
0.2, 5.1
-2.5, 4.8
-2.0, 2.5
-2.8, 2.5
0.66*
0.73*
0.31
0.06
0.04
Wake Percent
EtG
EtS
GGT
CDT%
AUDIT
5.8
3.9
3.6
1.6
2.8
0.7, 11
-1.7, 9.6
-3.7, 10.8
-3.9, 7.1
-2.3, 7.9
0.66*
0.43
0.39
0.17
0.30
WRNMMC Research Study:
Alcohol and Sleep Problems - SUMMARY
EtG and EtS had a moderate to high predictive value for
diagnosing OSA
GGT and CDT% results showed a small effect size for the
respiratory measures.
The AUDIT score was not predictive
This study also provides some hints about the stability of sleep
problems among the individuals with an alcohol use disorder.
EtG = Ethyl Glucuronide, EtS = Ethyl Sulfate, GGT = gamma
Sleep Problems
Among Tobacco Users
Motivating individuals to quit tobacco use can be an uphill
struggle
“One problem at a time”
Clinicians have a choice
Most individuals with a tobacco use disorder are familiar
with the major physical problems associated with smoking
Sleep Problems
Among Tobacco Users
Clinicians seeking guidance on the range of sleep
problems associated with tobacco use may be surprised by
the paucity of published literature on the subject
Limited PSG research reveals changes in
• Total sleep time
• Sleep onset
• Breathing
WRNMMC Research Study:
Tobacco and Sleep Problems
All subjects were enrolled in a substance abuse treatment
program
All subjects simply reported their use or non-use of tobacco
products
Participants agreed to complete three home sleep studies evenly
spaced over a one month
At baseline and at one month the subjects completed the
Pittsburg Insomnia Rating Scale, Zung Self-Rating Depression
Scale, Zung Self-Rating Anxiety Scale, and Epworth Sleepiness
Scale. Subjects completed the Alcohol Use Disorders
Identification Test only at baseline.
WRNMMC Research Study:
Tobacco and Sleep Problems
Twenty - eight active duty subjects reported their tobacco use
with half (n=14, 28, 50%) denying use.
Among the total group most were enlisted service members
(n=22/28, 79%), male (n=23/28, 86%),
Between the ages of 21-35 (n=21/28, 75%),
Deployed to an area of combat operations (n=18/28, 64%).
The average BMI for the group was 26.9 (n=28, SD 5.0).
WRNMMC Research Study:
Tobacco and Sleep Problems
No statistical differences between the tobacco users and
non-tobacco users based on the BMI (p=.13), AUDIT
(p=.37), Zung Depression (p=.11), Pittsburgh Insomnia
rating Scale (p=.18), and the Epworth (p=.1).
WRNMMC Research Study:
Group Comparisons
Test
Tobacco Use/n
Mean
SD
Sig (2-tailed)
AUDIT
Yes/14
No/14
15.4
12.3
9.6
8.0
.37
SDS
Yes/14
No/13
54.6
46.0
9.6
16.2
.11
SAS
Yes/14
No/13
42.2
32.2
9.5
14.9
.05
PIRS
Yes/14
No/14
41.3
34.2
10.0
16.3
.18
Epworth
Yes/14
No/14
12.2
8.4
6.3
5.6
.10
BMI
Yes/14
No/14
28.3
25.4
5.9
3.5
.13
WRNMMC Research Study:
Item Responses - Baseline
S
A
S
S
D
S
Test Question
Tobacco Use/n
Mean
SD
Sig (2-tailed)
Q7: Losing Weight*
Yes/14
No/12
1.71
2.67
1.07
1.07
0.03
Q10: Tired*
Yes/14
No/12
3.14
2.33
.95
.98
0.04
Q13: Restless*
Yes/14
No/12
3.07
2.33
.83
.78
0.03
Q 15: Irritable*
Yes/14
No/13
2.93
2.15
1.0
.99
0.05
Q 8: Tired**
Yes/14
No/13
3.07
1.92
.83
1.38
0.01
Q 14: Numbness**
Yes/14
No/13
2.21
1.08
1.19
1.32
0.03
Q 16: Frequent** Urination Yes/14
No/13
2.21
1.08
1.25
.95
0.01
WRNMMC Research Study:
Item Responses – One Month
SAS
SDS
Test Question
Tobacco Use/n
Mean
SD
Sig (2-tailed)
Q9: Fast Heart Rate*
Yes/7
No/8
2.0
1.3
.82
.46
.04
Q13: Restless*
Yes/7
No/10
2.29
1.5
.49
.71
.02
Q3: Panicky**
Yes/8
No/9
2.25
.89
1.04
.93
.01
Q4 : Falling Apart**
Yes/8
No/8
1.63
.38
1.06
.52
.01
Q6: Tremble**
Yes/8
No/9
1.88
.33
1.25
.71
.01
Q8: Tired**
Yes/8
No/9
2.13
1.0
1.36
.87
.06
Q10: Fast Heart Rate**
Yes/8
No/9
1.75
1.08
1.25
.89
.03
Q11: Dizzy**
Yes/8
No/8
.88
.00
1.13
.00
.03
Q14:Numbness**
Yes/8
No/9
1.88
.13
1.13
.35
.00
Q17: Dry Hands**
Yes/8
No/9
2.63
.78
1.30
.83
.00
WRNMMC Research Study:
Respiratory Measures
*First Sleep
Study
**One Month
Later Sleep
Study
Sleep Variable
Tobacco Use/n
Mean
SD
Sig (2-tailed)
Apnea Hypopnea Index*
Yes/ 13
No/ 12
11.7
3.4
13.7
4.8
.06
Respiratory Disturbance
Index*
Yes /13
No / 12
19.2
9.4
11.4
5.6
.01
Respiratory Disturbance Index Yes /11
REM*
No/ 8
25.6
14.7
8.7
4.5
.01
Oxygen Saturation*
Yes/ 13
No/ 12
94.5
95.9
1.7
1.4
.04
Respiratory Disturbance Index Yes/ 5
REM**
No/ 12
25.5
13.5
14.2
8.8
.05
Apnea Hypopnea Index
REM**
Yes/ 5
No/ 12
16.7
5.8
15.4
6.9
.06
Oxygen Saturation**
Yes/8
No/ 13
94.5
95.7
1.5
.85
.03
WRNMMC Research Study:
Tobacco and Sleep Problems
Summary
Tobacco users report more somatic symptoms than nontobacco users such as feeling tired, restless, irritable, and
numb. Findings replicated one month later.
Higher rate of breathing problems among self-identified
tobacco users
More likely to occur during REM sleep
Questions?