The majority of addiction treatment programs screen for cravings, address trauma, and manage medications. Fewer will provide much needed care for insomnia, and many will simply advise individuals to speak with a physician. The reality is that disrupted sleep is both a treatment concern in itself and can be a predictive factor for ongoing abstinence.
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The importance of recognizing sleep as a separate challenge and not a part of the detox process
There is a common belief that with the end of active withdrawal symptoms, insomnia will resolve. However, the period of impaired sleep can linger on for weeks or even months post-detox, when sleep is most needed to support the recovery of the central nervous system. Insomnia can persist even when the individual feels physically well and manages to attend all treatment sessions.
The reason for this is that lack of proper sleep deprives the individual of the psychological resilience they need to engage in the treatment process. According to the review conducted by Brower in 2003, insomnia affected between 36% and 91% of individuals with alcohol use disorder, and residual insomnia was a significant predictor of relapse.
The impact of various substances on the sleep cycle
To understand the mechanism behind such a phenomenon, it is useful to recall how different substances influence the architecture of sleep, namely how much time is spend in light, deep, and REM stages. Alcohol has been shown to decrease the amount of REM sleep during the first half of the sleep cycle while causing a rebound effect during the second half, contributing to frequent awakenings.
It also impairs slow-wave sleep, which is important for tissue repair. Stimulants prevent falling asleep, while opioids reduce the amount of deep slow-wave and REM sleep, increasing the amount of light sleep stages.
The effects of substances on sleep physiology are not immediately reversed after the cessation of use, as the circadian rhythm is disrupted due to the altered patterns of nutrition, work, and exposure to sunlight. Moreover, the relative lack of structure during the inpatient treatment can contribute to the development of insomnia as well.
The mechanism linking sleep deprivation to relapse
The link between poor sleep and relapse has both a psychological and neurobiological basis, as studies show that sleep deprivation increases the reactivity of the prefrontal cortex during exposure to stimuli associated with the substance of choice.
Meanwhile, sleep deprivation causes dysregulation of the dopamine system, rendering the individual more prone to developing cravings and less able to ignore cues. Poor sleep also negatively affects the neurocircuitry responsible for the regulation of mood, which can lead to worsening of mood symptoms that, in turn, interfere with recovery.
Both insomnia and substance use disorder can precipitate episodes of depression and anxiety, which, in turn, disrupt sleep further. The relationship is bidirectional and both conditions need to be addressed at the same time.
A thorough sleep assessment and the implementation of measures to prevent sleep deprivation must be considered an essential element of any treatment program, on par with nutritional and physical activity counseling.
For instance, a substance use disorder treatment center may provide excellent care for the individual’s anxiety, but if that individual continues to feel highly alert during the day, their ability to fall and stay asleep will continue to be impaired as well. Similarly, if the individual is prescribed a hypnotic medication to help them sleep, but the root cause of their insomnia, such as depression, is not addressed, their chances of achieving long-term recovery will be significantly diminished.
Sleep plays a part in the neuroplasticity processes happening in the brain during treatment, specifically the formation of new synapses facilitating healthier response to stress. The better an individual sleeps, the more likely they are to successfully acquire new coping mechanisms.
The clinical implications of the sleep-recovery connection
When considering the multitude of beneficial effects stemming from uninterrupted sleep, it becomes evident that its restoration should be a high priority for any treatment facility.
Such a priority should be on par with other essential elements of treatment, such as psychotherapy and medication-assisted treatment. In practice, this means implementing standardized screening procedures for sleep disorders at the beginning of treatment and regularly during the course of treatment.
For example, individual may experience normal sleep throughout the inpatient treatment but develop insomnia during the outpatient stage due to the change in the setting. If the sleep screening was completed only at the beginning of treatment, such issues would go unnoticed, and the individual would not receive the help they need in a timely manner.
The practical steps to resolving insomnia
The resolution of chronic insomnia rarely entails selecting a single intervention, as sleep deprivation is usually the result of multiple factors.
However, there is a set of individual, non-pharmacologic measures, often referred to as sleep hygiene, that have been shown to improve sleep quality in a variety of populations.
Waking up at the same time every day, even on weekends, facilitates the synchronization of the circadian rhythm. Exposure to natural light, preferably right after waking up, regulates the circadian rhythm and facilitates the consolidation of sleep at night. Avoiding caffeine consumption after noon prevents insomnia due to stimulants. Maintaining a strict bedtime schedule encourages the body to associate the bedroom with sleep and promote relaxation only when it is time to sleep. Finally, engaging in some quiet, calming activities ten minutes before bedtime helps the body relax and prepares it for rest.
These relatively simple measures are relatively accessible for most individuals, although their effects may be delayed since sleep hygiene is a long-term investment. They are also not a replacement for the clinical interventions, such as CBT-I, which can be necessary to resolve insomnia that impacts the individual’s daily functioning.
The role of CBT-I in treating substance use disorders
Cognitive behavioral therapy for insomnia addresses the psychological reasons for prolonged sleep deprivation, such as high levels of anxiety with respect to bedtime and catastrophic beliefs about sleep loss. With the guidance of a clinician, the individual practices challenging such maladaptive thoughts and replaces them with more adaptive alternatives.
They can also practice relaxation techniques to reduce physiological arousal and reduce the manifestation of insomnia. CBT-I helps to adjust one’s sleep patterns, such as limiting time spent in bed to encourage faster falling asleep and reduce chances of interrupted sleep.
All of these are crucial benefits for the individual in recovery, as they have limited options when it comes to pharmacologic management of sleep deprivation.
The individual in recovery may have limited options for hypnotic medications, whether they are over-the-counter or prescription, because these medications can lead to tolerance. Such medications are also meant to be used intermittently and in short bursts; using them for an extended period of time can lead to dependence or abuse. A CBT-I guided treatment helps to resolve the insomnia without introducing additional substances, thus eliminating the risks linked to the use of hypnotics.
The questions to ask when researching treatment facilities
Since uninterrupted sleep plays such an important role in an individual’s recovery, it makes sense to ask how sleep is supported when selecting a rehab facility. The following questions can serve as a guide when communicating with potential treatment facilities.
Does this program evaluate my sleep patterns upon arrival? Do they propose CBT-I as a course of treatment or refer to a specialist? Are they going to assist me with developing a personalized sleep plan or will I be responsible for that? Are the recommendations about bedtime scheduling integrated into the treatment or are they considered an optional extra? Do they intend to reassess my sleeping patterns half a year into the treatment, or is the subject not discussed again after the first week?
The answers to these questions can highlight the areas of emphasis of a particular treatment facility. Some programs, including those offered by Legacy Healing NJ, have started to integrate sleep health into the broader context of health and wellness, providing more continuity of care than those that do not consider it seriously.
This continuity of care is reflected in the long-term outcomes of the clients, including their ability to obtain uninterrupted sleep during the aftercare and transitional living phases.
Sleep plays an essential role in the health and wellness of individuals in recovery
While most treatment programs address the challenges related to cravings, few address insomnia. Better rest supports emotional, psychological, and physical health, which is crucial for an individual in recovery. Consistent sleep can also make everyday recovery tasks feel more manageable by supporting concentration, patience, and participation in treatment. When sleep remains disrupted, discussing the pattern with the treatment team can help ensure that it is considered alongside other recovery needs rather than treated as an isolated inconvenience or simply left to improve on its own throughout each stage of the process.
Sleep disorders that emerge during treatment can serve as early warning signs of an impending relapse, making timely intervention critical in such situations.