December 12, 2011

Getting over the exhaustion hump and getting to sleep

Here’s why you can’t sleep, and what you can do about it 

By Stacia Nash
You’ve spent the day doing things to support your recovery—you went to a meeting, took a run and cooked dinner. But now it’s time for bed and you’re wide awake and frustrated. The next day, you’re tired and everything seems harder than it was yesterday. And it’s true, recovery is even harder when you’re exhausted.
During the recovery process, sleep is typically one of the last things to fall into place. “Sleeping disorders are very common,” says Kenneth W. Thompson, MD, FASAM and medical director of the Caron Treatment Center in Wernersville, Penn. “Ninety percent of our patients have sleep difficulties. They get inadequate amounts of sleep or have a perception of sleep deficits.”
Numerous studies have shown that alcohol plays a major role in how we sleep—even after alcohol consumption has ceased. For those in recovery, this means that sleep problems are the norm, not the exception.
During a natural sleep cycle, we go through two alternating states of sleep: slow wave sleep (SWS) and rapid eye movement (REM) sleep. Most of our sleep is deep, restful SWS and about 25 percent of our sleep is the dream-associated REM phase. Sleep is largely controlled by nerve cells in the lower brain stem that produce serotonin, a neurotransmitter associated with the onset of sleep and the regulation of SWS. Other nerve cells produce norepinephrine, which helps regulate REM.
Although the exact roles and interactions of both sleep neurotransmitters are not known, sleep specialists do know that alcohol affects their function, which is one reason why people commonly use alcohol as a sleep aid. Ironically, once the sedating effects of alcohol wear off, it actually increases wakefulness during the second half of the night.
When the brain has become accustomed to alcohol use, it may take months for it to revert to normal sleep patterns. “Some people have a couple of months of sleep problems,” says Thompson of his recovery patients. “This is a reality of early recovery.”
It is important to remember that sleep is a necessary process and is important to our well-being. A lack of sleep can have serious health consequences including increased risk of depression, heart disease and sleep apnea, a disorder in which the upper air passage narrows during sleep, interrupts breathing and awakes the individual.
Chronic sleep apnea significantly reduces sleep time and increases daytime sleepiness as well as a person’s risk for heart attack and stroke. Exhaustion is one of the biggest triggers for relapse, so it is important to get to the root of the sleep trouble. 
“When treating sleep disorders, the goal is to treat the underlying problem,” says Subramanian Paranjothi, medical director at St. John's Mercy Health Care in St. Louis. “When it comes to sleep disorders with alcoholics, the question is whether it is because of underlying anxiety or depression or is it because of the alcohol. Anxiety and depression commonly come along with alcoholism.”
Thompson, who underwent his own recovery 22 years ago, says that recovering alcoholics suffer sleep impairments unique to the process of recovery—what he likes to call vultures on a bedpost. “As we stop drinking, we start to wake up, have the holy cow kind of feeling. We may say to ourselves, ‘Look at what I’ve done!’ and feel resentment, sorrow, shame. It’s important to deal with these issues in a recovery process. Intrusive thoughts really can disrupt sleep at night,” he says.
Due to the nature of addiction, he stresses that people in recovery need special attention when dealing with sleep disorders. “Some recovering alcoholics have persisting sleep problems that won’t get better,” he says. “They need to go to a specialized therapist who deals with sleep disorders. And they have to be careful about who is prescribing and what is being prescribed for sleep. A lot of doctors don’t understand relapse or what can trigger relapse.”
Most medical professionals agree that recovering alcoholics should be wary of taking medication to deal with their sleep disorder. Commonly prescribed drugs such as Ambien and Lunesta, while not physically habit-forming, may cause dependency. “These types of drugs can trigger a relapse,” Thompson says. “They trigger a reward area in the brain similar to alcohol. It reminds one of drinking and can create a relapse.”
Currently, the National Institute on Alcohol Abuse and Alcoholism is participating in a research program sponsored by the National Association on Sleep Disorder Research to study sleep problems associated with alcohol abuse and the possible development of sleep medications for this group. Due to the nature of alcoholism, this is somewhat controversial among the medical community. 
Overall, people in recovery should start to sleep normally within three months. “It's important to realize that sleep may not be as good as they want it to be,” warns Thompson. “After a couple of weeks, it’s not realistic to expect great sleep. If you have great expectations, it makes sleeping worse.”
If you are having a hard time with sleep, there are some steps you can initiate to help the process. For starters, practice good sleep hygiene such as avoiding caffeine and nicotine before bedtime, stick to a regimented sleep schedule and be well-informed about the effects of any medications you may be taking. Engage in personal relaxation activities such as prayer, meditation or reading and create a relaxing sleep environment.
And perhaps most important for recovering alcoholics, Thompson says, is mentally preparing for rest. “Deal with things as you face them and you are likely to feel more relaxed. Deal with anger and take your own personal inventory of the day.”

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