Are problems sleeping common during MMT?

 Sleep disturbances affect up to half of the American population, depending on how surveys are done, and up to 15% of those afflicted persons have underlying substance abuse problems. Of some concern, many patients in methadone maintenance treatment (MMT) appear to have serious sleep disturbances.

The need for sleep varies from one person to another, but ranges up to 10 hours during a 24-hour period. Both the quantity and quality of sleep are important, and patients may complain that they do not sleep at all, when they are actually describing a lack of deep sleep, perhaps less spontaneous dreaming, and/or frequent awakenings.

Unfortunately, sleep can be disrupted by many factors, such as: psychological and medical disorders, effects of medications or substances of abuse, or lifestyle (e.g., lack of exercise). Occasional sleep disturbances are a universal human affliction and practically every adult will experience self-described insomnia at some point in life. For many, insomnia is a passing response to life stresses. But, persistent sleep disorders may be symptomatic of more serious conditions.

Persons who abuse alcohol and other drugs are at high risk for sleep disorders. This is due to the negative effects of those substances or their withdrawal on normal sleep patterns. Sleep is not immediately recovered even if drug or alcohol abstinence is achieved and, in fact, more normal sleep may require months or even years to return.

Specifically relating to opioid drugs, some studies have found that the primary effect on sleep of short-term ( acute) opioid administration is to hasten falling asleep, but the restfulness of sleep and total sleep time are reduced. Long-term (c hronic) opioid abuse may lead to tolerance of some negative effects on sleep, although more serious insomnia may develop.

It is believed that methadone may contribute to insomnia by disrupting normal sleep phases during the night; however, the exact reasons for this are unknown. MMT patients also have a high prevalence of depression and anxiety disorders, which independently and negatively affect sleep. Small studies have indicated increased disruptions of sleep, including disturbed breathing (apnea), among methadone-maintained patients.

In one large study of MMT patients – receiving average methadone doses of 93 mg/day and an average of 3.2 years in treatment – most of the subjects (84%) had serious sleep problems. More than a third of them also had major depression and nearly half had general anxiety disorder. Depression, anxiety, nicotine dependence, body pain, and unemployment were significantly associated with poorer sleep quality during MMT; however, methadone dose was not a contributing factor in the overall analysis. Approximately 14% of the patients reported ongoing alcohol, heroin, and/or sedative abuse.

Untreated sleep disorders may influence continued drug abuse or relapse in MMT patients who are attempting to self-medicate their distress. Therefore, the use of non-addicting sleep therapies is critical in this population. In the final analysis, since opioids including methadone appear to affect sleep, MMT patients may have to accept some degree of sleep disturbance as a normal part of the addiction recovery process. However, it is vital to also consider that a return to more normal sleep patterns would require stabilized methadone maintenance and may take a great deal of time. For example, a person who is receiving inadequate methadone dosing could be frequently awakened during the night by opioid-withdrawal symptoms, including pain.

Unfortunately, there do not appear to be any published recommendations of pharmacotherapies for sleep specifically in MMT patients. The choice of which non-addicting medications might best help to resolve sleep problems and retain methadone patients in treatment needs further study.