Journal of Sleep Disorders: Treatment and CareISSN: 2325-9639

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Research Article, J Sleep Disor Treat Care Vol: 3 Issue: 3

Factors Related to Relapse in Substance-Dependent Patients in Hospital Detoxification: The Relevance of Insomnia

Lara Grau-López1,2*, Carlos Roncero1,2,3, Laia Grau-López4, Constanza Daigre1, Laia Rodriguez-Cintas1, Yasmina Pallares1, Ángel Egido1 and Miquel Casas2,3
1Vall d’Hebron CAS, Vall d’Hebron University Hospital, Public Health Agency of Barcelona, Spain
2Department of Psychiatry, Vall d’Hebron University Hospital, Barcelona, Spain
3Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Spain
4Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
Corresponding author :Lara Grau-López MD
Psychiatry Department. Vall d’ Hebron University Hospital, Passeig Vall d’ Hebron, 119-129, 08035 Barcelona, Spain
Tel: +34934893880
E-mail: [email protected]
Received: January 27, 2014 Accepted: April 05, 2014 Published: April 09, 2014
Citation:Grau-López L, Roncero C, Grau-López L, Daigre C, Cintas LR, et al., (2014) Factors Related to Relapse in Substance-Dependent Patients in Hospital Detoxification: The Relevance of Insomnia. J Sleep Disor: Treat Care 3:3. doi:10.4172/2325-9639.1000138

Abstract

Factors Related to Relapse in Substance-Dependent Patients in Hospital Detoxification: The Relevance of Insomnia

There is a bidirectional relationship between substance use and insomnia. Little has been described about the influence of insomnia on the prognosis of substance-dependent patients. The objective of our study is to describe the prevalence of insomnia during active consumption and hospitalisation for detoxification, and its influence on relapses at 3 and 6 months in substance-dependent patients. We conducted a prospective study of substance-dependence inpatients and performed psychiatric follow-up on an outpatient basis every month over the six months following discharge. Insomnia prior to admission was measured by taking a clinical interview from the patient concerning sleep habits, and during hospital stay using a sleep log filled out by nurse team. Demographic, clinical, diagnostic and therapeutic variables were recorded and a structured clinical interview (SCID) was conducted to assess psychiatric diagnoses. Relapse was deemed to be renewed use of the substance that brought about admission, which was assessed by taking a history
and/or alcohol testing and/or urinalysis.

Keywords: Substance abuse, addiction, relapse, insomnia

Keywords

Substance abuse; Addiction; Relapse; Insomnia

Introduction

Insomnia is a sleep disorder that is defined in the International Classification of Sleep Disorders [1] as difficulty falling asleep or staying asleep, early awakening or poor sleep quality in spite of good circumstances for restful sleep. Additionally, patients must present at least one of the following symptoms during the day: fatigue, diurnal hypersomnolence, lack of motivation and initiative, attention, concentration or memory disorders, irritability or other mood changes, impaired social or work performance with repeated errors at work or when driving and physical symptoms such as tension, headache or gastrointestinal disturbances and worry or preoccupation concerning insomnia. Insomnia is classified as either primary insomnia or secondary insomnia, which is considered to be caused by medical or psychiatric disease or substance use [1].
The relationship between insomnia and drug addiction is bidirectional, in that patients using substances have a higher prevalence of insomnia than the general population, while those with insomnia have a higher probability of developing a substance use disorder [2-4]. The prevalence of insomnia in drug-dependent patients in part understood and differs according to the substance consumed. The majority of studies having been conducted in alcoholics, in whom the prevalence of insomnia is described as reaching up to 61% [5-8].
Substance use disorder is a chronic disease in which relapse is a part of the disease process, and there are high rates of relapse even following treatment [9-13]. Several factors associated with relapse have been described, including greater probability of medical or psychopathological comorbidities, polysubstance use, greater duration of consumption, previous relapses, criminal record [12,14-16], poor attitude toward treatment and little family involvement [12,17]. There is controversy concerning the type of legal or illegal substance associated with the greatest probability of relapse, although earlier studies report them to be heroin and alcohol [9,18-20].
Few studies are available concerning whether insomnia affects relapse in patients [3]. Additionally, the results are contradictory, since insomnia has been associated with the risk of relapse, primarily in alcoholics [7], while other studies have not demonstrated an association between insomnia and relapse [21].
Due to these controversies, our study was intended to analyse the relationship between insomnia and relapse. The objectives of our study were to describe the prevalence of insomnia in drug-dependent patients during active consumption both prior to hospital admission for detoxification and during the detoxification hospitalization, as well as to analyse the relationship between insomnia and relapse at 3 and 6 months of follow-up after discharge, while also considering sociodemographic, clinical and therapeutic variables.

Materials and Methods

Patients
We conducted a prospective study of patients diagnosed with substance dependency disorders admitted voluntarily to the hospital detoxification unit of Vall d’Hebron University Hospital between June 2008 and November 2012, and performed follow-up over the six months after discharge. All patients were interviewed previously to the detoxification income and they signed an agreement of hospitalization.
Inclusion criteria were presentation of a substance dependence disorder according to DSM-IV-TR criteria, admission to the hospital detoxification unit, follow-up during the following six months and signing of the informed consent previously approved by the hospital ethics committee. Patients who requested voluntary discharge during hospital stay were excluded. Patients did not receive financial compensation for participating in the study.
Procedure
On the first day of hospital stay a history was taken that included a history of prior insomnia. To assess insomnia during hospitalisation a daily interview was conducted concerning the previous night's sleep and a nocturnal sleep log was completed (Figure 1).
Figure 1: Nocturnal Sleep Agenda.
Psychological assessment was also performed, the appropriate detoxification treatment was instituted and patients participated voluntarily in group psychotherapy performed during hospital stay. All patients received decreasing doses of benzodiazepines, regardless of the substance that led to admission and adjuvant drugs to treat comorbid psychiatric symptoms. Smokers received nicotine replacement therapy patch monotherapy during hospitalization and the most common was 21 mg/24 hours patch. If patients had insomnia during hospitalization were prescribed hypnotic treatment after the admission, such as antidepressants (mirtazapine or trazodone), antipsychotics (quetiapine) or antiepileptics (gabapentin or pregabalin) with hypnotic function.
At the time of discharge they were given follow-up appointments and when appropriate voluntary urinalysis for heroin, cocaine, cannabis and benzodiazepines, and alcohol testing by breath BAC were conducted. Standard treatment carried out during follow-up consisted of medical visits in which pharmacological prescriptions were reviewed and some patients underwent psychotherapy.
Variables and evaluation tools
• Record of variables designed ad hoc for follow-up of patients of the Vall d’Hebron drug dependency unit, including sociodemographic (sex, age, living with family and criminal record), clinical (primary substance that led to admission, number of substances consumed, final binge prior to admission, meaning the consumption of a larger amount of the substance than normal, and personal history) and therapeutic variables (prior admissions, duration of current hospital stay, psychotherapy during hospitalisation and referral on discharge).
• SCID-I (semi-structured clinical interview for Axis I disorders of DSM-IV) [22]. The sections referring to affective, anxiety, psychotic, eating and substance use disorders were used.
• SCID-II (semi-structured clinical interview for Axis II disorders of DSM-IV) [23].
• Substance detection tests: the results of urinalysis for heroin, cocaine, cannabis and benzodiazepines, and alcohol testing by breath BAC were systematically recorded on the day of admission and for some patients during follow-up.
• Relapse: assessed at 3 and 6 months by patient self reporting and diagnostic detection tests for substances (alcohol test and/or urinalysis). Relapse was deemed to be recurrence of use of the primary substance which led to admission to the hospital detoxification unit. Criteria for relapse differed according to the substance that motivated admission: for alcohol, "relapse" was deemed to be alcohol consumption on five consecutive days or consumption of more than five units of alcohol in one day. For other substances (cocaine, heroin, cannabis, benzodiazepines, or other illegal drugs), relapse was deemed to be three consecutive positive urine tests, or five positive tests in one month, or when the patient admitted consumption similar to the consumption pattern that led to admission [9,24].
• Insomnia: deemed present in those who showed sleep initiation dysfunction (requires more than half an hour to fall asleep), fragmented nocturnal sleep (awakened more than twice during the night), early awakening (awakened one hour before the usual time), global insomnia (presenting the three aforementioned types of insomnia) and poor sleep quality (did not meet any of the three criteria mentioned but showed diurnal effects) [25].
Statistical analysis
As ours was a descriptive study, no calculation of sample size was made and a convenience sample was used.
Descriptive statistics (mean, standard deviation, frequency tables) were generated and analysed using bivariate analysis. Insomnia and demographic, clinical and therapeutic characteristics of patients who relapsed at 3 and 6 months were compared with those who did not relapse. The Chi Square test was used to compare categorical variables and the Student t-test for continuous variables was used to compare the two groups. Multivariate analysis including variables significantly associated with relapse was performed using bivariate analysis. Stepwise logistic regression was used to evaluate the independent effect of each variable. Data were collected and analysed using the SPSS statistical package, version 18.0. Statistical significance was deemed to be p<0.05 in all cases.

Results

Description of the sample
From June 2008 to November 2012, 491 patients were admitted to the hospital detoxification unit of Vall d’Hebron University Hospital. Of these, 57 requested voluntary discharge and therefore did not complete detoxification and were excluded from the study. There are statistical differences between exclude group and study group when the age and the substance reason for admission were analyzed. Patients excluded by voluntary discharge were younger (37.9±6.5 vs 40.6±10.1; t=2.67, p=.009). Alcohol-dependent patients and cocaine-dependent patients were excluded by voluntary discharge less frequently than participant patients (41% vs 24.6% p=.02, 33.9% vs 21.1% p=.05, respectively) and heroin-dependent patients were excluded by voluntary discharge more frequently than participant patients (42.1% vs 12.9% p=.001).
The final sample therefore consisted of 434 patients admitted during the study period and who complied with follow-up for at least 6 months.
Table 1 describes the sociodemographic, clinical and therapeutic variables of the sample. In order of frequency, the primary substances motivating admission were alcohol (41%), cocaine (33.9%), opiates (12.9%), cannabis (7.4%) and benzodiazepines (4.8%). Polysubstance use (history of addiction to more than three substances) was seen in 46.1%. The percentage of patients who had relapsed at 3 months from discharge was 48.6% and at 6 months 67.5%.
Table 1: Variables associated with the possibility of relapse.
Preadmission insomnia (during consumption) was reported by 64.3% of patients and 66.1% reported insomnia during hospitalization (in abstinence). Table 2 shows differences in the magnitude of insomnia within substance dependence. Insomnia prior to admission for detoxification was significantly less frequent in patients admitted for cannabis detoxification. Insomnia in the initial phases of abstinence during hospitalization was significantly more frequent in patients with dependence of heroin, alcohol and benzodiazepines.
Table 2: Differences in the magnitude of insomnia within substance dependence.
Results by relapse at 3 and 6 months of outpatient follow-up subsequent to discharge:
Univariate analysis: Significant differences were detected in several variables. At both 3 and 6 months of follow-up relapsed patients were most commonly those without family support, polysubstance users, patients with prior admissions for detoxification and those who did not enter therapeutic communities. At 3 months of followup relapse was also more frequently seen in those with a history of having been in prison and those with medical comorbidities, while at 6 months it included those who showed positive urinalysis at hospital admission. However, patients with comorbid psychotic disorders relapsed less frequently at 6 months from discharge (Table 1).
Table 3 shows the types of insomnia presented by patients prior to and during hospitalization and their relationship with relapse at three and six month after discharge.
Table 3: Relationship of pre-admission and admission insomnia with relapse at 3 and 6 months after discharge.
Of the patients with preadmission insomnia, 68.3% relapsed at 3 months from discharge, as did 71% of patients with insomnia during hospitalization (in abstinence). Patients who relapsed at 3 months of follow-up showed greater sleep initiation dysfunction prior to and during hospitalisation. Other types of insomnia (fragmented sleep, early awakening, global insomnia and poor sleep quality) were not associated with relapse.
Of the patients with preadmission insomnia (during active consumption), 69.2% had relapsed at 6 months from discharge. Patients who relapsed at 6 months of follow-up showed significantly greater sleep initiation dysfunction and global insomnia during hospitalisation.
Multivariate analysis: In multivariate analysis, living with the family (OR 0.56, IC 95% 0.36-0.85), referral to a therapeutic community (OR 0.37, IC 95% 0.22-0.62), preadmission insomnia (OR 1.17, IC 95% 1.67-2.03) and insomnia during hospitalization (OR 1.27, IC 95% 1.76-2.14) were independently associated with the possibility of relapse at 3 months after adjustment of the variables for those showing statistical significance in univariate analysis (living with family, criminal record, personal medical history, polysubstance use, previous admission for detoxification, referral at discharge, preadmission insomnia, preadmission sleep initiation dysfunction, insomnia during hospitalization and sleep initiation dysfunction during hospitalization) (Table 4).
Table 4: Variables independently associated with the chance of relapse at 3 and 6 months after hospital discharge.
In multivariate analysis, living with the family (OR 0.55, IC 95% 0.35-0.86), referral to a therapeutic community (OR 11.21, IC 95% 0.27-0.71), comorbid psychotic disorder (OR 0.32, IC 95% 0.15- 0.68) and the number of prior hospital admissions for detoxification (OR 1.18, IC 95% 1.01-1.38) were independently associated with the possibility of relapse at 6 months after adjustment of the variables for those showing statistical significance in univariate analysis (living with family, comorbid psychotic orders, polysubstance use, positive urinalysis at admission, number of previous admissions for detoxification, referral upon discharge, preadmission insomnia, sleep initiation and global insomnia during hospitalization) (Table 4).

Discussion

Our study shows that the prevalence of insomnia is high both during active consumption in the month prior to admission for hospital detoxification (64.3%) and during hospitalization (66.1%). These results are consistent with the prevalence of insomnia found in other studies carried out in addicted patients. The majority of the studies have been carried out in alcoholics, for whom the prevalence of insomnia has been described in up to 61% [8]. In patients with other disorders due to substance dependence, the prevalence of insomnia is partially understood and varies according to the substance consumed (psychoactive drugs 70%, opiates 75-80% and cannabis 76%) [26-29]. These results are also similar to the prevalence of insomnia found in our study. It should be pointed out that the prevalence of insomnia is greater in addicted patients than in the general population, where the prevalence of insomnia varies between 12% and 20% [30].
Insomnia is independently associated with relapse at 3 months after hospital detoxification, whether it occurs during active consumption prior to admission or during hospitalisation when patients are in abstinence. However, although preadmission insomnia is associated with relapse at 6 months from hospital discharge in univariate analysis, it does not show independent association. These results are consistent with those of other studies that have associated insomnia with relapse in alcohol consumption. It has been reported that at 5 months of follow-up 60% of alcoholic patients with insomnia had relapsed whilst only 30% of those with no insomnia had relapsed [7]. It has also been demonstrated that abstinence from alcohol or moderate consumption of alcohol reduces the possibility of presenting insomnia at 6 months of outpatient follow-up [6]. Putnins et al. studied 60 patients dually diagnosed with bipolar disorder comorbid with substance dependence, the majority of whom were alcoholics (65%), and observed that patients with sleep disorders had a worse prognosis for affective disorder, but that it did not predict recurrence of substance consumption [21].
Our study shows that roughly half (48.6%) of patients relapse at 3 months and 67.5% at 6 months from hospital discharge. These data are consistent with those found by previous studies that describe the high percentages of relapse, ranging from 72% to 91% of patients in the first year of follow-up, after detoxification treatment [9,10,16,31,32].
In our study, living with family and entering a therapeutic community after hospitalisation for detoxification were independently associated with relapse at 3 and 6 months after hospital discharge. Various studies have demonstrated that family support [12,17] and, as would be expected, being in a protected environment, favour abstinence [33]. Comorbid psychotic disorders or multiple prior admissions were independently associated with relapse at 6 months after hospital detoxification. It has been described that patients with substance use disorders comorbid with other psychiatric disorders have more severe illness and worse prognosis for both conditions [9,34-36]. Patients who require multiple admissions for detoxification are patients with a severe and chronic illness which has a poor longterm prognosis, and various studies have also associated multiple admissions with a greater probability of recurring consumption [15,16,33].
Our study is a prospective study using a broad sample of patients to determine whether insomnia is a factor associated with the possibility of relapse after detoxification. Very few studies have assessed the association of insomnia with the probability of recurring consumption after detoxification, and most of these studies have been carried out in alcoholics [6,7,21]. However, certain limitations of our study must be mentioned, such as the possible sedative effects of the detoxification treatment to deal withdrawal symptoms and assessment of insomnia, since although patients were exhaustively assessed using psychometric tests that validate the clinical diagnoses, preadmission insomnia was self-reported. We found differences in age and substance reason for admission in alcohol, cocaine and heroin, between patients excluded by voluntary discharge and patients that complete detoxification process. These differences can affect the external validity of results.
In conclusion, in our study insomnia was independently associated with a greater probability of relapse at 3 months from hospital detoxification. It is difficult to determine a causal explanation for the association between insomnia and relapse. One hypothesis is that relapse in addicted patients with insomnia is related to selfmedication, since they may use substances such as benzodiazepines, illegal drugs or alcohol to treat insomnia [4]. It has also been suggested that there is a bidirectional relationship between insomnia and substance consumption, and that insomnia may be due to neurobiological changes secondary to consumption or that both may be manifestations of a primary disorder.
Further study of this subject is required to determine the factors associated with insomnia. We can conclude that assessment and treatment of insomnia in addicts is very important, since insomnia leads to deterioration in patients’ quality of life and its presence is associated with a greater probability of recurring consumption in the short term.

Acknowledgments

The authors thank the psychologists who performed the diagnostic interviews and nurse Oriol Esteve who collaborated in collected the data. The authors also thank the Agencia de Salut Publica de Barcelona for supporting the outpatient drug clinic Vall Hebron.

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