Are you one of the 70 million people in the U.S who experience sleep problems? About one-third of adults get fewer than 7 hours of sleep and report symptoms of insomnia. About 10% of adults at any given time meet the criteria for insomnia disorder, reporting ongoing difficulty getting to sleep, staying asleep, and/or returning to sleep that results in problems with functioning. Another common sleep disorder is sleep apnea (about 10% of adults), in which the person stops and starts breathing again many times during sleep. Sleep apneas can lead to life threatening conditions and requires formal assessment and treatment by a medical provider. As we noted in the Beyond the Field article “Sleep, Trauma and Substance Use,” quality sleep is key to overall health, emotional stability, planning, and sound decision-making. Poor sleep is associated with accidents, heightened pain sensitivity, unemployment, and mental health problems. For treatment court participants, sleep problems can interfere with recovery, making it more difficult to engage in treatment, maintain employment, and use skills to cope with psychiatric symptoms.

 

People with opiate use disorders (OUD) are at much higher risk of sleep impairments than the general population. Researchers report that as many as 84% of people with OUD experience significant sleep disturbances. Opiate use can create and perpetuate a harmful cycle, in which sleep problems and pain sensitivity trigger opiate use, and opiate use in turn leads to poor sleep and greater pain sensitivity – especially as withdrawal becomes part of the cycle. Furthermore, people with OUD are at much higher risk of not only obstructive sleep apnea, but central sleep apnea when the brain stops sending signals to the muscles that control breathing. This is a condition distinct from the immediate impact on respiration that can follow opiate administration. Studies indicate that about 40% of people with OUD have some form of sleep apnea – four times as many people in the general population. The relationship between OUD and sleep is complex: there are many factors that contribute to poor sleep among individuals with OUD, including co-occurring psychiatric disorders, financial stress, unstable housing, living in unsafe areas, a history of trauma, as well as the use of alcohol, nicotine and other drugs. (Dunn et al., 2018).

 

While the benefits of medication assisted treatments for OUD (MOUD) are well documented (SAMHSA, 2021), better sleep does not appear to be one of them. Research indicates that sleep does not improve with MOUD. A large study of individuals using methadone found that most reported moderate to severe sleep disturbance at the start of methadone treatment and that their disordered sleep persisted throughout treatment (Nordmann et al., 2016). Likewise, patients treated with buprenorphine did not fare any better in terms of improved sleep (Dunn et al., 2018). Again, the roots of sleep disturbance in OUD are complex. For individuals using both methadone and buprenorphine, psychiatric impairments were the strongest predictor of disordered sleep. Researchers are exploring the possibility that the medication itself causes some sleep problems or makes pre-existing sleep problems worse. MOUD is a critical component of OUD treatment, so it is important that treatment court team members are aware of how common sleep issues are among their participants and find ways to support them.

 

So, what can you do to assist participants experiencing disordered sleep? An important first step to addressing this issue is to increase awareness among all team members as to just how common disordered/dysregulated sleep is among individuals with OUD and receiving MOUD. Furthermore, team members should be knowledgeable about the relationship between poor sleep quality and some problematic behaviors (e.g., poor attendance, disengagement, forgetfulness, etc.) they observe among participants. It is important to note that individuals may not be aware that their sleep quality is poor nor that it is negatively impacting other aspects of their lives.

 

Below are relatively simple (and free) steps your treatment court team can take to bring this issue into the forefront of your work with participants.

 

1.    As part of your enrollment/intake process, ask individuals about their sleep patterns.

 

2.    In addition to asking individuals these questions in casual conversation, you can add an empirically validated screening tool to your enrollment/intake process. While not a comprehensive list, the below-listed screening tools are free and can be administered by non-clinicians:

 

Each of these tools includes a scoring rubric which will determine if someone should be referred to a medical provider for a comprehensive medical assessment to rule out other high-risk conditions that may be affecting sleep (e.g., sleep apnea). When in doubt, refer an individual to a medical provider for an assessment as their condition could be life threatening.

 

3.    It is also crucial for participants to know that disordered/dysregulated sleep is a very common experience among individuals with OUD and receiving MOUD. Once serious physiological/biological conditions have been ruled out by medical professionals, treatment court team members can and should normalize the realities of sleep dysfunction and work with participants to identify strategies that will assist in mitigating the negative side effects associated with poor sleep. Moreover, it’s important that treatment court team members reaffirm the benefits of MOUD and together with the below-listed suggestions, sleep may improve over time and recovery will continue.

 

Below are several prompts that can be used by any member of the treatment court team. For example, a case manager during a case management session, probation officer during a reporting meeting, peer recovery support specialist during 1-1 interactions, or a judge during the court review session. 

 

Call to action:

Discussing disordered/dysregulated sleep is not practicing medicine. All members of the treatment court team should normalize disordered/dysregulated sleep, work to increase knowledge in this area, and actively work to support participants experiencing this issue.

 

Your treatment court team can take several steps to improving the program’s capacity to address the needs of participants. To this end, we would offer the following suggestions for specific action steps you can take: