OUD, MOUD, & Sleep Disorders

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).
Do Medication Assisted Treatments Address Sleep Problems?
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.
An Action Plan for Addressing Sleep Disturbance in OUD and MOUD
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.
  • How many hours of sleep do you get each night (on average)? What time do you go to bed and wake up?
  • Where do you sleep?
  • Do you have trouble falling asleep? Do you have trouble waking up?
  • On a scale of 1-5 (1=not at all rested to 5=very rested), how rested do you feel when you wake up? 
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. 
  • Ask about the environment and other protective factors: “I know you’ve been having sleep problems. Can we help you talk to your family/roommates about that so they can support you? How can we support you in getting safer/more stable housing?”
  • Urge treatment for mental health challenges: “I hope you are getting help for problems like stress and depression and trauma – that can also help with sleep. And vice versa. Can we help you get the treatment you need?”
  • Help them use cognitive reminders to assist with everyday tasks that may be negatively impacted by lack of sleep: “It’s easy to forget what you’re doing if you haven’t had good sleep. Let’s review how a planner or calendar can help you stay organized? You can set reminders on your phone. I can help show you how to use one…”
  • Encourage them to decrease nicotine and alcohol use: “You wouldn’t think so, but tobacco, e-cigarettes, and alcohol can really mess with sleep. Is that something you want to think about or change?”
  • Ask about how they engage in physical activity: “I know how hard it is to get good sleep too. Walking during lunch has really helped. What sorts of physical activity do you engage in? When could you incorporate physical activity into your weekly schedule?”
  • Ask if clients are using any mindfulness apps or working on relaxation in therapy. “So, mindfulness and breathing differently really help some people relax and fall asleep. Have you talked about that with your counselor?”
  • Free, evidence-based apps such as iBreathe may be helpful.
  • Help clients develop a structured daily schedule that includes sleep. It will vary depending on employment (e.g., 3rd shift will be different from 2nd shift); parenting or other caregiving, etc.
  • Ask about how they can make their sleeping space and bedtime routine more supportive of sleep: “Can you control the lighting or noise level where you sleep? Can you put away your phone a half hour before bedtime?”
  • Offer cognitive behavior therapy for insomnia (CBT-i) as part of your menu of evidence-based treatment. Some of the above activities above are covered in more depth in CBT-i.
  • The U.S. Department of Veteran’s Affairs (VA) has developed CBT-i Coach, a free app that supplements healthcare treatment but can be used on its own https://mobile.va.gov/app/cbt-i-coach
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:
  • Identify at least one medical doctor in your area with whom your team can refer individuals in need of routine medical exams, assessments for specific conditions, etc.
  • Identify at least one pharmacist in your area with whom you can consult regarding medication interactions and general questions regarding medications.
  • Build a relationship with a medical and/or pharmacy school in your area. Medical/pharmacy students could observe your treatment court planning and court sessions, as well as provide consultation.


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Written by Kristen DeVall, Ph.D. & Sally MacKain, Ph.D.

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