Megan E. Kurth

Obstructive sleep apnea is more common than central sleep apnea in methadone maintenance patients with subjective sleep complaints.

OBJECTIVES Opioid-dependent patients treated with methadone have subjective sleep complaints and disrupted sleep on polysomnography (PSG). Previous studies of sleep-disordered breathing (SDB) in this population have focused on central sleep apnea (CSA). Our objectives were to: (1) characterize obstructive sleep apnea (OSA) and CSA in patients in methadone maintenance treatment (MMT) for opioid dependence; (2) examine factors associated with SDB in this population; and (3) investigate whether SDB was related to severity of subjective sleep complaints in MMT patients with subjective sleep disturbances. METHODS We analyzed OSA and CSA from one night of home PSG in 71 patients who were in MMT for at least 3 months and had a Pittsburgh Sleep Quality Inventory (PSQI) score >5. RESULTS OSA (defined as obstructive apnea-hypopnea index (OAHI) > or = 5) was observed in 35.2% of our sample. OSA was associated with higher body mass index, longer duration in MMT, and non-Caucasian race. CSA (defined as central apnea index (CAI) > or = 5) was observed in 14.1% of the sample. CSA was not associated with methadone dose or concomitant drug use. Subjective sleep disturbance measured with the PSQI was not related to OSA or CSA. CONCLUSIONS SDB was common in this sample of MMT patients and OSA was more common than CSA. Given the lack of association between presence of SDB and severity of subjective sleep difficulties, factors other than sleep apnea must account for complaints of disturbed sleep in this population.

Assessing sleep in opioid dependence: a comparison of subjective ratings, sleep diaries, and home polysomnography in methadone maintenance patients.

OBJECTIVES Comparisons of subjective and objective sleep measures have shown discrepancies between reported sleep and polysomnography (PSG) in non-drug dependent individuals with and without insomnia. Sleep may affect behavioral and physiologic aspects of drug abuse and dependence; patients in methadone maintenance therapy (MMT) for opioid dependence frequently report sleep problems. Whether subjective sleep reflects objective sleep in MMT patients is unknown. We undertook these analyses to establish the correlations among subjective and objective sleep measures in MMT patients. METHODS We compared one week of daily sleep diaries, one night of home PSG, a questionnaire completed the morning after PSG, and the Pittsburgh Sleep Quality Inventory (PSQI) as well as demographics and drug use measures in 62 MMT patients with disturbed sleep (PSQI score > 5). RESULTS Subjective and objective sleep durations were similar in this sample; average sleep times for the diary, morning questionnaire, and PSG were 340, 323, and 332 min, respectively. Average diary sleep time, subjective ratings of feeling rested, and PSG sleep efficiency were correlated significantly with PSQI score. Age was inversely correlated with PSG sleep time. Participants whose urine toxicology showed benzodiazapine use reported significantly longer sleep times on the morning questionnaire. CONCLUSIONS Objective sleep measures confirm subjective measures in MMT patients with disturbed sleep. The high prevalence of sleep complaints in this population likely reflects pathology rather than sleep misperception. Both objective and subjective measures are useful in research and clinical settings for assessing sleep in opioid-dependent patients.

Varenicline for smoking cessation among methadone-maintained smokers: A randomized clinical trial

BACKGROUND With smoking rates far exceeding the general population, methadone-maintained (MMT) opiate-dependent smokers experience high rates of tobacco-related health consequences. Previous treatment studies have used nicotine replacement and produced low quit rates. METHODS We test, using a three-group randomized design, the efficacy of varenicline versus placebo, in comparison with nicotine replacement therapy (NRT) that combines nicotine patch prescription plus ad libitum nicotine rescue, for smoking cessation. We recruited methadone-maintained smokers from nine treatment centers in southern New England and provided six months of treatment, and a minimal behavioral intervention at baseline (NCIs 5As). Outcomes included carbon monoxide (CO) confirmed 7-day point smoking cessation prevalence at 6 months and self-reported change in mean cigarettes per day. RESULTS The 315 participants had a mean age of 40, with 50% male and 79% non-Hispanic White, smoked an average of 19.6 (± 10.4) cigarettes/day, and had a mean daily methadone dose of 109 mg. Intent-to-treat analyses, with missing considered to be smoking, showed the rate of CO-confirmed 7-day abstinence at 6-months was 5.4% overall, with varenicline 3.7% compared to placebo 2.2%, and NRT 8.3% (p>.05). Adherence rates during the 7-days immediately prior to 6-month assessment were 34.2% in varenicline, 34.4% in placebo, and 48.8% in NRT. Between baseline and 6-months there was an overall self-reported mean reduction of 8.3 cigarettes/day. CONCLUSION Varenicline did not increase quit rates over placebo. Smoking cessation rates in methadone-maintained smokers are low and novel treatment strategies are required.

TRAZODONE FOR SLEEP DISTURBANCE DURING METHADONE MAINTENANCE: A DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL

BACKGROUND To test whether trazodone, one of the most commonly prescribed medications for treatment of insomnia, improves subjective and/or objective sleep among methadone-maintained persons with sleep complaints, we performed a randomized, double-blind, placebo-controlled trial with 6-month follow-up. METHODS From eight methadone maintenance programs in the northeastern United States, we recruited 137 persons receiving methadone for at least 1 month who reported a Pittsburgh Sleep Quality Index (PSQI) score of six or higher. Two-night home polysomnography (PSG) was completed at baseline and 1 month later, with morning surveys and urine drug toxicologies. Interviews assessed sleep over the past 30 days at baseline and 1-, 3-, and 6-month follow-ups. RESULTS Participants averaged 38 years of age, were 47% male, and had a mean PSQI total score of 12.9 (±3.1). At baseline, intervention groups did not significantly differ on 10 PSG-derived objective sleep measures and 11 self-reported measures. Over 88% (n=121) of participants completed the PSG at 1-month. Without adjusting p-values for multiple comparisons, only 1 of 21 sleep measure comparisons was statistically significant (p<.05). The effect of trazodone on mean PSQI scores during the 6-month follow-up was not statistically significant (p=.10). Trazodone neither significantly increased nor decreased illicit drug use relative to placebo. CONCLUSIONS Trazodone did not improve subjective or objective sleep in methadone-maintained persons with sleep disturbance. Other pharmacologic and non-pharmacologic treatments should be investigated for this population with high rates of insomnia.

Prescription medication exchange patterns among methadone maintenance patients

BACKGROUND Exchange of prescription medications is a significant public health problem particularly among substance abusing populations. Little is known about the extent of medication sharing and receiving behaviors in methadone maintenance treatment (MMT) populations and the factors associated with such behaviors. METHODS We examined rates, and factors associated with past year medication sharing and receiving practices of 315 MMT smokers who had enrolled in a clinical trial of smoking cessation. Sequential logistic regression models estimated the effect of demographic and substance use variables on the probability of sharing or receiving medications. RESULTS Participants averaged 40 years of age, and 49% were male. Among persons prescribed medications, 19.9% reported sharing. Nearly 40% had used medication not prescribed to them. Pain medications, sleep medications, and sedatives, were most commonly shared and received. Younger age was a significant predictor of both sharing medications (OR=0.92, 95%CI 0.88; 0.96, p<.01) and receiving medications (OR=0.94, 95%CI 0.92; 0.97, p<.01). Financial hardship (OR=2.05, 95%CI 1.13; 3.72, p<.05), and recent use of heroin (OR=5.59, 95%CI 1.89; 16.57, p<.01) or cocaine (OR=3.70, 95%CI 1.48; 9.28, p<.05), were also independently associated with a significantly higher likelihood of receiving prescription drugs of abuse. CONCLUSIONS The high prevalence of prescription medication sharing and receiving behaviors among persons in MMT often include substances with abuse potential and suggest the need for comprehensive approaches for minimizing this phenomenon.

Ramelteon and Improved Insomnia in Alcohol-Dependent Patients: A Case Series

In this case series of 5 alcohol-dependent patients with insomnia who had initiated abstinence, a 4-week course of ramelteon 8 mg nightly was associated with markedly improved insomnia scores, increased total sleep time, and decreased time to fall asleep. Given its lack of abuse potential and evidence of low melatonin levels in alcoholism, ramelteon deserves further study as a treatment for insomnia in this group of patients.

Marijuana use patterns and sleep among community-based young adults

ABSTRACT Marijuana is the most commonly used recreational drug in the United States. Research on the relationship between marijuana and sleep is still in its infancy. The study examined differences in sleep characteristics between a community sample of daily users, non-daily marijuana users, and non-users. A total of 98 subjects (45 M; 53 F) participated. The mean age was 22.3 (standard deviation = 3.0). There were 53 females and 55% of the sample was Caucasian. Recruitment was done online and via print advertisements in the community. Groups were categorized as non-daily users (n = 29), daily users (n = 49), and non-user controls (n = 20). Sleep was characterized by the Pittsburgh Sleep Quality Index, Insomnia Severity Index, Epworth Sleepiness Scale, and the Morningness Eveningness Questionnaire. A standard cut off score of >10 for the Insomnia Severity Index was found in 38.8% of daily users, 10.3% of non-daily users, and 20% of non-users. Pittsburgh Sleep Quality Index scores in daily users (7.0+/–3.8) were higher than non-daily (4.9+/–3.2) and non-user controls (5.0+/–3.7), p = .02. Insomnia Severity Index scores in daily users (7.9+/–6.1) were higher than non-daily (5.1+/–4.3) and non-user controls (4.3+/–4.8), p = .01. Covariate adjusted regression analyses revealed mean Pittsburgh Sleep Quality Index and Insomnia Severity Index scores were significantly lower for non-daily users and controls relative to the daily users. When adjusting for depression and anxiety, these unique associations were not significant. There were no differences in the Epworth Sleepiness Scale or Morningness Eveningness Questionnaire. Daily marijuana users endorsed more sleep disturbance than non-daily users. Future studies should consider mood in the relationship between marijuana use and sleep.

Impact of marijuana use on self‐rated cognition in young adult men and women

BACKGROUND AND OBJECTIVES Marijuana (MJ) is a widely used substance that has been shown to impair cognition in laboratory settings. There is a growing number of medical MJ dispensaries and state policies permitting the use of MJ in the United States. This study is a naturalistic study that explores the association of same day MJ use on self-rated cognition in young adult men and women. METHODS Forty-eight (n = 48) young adults (22 F; mean age = 22.3) participated. After a baseline assessment, participants made daily phone calls to study staff over the next 3 weeks. Cumulative minutes of MJ use in the last 24-hours were assessed. Demographic information collected and self-ratings of cognitive impairment were assessed using six questions about areas of difficulty thinking each day. RESULTS There was a significant relationship between greater number of minutes of MJ use and higher levels of self-rated cognitive difficulties (b = .004; SE = .001; p < .006). There was no main effect of gender (b = 1.0; SE = .81; p < .22). Planned evaluation of the interaction between gender and minutes of MJ use was not significant statistically, suggesting a similar relationship between minutes of MJ use and cognitive difficulties among women compared to men (p < .54). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE There is an association between current and heavy MJ use and self-perceived cognitive ability in both males and females. These findings reveal important information regarding one consequence of MJ use that has real-world meaning to young adult smokers. (Am J Addict 2015;24:160-165).

Alcohol treatment outcomes following discharge from a partial hospital program

ABSTRACT Background: Thousands of individuals in the United States seek alcohol treatment each year, typically in outpatient settings. Partial hospital programs provide a high level of structured, individualized outpatient care for individuals who are in treatment for alcohol use disorder. Previous research in other outpatient and inpatient settings has found that psychological distress, pain, and aftercare utilization are associated with treatment outcomes. Objectives: The current study evaluates baseline characteristics and aftercare utilization predictors of alcohol use outcomes of individuals in a week-long partial hospital program. Methods: The 113 participants (59.3% male) were interviewed during their time in the program and then were reassessed one month post-discharge. Results: Results indicated that a greater number of mental health provider visits and 12-step attendance were associated with abstinence at follow-up such, while baseline characteristics did not consistently predict outcomes. Conclusions: Findings highlight the importance of aftercare planning, particularly in our more severe, clinical sample.

Health Services Use Among Jailed Women with Alcohol Use Disorders

Correctional facilities now house unprecedented numbers of women with complex treatment needs. This investigation applied the Behavioral Model for Vulnerable Populations to study 168 jailed women with alcohol use disorders. It described the sample’s predisposing (age, race, victimization), enabling (health insurance), and need (self-reported medical, substance use, and mental health problems) factors and examined associations of these factors with pre-incarceration services utilization. Most participants had clinically significant levels of depression and PTSD symptoms, most took psychiatric medications, and most had been victimized. Participants reported considerable health services utilization. Younger, Black, and uninsured women utilized fewer medical and mental health services. Drug use was associated with less use of medical services, but more use of alcohol and drug services. High rates of health services use support the need for integrated, ongoing care for substance-using women before, during, and after incarceration.