Sleep and Recovery
Recovering Night: Alcohol, Substances and Sleep
A few years ago I found myself at an AA meeting in a small community in Southern California. It had been some time since I had accompanied a friend in recovery to a meeting. Having periodically attended various 12-step meetings around the country over the past couple of decades, I generally knew what to expect. The only surprise here was that the smokers were now huddled outside, quickly getting a last nicotine fix before the start of the meeting. Inside, the coffee drinkers were busy customizing their hits of caffeine.
Aware that the issue of nicotine and caffeine use in recovery had been beaten to death, I let it go and sank into my chair with anticipation of the heartfelt stories to come. I’ve always had a deep regard for the fellowship—the deep sense of welcome, support and openness. But then, surprisingly, I found myself dozing off. Certainly not for lack of interest in the stories. Recent cross country travel had left me sleep deprived and jet lagged. When we are sleepy and happen to find ourselves in a socially safe and supportive environment, it’s really difficult to stay awake.
Later that evening, back home with the friend who had invited me to the meeting, I watched him casually pop an Ambien, a fashionable prescription sleeping pill. I couldn’t help myself. “Hmm. Do you really need to take that?” I asked. He paused, looked me in the eye and said, “Every night… for five years now. I’d be up all night without it.”
I let it go.
But, not really.
The contrast between the spirit of sobriety in the meeting and my friend’s dependence on sleeping pills was striking. As a psychologist specializing in sleep and dreams, it left me thinking about the key role of sleep problems in addictions and recovery. Over the years, I had seen hundreds of patients with troubled sleep who were also dependent on alcohol. And many others who used alcohol more sparingly, but quite consistently as a sleep aid. Then there was an even larger group who routinely relied on other licit and illicit substances like sleeping pills, tranquilizers and marijuana to knock themselves out at bedtime.
Sleep problems are epidemic in our world today. From a simple numbers standpoint, sleep disorders are the most prevalent health concern in America. Seventy-six percent of American adults report symptoms of sleep problems at least a few nights every week. Most struggle with insomnia—difficulties with falling asleep, staying asleep, and/or maintaining quality sleep through the night. Chronic sleep loss leaves us depleted, fatigued and excessively sleepy by day, potentially interfering with all aspects of life. There is strong, mounting evidence that compromised sleep is associated with a wide range of serious medical conditions including cardiovascular disease, infections, diabetes, obesity and even cancer. Fully 80 percent of people with psychiatric concerns also suffer from sleep disorders. Insomnia, which is a classic symptom of depression, is also a major cause of depression. In fact, a year of insomnia is the single strongest predictive factor for future depression.
It’s well known in both professional and recovery communities that most alcoholics have significant sleep problems prior to active drinking, during active drinking, and often through treatment and recovery, as well. While 15 percent of the general adult population struggles with chronic insomnia, more than 50 percent of alcoholics report having sleep problems that predated their drinking by years.
Dependence on substances is also epidemic in our world. We turbo charge our daily lives with counterfeit energies--stimulants including highly processed carbohydrates, caffeine and nicotine. And, then, accelerating out of control, we depend on sedating substances like alcohol, marijuana and sleeping pills to provide a kind of counterfeit rest at night. Part of the special appeal of alcohol is that it initially functions as a stimulant and then becomes a depressant. In this way, it doubles as an agent of both counterfeit energy and counterfeit rest.
There is a common belief in our world that it is often necessary and reasonable to “take something to sleep.” I think it is questionable, however, if sleep inducing substances actually provide true, restorative sleep. Although they might offer us temporary relief by masking symptoms of insomnia, this does not constitute good sleep any more than masking the symptoms of anxiety with alcohol provides good mental health.
Many people believe that alcohol actually helps them sleep. Although it appears to facilitate sleep onset, alcohol suppresses melatonin, alters our circadian rhythms, and significantly disrupts sleep and dreaming later in the night. Drinking is also known to exacerbate snoring and sleep apnea, a serious condition in which breathing is compromised during sleep.
We continue to naively mistake the jittery buzz of counterfeit energies for natural vitality and the doped-up drowsiness of sedating substances for true sleep. Consequently, we remain in deep denial about the obvious link between our dependence on substances and the sleep disorders epidemic. It is striking that so few professional treatment programs address sleep aspects of recovery in a meaningful way, leaving their clients vulnerable to failure and relapse.
Even though sleep problems are common among alcoholics, there is little mention of them in the Big Book. There was limited social consciousness about them since they had not yet become a serious concern. Recovering alcoholics at the time had limited options for addressing their sleep struggles. They could use barbiturates, the highly addictive and potentially lethal sleeping pills available at the time or, as I suspect most did, they could just tough it out.
Because it could seriously interfere with one working the program, the excessive daytime sleepiness symptomatic of chronic sleep disturbance had to be managed in some other way. Enter nicotine and caffeine. These two highly stimulating substances could alleviate excessive daytime sleepiness by providing energy, albeit counterfeit, on demand. I believe that smoking cigarettes and drinking coffee became strongly sanctioned practices in AA because of their effectiveness in masking the daytime symptoms of disturbed sleep.
Although they do not alter waking consciousness the way alcohol does, caffeine and nicotine both interfere with melatonin production, damage circadian rhythms and compromise healthy sleep and dreams. At least as compelling is the negative impact of smoking on health. A recent review in the Journal of American Medical Association reported that alcoholics were significantly more likely to die of smoking related illnesses than from diseases associated with drinking. Despite this, many in recovery remain in denial about their dependence caffeine and nicotine. I believe that the habitual use of these substances can both encourage alcohol dependence as well as disrupt the sleep of alcoholics in recovery.
In large part, sleep and substance problems are linked to our damaged relationship to circadian rhythms--to the daily cycle of light and darkness. In nature, light stimulates and energizes us, while darkness facilitates rest and sleep. Light triggers the release of serotonin, which energizes us by day. Dusk and darkness trigger the production of melatonin, the key neurohormone that mediates sleep and dreams. Unfortunately, modern lifestyles significantly limit both our exposure to natural light by day and to dusk and darkness at night.
Beyond the effects of chronic sleep loss, our daytime energy is further compromised by our peculiar tendency to avoid sunlight. The vast majority of us spend the bulk of our waking hours indoors. In fact, the average American adult gets about one hour of natural outdoor light exposure per day. In contrast to this underexposure to light by day, most of us are overexposed to light at night.
Not surprisingly, evening appears to be the most common period of substance and medication use. While many are concerned with trying to slow the frenetic pace of their days, others turn to energizing foods and substances in search of a second wind. Or, often unconsciously, they turn to light. Light can readily functions much like a substance at night providing significant counterfeit energy. Even relatively small amounts of light in the hour or two prior to bed can discourage rest by suppressing melatonin and encourage wakefulness, activity and productivity.
Six Steps to Serene Sleep
To improve sleep, sleep problems must be addressed in a comprehensive way that includes sensitivity to the full range of biological, psychological and environmental factors. Neither does a “one size fits all” approach work. We must personalize our approach to healing sleep. At the risk of appearing to reduce healthy sleep to a formula, which I do not believe is possible, I would like to offer six general recommendations for improving sleep:
- Practice rest. Become more mindful of the ebb and flow your energy throughout the day. When you feel it is running low, instead of relying on counterfeit energies, experiment with allowing yourself a moment of rest. Consider engaging in a brief meditation, contemplation, prayer, or a breathing exercise. Additionally, experiment with developing special rituals for slowing down and resting an hour to before bedtime.
- Get shady and cool as night. Just like the outer world, we need exposure to darkness and we literally need to cool down in order to sleep well. To trigger a natural rise in your melatonin, dim the lights in and around your home for a couple of hours before bedtime. If this is inconvenient, consider using “blue-less light” products that do not suppress melatonin. (See lowbluelights.com) You can use this time for restful activities such as gentle yoga, journaling, meditation, and/or intimate times with friends or loved ones.
- Create a sleep sanctuary. Re-fashion your bedroom so that it does not tether you to the waking world. More specifically, make sure your bedroom is cool, dark, and quiet. And use a HEPA filter to make sure you’re breathing clean air at night. Over time, gradually move toward using more organic or “green” bedding products. Above all, make sure you feel psychologically safe in your bedroom.
- Surrender to sleep. If you depend upon them, gradually relinquish your use of sleep substances. Instead of “taking something to sleep,” consider “letting go of something to sleep.” Begin looking at sleep as part of your spiritual practice. Falling asleep—whether at the beginning of the night or after a middle of the night awakening-—is not an act of will, but one of willingness. I believe the simplest yet the most difficult aspect of getting to sleep is the surrender of one’s volition. We cannot literally “go to sleep” as an act of will. We can, however, let go of our waking sense of self. In doing so, we let go of our ordinary sense of self and, metaphorically, we die. All complexities aside, we come to understand that falling asleep is an act of faith.
- Manage your nighttime wakefulness gently. To minimize difficulties falling asleep, go to bed only when you're feeling sleepy. Once in bed, do not watch the clock. In fact, it's best to get the clock away from your head (it can suppress melatonin) and out of view. Be especially gentle with yourself if you awaken in the middle of the night. To keep your bed from becoming associated with struggles to get back to sleep, get out of bed for a few minutes and sit quietly in a dim or dark space. You can use this time to meditate or pray. Return to bed when you become sleepy.
- Arise with intention in the morning. If awakening is a kind of birth, then morning is the childhood of the rest of our day. Allow yourself to awaken slowly and gradually, being mindful of what we commonly think of as grogginess. Since we usually awaken in the morning from dreams, what we call grogginess is actually an exquisite, hybrid state of dreaming and waking consciousness. Lingering in your grogginess will deepen your connection with dreams. Just allow any dream images to float into consciousness before you get out of bed. Consider journaling your dream experiences.
I believe that people active in alcohol recovery programs could benefit from a firm commitment to improve the quality of their sleep and dreaming. I believe that the practices that support healthy sleep and dreaming are, in fact, consistent with those found in recovery programs. If insomnia or other sleep difficulties persist, however, consider consulting a qualified health care professional.