Alcohol and Sleep: A Cautionary Tale

These days an old friend of mine is sliding deeper into dependence on alcohol. It’s sad and hard to watch. George stays with us twice a year while visiting his family, who live a few miles away. These family visits are fraught with discord. So by 5 p.m. George is often back at our house for the night—wine or whiskey in hand.

New research explains how alcohol dependence causes insomnia that persists for many years after withdrawal.

Alcohol abuse may harm sleep for many yearsThese days an old friend of mine is sliding deeper into dependence on alcohol. It’s sad and hard to watch.

This friend—I’ll call him George –stays with us twice a year while visiting his family, who live a few miles away. These family visits are fraught with discord. So by 5 p.m. George is often back at our house for the night—wine or whiskey in hand.

George suffers terrible insomnia. But you’d never know it during our happy hour, when he comes alive. He’s always ready with a toast to friends whose home, he says, is an oasis of calm next to the turbulence of his family. Toxic family relationships are George’s main topic of conversation during happy hour: his mother, a woman without much warmth whose love her sons still compete for; a bullying older brother; and a sister-in-law who stokes the rivalry already going between the brothers at every opportunity.

Visits in the Past

In the past George’s negative feelings toward his family would eventually work themselves out—helped by the Finian’s—and then he’d get around to asking my husband and me about our lives. George can be a wonderfully attentive listener. He’s also got wide-ranging interests and concerns.

A few years ago he confessed to worrying about the high doses of Ambien he needed to take to get even 3 or 4 hours of sleep. I can attest to the brevity of George’s nights. His room light has been on when I was up for bathroom calls at 1 or 2 a.m. And no sooner am I down the stairs at 5:30 than he’s in the kitchen asking for strong coffee. It doesn’t matter how wasted he feels, he says. Once he wakes up in the morning, it’s impossible to get back to sleep.

On This Visit, Changes

Our happy hour conversation didn’t get very far on George’s recent visit. Each night he glommed onto the family drama and could not let it go. Nor could he stop drinking. One night he drank a beer and then a bottle of Pinot Noir and, just as he was heading toward the pantry for more, my husband and I fled up the stairs, begging off because of tiredness. Really it was the relentless talk about his family we wanted to escape. At midnight I tiptoed downstairs to adjust the heat and there was George, still drinking and talking on the phone.

In the morning, he came down behind me for his coffee. But when I put the water on, he changed his mind: he was going back upstairs for a little more shut-eye, he said.

That’s odd, I thought to myself. Never in all his other visits had George gone back to bed. Once he was up, he was up for good. My hunch was that he’d taken a sleeping pill quite a bit later than usual and, deciding it wasn’t working, got out of bed only to be hit by sudden sleepiness when the Ambien finally kicked in.

Reflecting on the Situation

George’s situation has taken a turn for the worse–there’s no denying it—and this is upsetting enough. But when I consider what lies in store for him, no scenario I can imagine looks good.

Continuing to drink at the level he’s drinking now is compromising his overall health, and plainly it’s hurting his sleep. But new research shows that even if George does someday go in for alcohol treatment, his sleep may be irreparably harmed.

Science Suggests Why

Adenosine is a neurotransmitter important to sleep, and it’s through adenosine that alcohol exerts its effects on the sleep-wake system, say researchers at the University of Missouri, following a series of lab experiments. In rats never before exposed to alcohol, a single dose resulted in the rats falling asleep more quickly and sleeping more deeply. It did this by increasing available adenosine in the rats’ basal forebrain, an area crucial to sleep. In turn, the adenosine suppressed the activity of wake-promoting neurons there, thus promoting sleep.

But in rats habituated to alcohol, withdrawal from alcohol had the opposite effect. It resulted in the rats experiencing significantly more wakefulness during both their activity and sleep periods–behavior that mimics the severe insomnia experienced by humans during acute alcohol withdrawal.

Excessive wakefulness would normally lead to a robust build-up of adenosine in the basal forebrain. But during alcohol withdrawal this did not happen in the rats. Sustained use of alcohol down-regulates the adenosine system and blunts the sleep system, the researchers concluded, making it harder to fall and stay asleep.

Long-Lasting Effects

It’s not just during acute withdrawal that alcoholics experience poor sleep. Clinical studies have shown that sustained withdrawal from alcohol in humans causes insomnia and sleep fragmentation for years to come.

My blog topics are usually more uplifting. But the only word for the story on alcoholism and sleep is bleak. However you choose to manage your insomnia—whether it’s CBT, meditation, sleep aids, alternative treatments or some combination of these–steer clear of alcohol, a harmful soporific close at hand.

Worry, Insomnia and Alcohol

Worry is the most common reason people cite for sleep problems, and worry and sleep disturbance invite the use of alcohol. Worried insomnia sufferers are twice as likely as people without sleep disturbances to become problem drinkers.

But I’ve spoken and corresponded with quite a few people who say an occasional drink or two before bedtime gives them a good night’s sleep. Here’s a look at the effects of alcohol on the brain and differences in how people respond to it.

worry-insomnia-alcoholWorry is the most common reason people cite for sleep problems, and worry and sleep disturbance invite the use of alcohol. About 30 percent of the people with persistent insomnia report using alcohol to get to sleep, and 13 percent take their last drink within 30 minutes of bedtime. Worried insomnia sufferers are twice as likely as people without sleep disturbances to become problem drinkers. (Find links and sources for this blog below.)

The possibility of developing alcohol dependence should give pause to insomniacs who drink, particularly those prone to drinking right before bed. It’s better to abstain within three hours of turning in.

That said, I’ve spoken and corresponded with quite a few people who say an occasional drink or two before bedtime gives them a good night’s sleep. Here’s a look at the effects of alcohol on the brain and differences in how people respond to it.

Under the Influence

Why does alcohol make people sleepy? Not a great deal is known about how and where alcohol acts to promote sleep. At least three key substances are involved.

  1. GABA is the main inhibitory neurotransmitter in the central nervous system, crucial to shutting the brain down at night. When GABA neurons are firing, the lights in the rest of the brain go out. Popular sleeping pills like Ambien and Lunesta work by enhancing the action of the GABA system. Studies have shown that alcohol does, too, especially at low doses.
  2. Glutamate is the main excitatory neurotransmitter in the brain, responsible for keeping us awake and alert. Studies have shown that alcohol interferes with activity at a particular glutamate receptor. This, too, would have a calming effect on the brain.
  3. Adenosine is a substance that affects the signalling of neurotransmitters like GABA and glutamate. In a recent study of alcohol’s effects on rats, alcohol increased the amount of adenosine available in an area of the brain important to sleep and waking. This inhibited the firing of orexin neurons, which are normally active during periods of wakefulness. The sleep-wake system in humans is very similar to that of rats. So the increased levels of adenosine that occur with alcohol use would tend to promote sleep.

Alcohol in People without Sleep Problems

Alcohol has somewhat different effects on insomniacs and normal sleepers. The average person who has a couple drinks before bedtime

  • falls asleep more quickly than usual
  • may sleep more deeply in the first half of the night
  • experiences disrupted sleep in the second half of the night, characterized by prolonged periods of dreaming, light sleep, and wakefulness.

Tolerance to alcohol’s sedative effects develops within three nights. The only way to continue getting the same effects is to increase the amount of alcohol consumed.

Alcohol in People with Insomnia

When insomniacs, who on average get less deep sleep than normal sleepers, drink near bedtime, research shows we

  • fall asleep more quickly
  • get more deep sleep than we normally would, even as much as normal sleepers
  • may not experience disrupted sleep in the second half of the night.

No wonder we head for the Chardonnay when the going and the sleeping get tough. Alcohol tends to improve our sleep at first. But insomniacs, too, habituate in less than a week. Just like normal sleepers, we have to drink more and more to keep getting the same effect and we risk developing alcohol dependence. Also, regular use of alcohol for sleep eventually degrades sleep quality and worsens insomnia.

So if you’ve got persistent sleep problems and you like to drink, use alcohol in the same way you would any other drug with serious side effects: with caution.

How does drinking at night affect your sleep?

References

1) David Armstrong and Alex Dregan, “A Population-Based Investigation into the Self-Reported Reasons for Sleep Problems, PLoS One 9 (2014).

2) C.D. Jefferson et al., “Sleep Hygiene Practices in a Population-Based Sample of Insomniacs,” Sleep 28 (2005): 611-5.

3) R.M. Crum et al., “Sleep Disturbance and Risk for Alcohol-Related Problems,” American Journal of Psychiatry 161 (2004): 1197-203.

4) Timothy Roehrs and Thomas Roth, “Sleep, Sleepiness, and Alcohol Use,” National Institute on Alcohol Abuse and Alcoholism.

5) R. Sharma, P. Sahota, and M.M. Thakkar, “Role of Adenosine and the Orexinergic Perifornical Hypothalamus in Sleep-Promoting Effects of Ethanol,” Sleep 37 (2014): 525-33.

 

Q & A: Be Your Own Sleep Scientist

“What good is keeping a sleep diary,” Lawrence wrote to Ask The Savvy Insomniac recently, “when all it’s going to do is confirm what I already know?”

It might seem pointless—and like a whole lot of bother—to keep a sleep diary when you’ve lived many years with insomnia and know its shape and contour like the back of your hands. But I think it’s a valuable investigative tool.

sleep scientistWhat good is keeping a sleep diary, Lawrence wrote to Ask The Savvy Insomniac recently, when all it’s going to do is confirm what I already know? Insomnia is my problem—I’m lucky if I get 5 hours a night. Exactly how am I going to benefit if I find out that Monday night I slept 4 hours and 45 minutes and Tuesday I slept 6 minutes less? A colossal waste of time that I can see. Besides, clock watching tends to make my insomnia worse.

It might seem pointless—and like a whole lot of bother—to keep a sleep diary when you’ve lived many years with insomnia and know its shape and contour like the back of your hands.

But I think it’s a valuable investigative tool. Not only can keeping a sleep diary give you a more realistic picture of how much and how soundly you sleep. It can also help you zero in on habits that may be interfering with—or helping—your sleep. You can then adjust your habits accordingly.

How a Sleep Diary Works

The American Academy of Sleep Medicine has a good sleep diary that you can download here. The task is to keep the diary for two weeks, noting every day when you do the following:

  • Go to bed (Don’t look at the clock after going to bed)
  • Sleep (Estimate the time you fall asleep), including time spent napping
  • Take medicine
  • Drink beverages with caffeine
  • Drink alcohol
  • Exercise.

You might also want to note how well rested you feel each morning.

Results

Tracking these variables over a two-week period may reveal quite a lot. In addition to discovering what your average total sleep time is (which may or may not be surprising), you might find that drinking a second cup of coffee at noon is OK, but a second cup at 2 p.m. tends to keep you up too late. Or you might discover that exercise helps you sleep more soundly. I did.

Now to be really scientific about this, you’d have to test these variables one at a time. One week, keep a sleep diary and vary the amount or timing of the caffeine you drink. The next week, vary the amount or timing of the alcohol. And so forth.

But for me personally, since I’m mostly a creature of habit, the amount and timing of the things I do doesn’t vary all that much from one day to the next. It’s the activities and habits that DO vary that may afford insight into how to avoid insomnia and improve your sleep.

Getting scientific about things can sometimes help.

Have you ever tried keeping a sleep diary? What, if anything, did you learn?

Q & A: A Nightcap to Woo Sleep?

A woman wrote to Ask The Savvy Insomniac about using alcohol to get to sleep.

The nightcap comes with caveats for both good sleepers and people with insomnia. I’ll offer the official story and then my take.

A woman wrote to Ask The Savvy Insomniac about using alcohol to get to sleep.

“Whenever I can’t sleep,” she wrote, “I drink a couple glasses of wine and then I’m out. But people on these websites are always saying you shouldn’t, you shouldn’t, and I don’t believe them. I DON’T drink every night, I am NOT an alcoholic. It puts me out and I get a decent night’s sleep, so what’s the big f**king deal?”

I can so relate to the exasperation this woman feels. People with insomnia get a lot of advice thrown our way, and much of it is negative. Don’t watch TV in bed, don’t drink coffee, don’t stay in bed unless you’re asleep. Don’t, don’t, don’t. I get sick of being told to forgo so many things that normal sleepers can enjoy at no cost to their sleep.

But the nightcap comes with caveats for both good sleepers and people with insomnia. I’ll offer the official story and then my take.

Effects of Alcohol on Sleep

Alcohol is good at putting people to sleep: it may even deepen your sleep at the beginning of the night, experiments have shown. But the body eliminates the alcohol in four to five hours, creating problems in the second half of the night. To compensate for the altered sleep in the first half, the brain engages in a riot of REM sleep (when dreams occur), light sleep, and wakefulness. So while alcohol puts people out in the beginning, it interferes with sleep later on.

Habituation

But the big problem with using alcohol to get to sleep has to do with tolerance, which develops quickly if you use it every night. Experiments on healthy sleepers have shown that whatever benefit alcohol affords–getting to sleep more quickly, for one–is lost within three days. The only way to keep getting the benefit is to increase the dose. Doing this, you set yourself on the path to dependency.

Insomniacs, too, habituate quickly. A pair of unpublished experiments conducted by sleep researcher Timothy Roehrs and colleagues in the Henry Ford Health System show that tolerance to alcohol taken at bedtime develops in insomniacs in less than a week. And a recent survey found that while hazardous drinking was not correlated with any particular measure of insomnia, it is strongly correlated with using alcohol to get to sleep.

Alcohol is a bad choice as a soporific for these reasons, and nobody can really dispute this. The experts advise avoiding alcohol in the three hours leading up to bedtime.

Occasional Use

But two glasses of wine on an occasional basis? No modern-day physician would recommend it (although plenty did in the past), but I’m more of a libertarian when it comes to individuals taking charge of our health. Many of us have better judgment than we get credit for, I think. Yes, we should pay attention to the studies and use caution when drinking alcohol, especially right before bedtime. But we also ought to feel comfortable going with what works.

A lot do’s and don’ts get tossed out to poor sleepers, and it’s good to be able to filter out the noise.

Have you ever used alcohol to get to sleep? How did/does it make you feel?

Alcohol and Sleep Problems in Primary Care Patients

Drinking to Get to Sleep

The story on alcohol and sleep is complicated. About 10 to 14 percent of adults in the United States use alcohol as a sleep aid. While it generally degrades the quality of sleep, the use of alcohol does not predict the development of persistent insomnia, say the authors of a large longitudinal study published in January 2012 in the journal Sleep. But—and here’s the troubling part—twice as many insomniacs become problem drinkers as people who sleep well.

Here is one woman’s story of how alcohol led to trouble sleeping and insomnia.

Insomnia more likely when relying on alcohol for sleepI mentioned to a gastroenterologist that I was writing a book about insomnia.

“Alcohol,” he said in response. “If you want to understand insomnia, look at alcohol and coffee.” His assumption that alcohol and coffee are causal factors in insomnia is widely held, and eventually I checked it out.

The story on alcohol and sleep is complicated. About 10 to 14 percent of adults in the United States use alcohol as a sleep aid. While it generally degrades the quality of sleep, the use of alcohol does not predict the development of persistent insomnia, say the authors of a large longitudinal study published in January 2012 in the journal Sleep. But—and here’s the troubling part—twice as many insomniacs become problem drinkers as people who sleep well.

Marilynn’s Story of Sleep and Alcohol

“Insomnia’s been a problem since I was very young,” Marilynn told me in an interview. “Unless the house was totally dark and quiet, I couldn’t sleep.” At her house those conditions were hard to come by. Her parents “always partied on the weekend, and very, very frequently during the week. It was just a noisy house.” The TV was always on, blasting away because her father was deaf in one ear. At parties the booze flowed freely. “In our house the bar was a shrine.”

“I remember my mom having bridge club and somebody letting me taste their creme de menthe,” she said. Marilynn was 9.  “So I just helped myself one night when the babysitter was upstairs and I was downstairs at the bar. I remember taking a glass …  and filling it with creme de menthe and thinking I was going to be sick to my stomach. But I also remember waking up the next morning and walking into this horrendous mess (from the party) downstairs. And I thought, ‘I slept through this. That stuff helped me sleep.’”

Marilynn dipped into the liquor cabinet occasionally for help in sleeping through the parties and her parents’ loud fights. Then in high school she learned about the dangers of drinking and stopped. But her problem with sleep continued unabated. Several years later she raised the sleep issue with her ob/gyn. “He suggested drinking a glass of red wine at night. He said two would be OK, too. And it worked for quite a while.”

Developing Tolerance

Then she found herself needing to increase the amount. To the wine she added a whiskey chaser. This, too, worked for a while. But by the mid-1990s, her drinking was out of control. She was hiding bottles from her husband and doing strange things at night.

“I wasn’t going to sleep,” Marilynn said. “I was passing out. I didn’t know then that I was also getting up.”

But her husband knew, and he was hiding the evidence. Then one morning Marilynn went down to the kitchen and found barley soup splattered all over the kitchen cupboards.

“’Who made this mess?’” she recalled shrieking at her husband. She had, he told her, and similar things had happened before.

“I had no recollection,” she said. “As far as I was concerned, I had slept through the night.” Around the same time, Marilynn lost her teaching job. She realized then that she had to get help, and she got it through AA. But while she’s given up drinking, her insomnia persists.

“I think it’s kept me very scattered, disorganized and unambitious. It’s been very, very limiting,” she said. “Definitely, absolutely, it’s what led to my problem with alcohol.”

Sleep problems are no trivial matter, as the link between insomnia and the higher rate of alcoholism suggests. If you’re going to imbibe, say the experts, do it early in the evening. But if you’re looking for a sleep aid, you’d be wise to choose something else.