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  • Updated 02.07.2022
  • Released 11.22.1993
  • Expires For CME 02.07.2025

Sleep and alcohol use and abuse

Introduction

Overview

Humans have consumed alcohol for thousands of years. Alcohol ingestion is commonly associated with the feeling of sleepiness, but this drug has contradictory effects on sleep under both acute and chronic use. One population survey in the United States found that half of the respondents had ingested alcohol in the past month (48). Alcohol is often used to self-medicate for mood disorders, pain, and, of course, sleep (43). Alcohol has been shown to shorten sleep latency in those who have rare to occasional alcoholic drinks (76), and this connection introduced the folk medicine concept of the “nightcap” as a sleep aid. Alcohol can produce a variety of issues during sleep, including an increase in snoring and gastroesophageal reflux. However, numerous studies have shown that alcohol is associated with multiple sleep disturbances, and some of these changes can become permanent with chronic alcohol use. Ethanol also appears to have an effect on circadian rhythms and insomnia in abstinent alcoholics, and these common issues increase the risk of relapse of alcohol abuse. Sleep disturbances often increase the risk of alcohol use, and sleep disruption may predict subsequent alcohol abuse. This article reviews the potential usefulness of medication and behavioral therapies for chronic alcohol use and sleep issues.

Key points

• Alcohol can initially have sedating effects on sleep but can disrupt sleep with acute and chronic use.

• Objective and subjective sleep disturbances can occur in the acute phase of ingestion and metabolism of alcohol, yet some long-term effects can be observed several years after drinking has stopped.

• Persistent sleep disturbances are common and are related to the relapse of alcohol abuse.

• Studies have shown that childhood and adolescent sleep disturbance may play a role in future drinking.

• Pharmacological and nonpharmacological treatments (eg, cognitive behavioral therapy for insomnia) have been shown to improve sleep in recovering alcoholics.

Historical note and terminology

Alcohol has long been part of human culture as evidenced by brewed alcoholic beverages found in vessels 9000 years old (49). Although fermentation to produce alcohol has been around for thousands of years, distillation to produce more potent spirits, mainly for medicinal use, came about in the tenth century. Thus, the common name for spirits was deemed aqua vitae (“water of life”). By 1785, the negative effects of alcohol use were being noticed, eg, in Benjamin Rush’s manuscript “Inquiry into the Effect of Ardent Spirits on the Human Mind and Body” (88). Widely used for many purposes, alcohol can have a damaging effect and is associated with roughly 6% to 9% of all deaths (89). Alcohol is often consumed to self-medicate for mood disorders, pain, and, of course, sleep (43). Alcohol consumption is common in the United States. One survey noted that half of the respondents had ingested alcohol in the past month (48). Numerous studies have shown that alcohol is associated with multiple sleep disturbances, and some of these can become permanent with chronic alcohol use.

Alcohol, long recognized for its hypnotic effects, was a staple of early medicine for both analgesic and sedative benefits. Even now, consuming alcohol before bed is used to ease pain, anxiety, or depression and aid in falling asleep, among other ailments (43). Moderate consumption of alcohol, particularly wine, has been associated with a more active lifestyle and a better perception of health in Spanish elderly individuals (38). Other studies showed that even one moderate dose of alcohol at night leaves the individual more tired the next day and that chronic use of alcohol exacerbates several sleep disorders. Thus, the "nightcap," a highly esteemed folk medicine, is in fact a great thief of the night's sleep and the day's alertness. This has been shown repeatedly and in large samples of individuals who consume heavy alcohol weekly (100).

Due to the varied frequency and amount of alcohol consumed in the general public, a variety of terminology distinguishes between typical and pathological alcohol use. In 1819, German physician CW Hufelan used the term “dipsomania” to describe the uncontrollable craving for alcohol or drugs. The term “alcoholism” was credited to Swedish physician Magnus Huss, who first used the term to describe the adverse effects of alcohol; sleep disruption and other mood issues were later associated with the disorder.

Today, the ICD-10 and DSM-V provide distinct criteria for diagnosing disordered alcohol use. The DSM-V includes criteria for alcohol use disorder, which focuses on problematic patterns of alcohol use that lead to clinically significant impairment or distress as manifest by two or more symptoms (out of 11 questions) occurring in a 12-month period (70). One of these questions involves symptoms related to trouble sleeping when alcohol is wearing off. The ICD-10 distinguishes alcohol abuse (F10.1) and alcohol dependence (10.2) from nonpathological alcohol use (F10.09). The ICD-11 classifies the categories into “Episode of harmful use of alcohol,” “Harmful pattern of use of alcohol,” or “Alcohol dependence.” Thus, the latter divides the duration of alcohol use as part of the diagnosis and, thus, may more aptly apply to the differentiating effects on sleep.

An individual who does not meet the criteria for alcohol abuse or dependence but still suffers poor sleep from alcohol intake could be given a diagnosis of “inadequate sleep hygiene” under The International Classification of Sleep Disorders, third edition: Diagnostic and Coding Manual (ICSD-3). This classification system also includes subdivisions of “due to drug or substance” diagnoses for sleep apnea, sleep-related hypoventilation, parasomnias, sleep-related movement disorder, insomnia, and hypersomnia. For insomnia, however, the ICSD-3 acknowledges the difficulty in distinguishing between primary and secondary insomnia because insomnia may precede or become an independent disorder in the context of the drug or substance disorder. Therefore, the ICSD-3 suggests it is inappropriate to use the term “secondary insomnia.” The ICSD also provides the ICD-10-CM coding for substance-induced disorder (eg, F10.xxx-F19.xxx), which contains the codes for substance-induced sleep disorders (01).

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