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  • Updated 10.01.2023
  • Released 09.14.2000
  • Expires For CME 10.01.2026

Stimulant-dependent sleep disorder



Most CNS stimulant substances have adverse effects on sleep, resulting in sleep fragmentation, insomnia, and sometimes rebound hypersomnia. Individuals may take these stimulants to improve specific aspects of mood or performance or to compensate for sleep deprivation or other fatigue-causing disorders. Although stimulants may work through a variety of mechanisms, each has an effect on sleep. Thus, an understanding of the underlying pathophysiology may lead to more directed treatment of stimulant-dependent sleep disorder. Traditional stimulants, such as amphetamines, work through increasing wake-promoting catecholamines, whereas caffeine blocks sleep-promoting adenosine receptors. Each of these are associated with side effects. Newer CNS stimulants used for the treatment of residual daytime sleepiness and narcolepsy, such as pitolisant and solriamfetol, augment other monoamines and are associated with fewer adverse effects. The management of disorders resulting from the use of stimulants is focused on understanding overall treatment goals and limiting untoward side effects.

Key points

• CNS stimulants used for treatment of hypersomnia, excessive daytime sleepiness, and other neuropsychiatric disturbances, as well as abuse of substances that have CNS stimulant action, may cause insomnia.

• Withdrawal of stimulants is frequently associated with an increase in sleepiness that is most pronounced in the first 2 to 9 days but may persist.

• Chronic abstinence from stimulants may be associated with sleep disorders, including drowsiness.

• Chronic abstinence from cocaine may lead to “occult insomnia” or an ongoing sense of fatigue.

• Understanding the mechanisms of rebound hypersomnia may help improve efficacy and reduce adverse effects of CNS stimulant medications.

• Although there is no established approach to the management of stimulant-dependent sleep disorders, understanding the reasons for use of the stimulants, underlying treatment goals, and optimization of drug timing may improve symptoms.

Historical note and terminology

Amphetamines, as a drug, were originally discovered in the late 1920s and used over the next decades as a mood elevator, diet medication, and mechanism for improving attention. This substance was felt to improve attention and was used extensively in World War II to combat fatigue. The drugs were widely used for nonmedical reasons and were soon recognized for their abuse potential. By the 1970s, amphetamines came under more strict control.

Caffeine, on the other hand, is a natural substance produced by some plants in temperate climate to stave off attacks from insects. The substance is found to have positive effects for humans and has been consumed for thousands of years. An ancient Chinese legend states that Emperor Shen Nung first discovered tea in 2437 BCE when leaves blew into his boiling water. Coffee appears to derive from the Ethiopian Peninsula where, in the 9th century, a goat herder, Kaldi, found his sheep would not sleep after consuming coffee berries. Kaldi made a drink from the berries that was the predecessor of today’s coffee. Even then, the benefits of improving alertness were noted; higher doses have long been known to have deleterious effects on sleep.

Stimulant-dependent sleep disorder, recognized in the ICD-10, was originally defined as a "reduction of sleepiness or suppression of sleep by CNS stimulants and resultant alterations in wakefulness following drug abstinence.” Many forms of medications, recreational drugs, and other widely used substances may produce sleep disturbances either during periods of use or on withdrawal. According to the International Classification of Sleep Disorders, 3rd edition, (ICSD-3) "sleep disorders resulting from a drug or substance" can result in the following issues: (1) central sleep apnea; (2) sleep-related hypoventilation; (3) central disorders of hypersomnolence; (4) insomnia; (5) parasomnia; and (6) sleep-related movement disorders (02). Under either definition, the drug or substance can be a prescription medication, recreational drug, caffeine, alcohol, or food item. For stimulants, the most common sleep issue is insomnia, and the ICSD-3 includes “insomnia due to drugs or substances.” Insomnia complaints may arise either during the use of these substances or following their discontinuance. The ICSD-3 description of chronic insomnia recognizes that some classifications of insomnia use the term “secondary insomnia,” attributing the symptoms to substance abuse or withdrawal. Similarly, the ICSD-3 diagnosis of “Hypersomnia due to medication or substance” also includes the induction of sleepiness related to the withdraw of stimulants. No matter the terminology, the effect of stimulants on sleep is broadly accepted across the major classification systems.

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