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Please Read about sleep in Recovery from Dr Kevin McCauley, M.D.
Kevin T. McCauley, M.D.
Insomnia in Early Recovery
“You’ll never die from lack of sleep!”
You might hear this if you are new in recovery and having trouble sleeping. If you
do, I apologize. That statement is not only wrong, it is cruel. Insomnia is genuine
suffering. The patient is awake, night after night, and then drowsy in the daytime,
snoozing in group therapy and often given “check marks” or “write ups” by treatment
center staff for “not participating.”
I never hassle people who sleep in my lectures. And why is that? Well, there are a
number of reasons. I may in fact, be boring, but mainly because insomnia is a normal
symptom of being newly sober. It is one of the outward signs that the brain is slowly
repairing itself. I expect to see it, and getting angry with a patient who manifests a normal
symptom of being newly sober is a bit like getting angry with a heart attack patient
because they had some chest pain. Doctors do not get mad at patients for manifesting
normal symptoms of their disease. It is dumb.
Lack of sleep may not kill the patient, but insomnia - left unchecked - can lead to
relapse – and that can kill the patient, or at least lead to a negative outcome that could
have been prevented. Insomnia in the newly abstinent patient is something that I take
very seriously. Insomnia is an especially severe problem for newly sober heroin addicts.
To dismiss the patient’s suffering with a snappy and dangerous remark is to invite that
patient to relapse. It is the responsibility of the clinician to provide tools that the patient
can use to cope with their sleep disorder. Having said that - it is the responsibility of the
patient to use those tools.
If all you do for treatment is handcuff the patient to a radiator and bring them
Jack-in-the-Box twice a day for three months, believe it or not, by the end of that
“treatment” you will see some improvement in the patient’s addiction. However, when
you come to unlock them they will stab you to death with that little plastic fork they give
you to eat the apple pie. The reason for this overall improvement is that the brain will
repair itself to some degree in that three months, and the symptoms of Post-Acute
Withdrawal Syndrome will abate just with time sober alone. The point of treatment for
addiction is to support that healing – not screw it up.
You see, for every brain cell we have got – every neuron that helps us do our
thinking – we have two caretaker cells. That is right, the bulk of our brain mass is
essentially cells that are janitors – they clean up debris, repair connections, and help the
thinking cells restore the natural balance of neurochemicals. The minute the addict puts
down the bottle or the pipe or the needle, those cells go to work. Just in the five minutes
that the addict takes to read this essay, repair has occurred. The trick of treatment is to get
the addict as far out from their last episode of drug use as possible so that the maximal
amount of repair can occur. This way the newly sober addict stands a better chance of
developing the short-term coping skills that will carry them into long-term sobriety.
I know you have heard that drugs will destroy your brain. I know you have seen
the commercial with the egg in the frying pan, “This is your brain, this is your brain on
drugs, any questions?” Ha ha, very funny. But generally what we see when addicts put
together long-term sobriety is not a bunch of sober imbeciles, but people who get their
memories and their attention and their thinking back. The brain heals. So the commercial
Kevin T. McCauley, M.D.
is only telling you half the story. If it stays sober, the egg can un-fry, hop out of the frying
pan back into its’ shell and get on with its’ life.
Sleep, I am happy to tell you, is one of the first things to come back on-line as the
brain repairs itself. Generally, between 60 to 90 days of sobriety (and often quicker if the
patient is working Steps) I see patients experience what I call a “Perfect Night’s Sleep.”
What is a “Perfect Night’s Sleep?” Well, it looks like this: the patient turns out the light
and puts their head on their pillow at 11 p.m., they are asleep by 11:03 p.m., they sleep
exactly 7.5 hours without waking up in the middle of the night, they wake up
spontaneously, without an alarm clock, refreshed and ready to take on the day. An
afternoon nap is a nice treat, but it is not critical for functioning. That is a “Perfect
Night’s Sleep” and guess what? That is the way most people sleep! That is the way most
people sleep every night and do not give it another thought. But very often the addicted
patient has been struggling with sleep their whole life. And so when they experience a
“Perfect Night’s Sleep” right around 60 – 90 days of sobriety it can be a deeply emotional
experience. Then, the next week they get another “Perfect Night’s Sleep.” And the next
week - maybe two in row. By six to nine months of sobriety, the sleep problem is in the
box. The resolution of insomnia is one of the first rewards of sobriety that is waiting for
the addict – if they can just get some time away from drugs and alcohol.
This is why it is critical to avoid running to a sedative/hypnotic drug to manage
insomnia in the addicted patient. Once detox is finished, and the addict is still
experiencing insomnia, behavioral tools – things like “Sleep Hygiene” - are preferred
over a prescription for Valium, or Ambien, or Sonata, or whatever for sleep disorders.
We want to minimize the addict’s risk of relapse secondary to insomnia, yes, but we also
want the brain to heal. So we use behavioral tools, not pharmacological tools. These
behavioral tools are equally effective at promoting sleep as the sedative/hypnotic drugs –
they are just not quite as quick and easy as taking a pill.
You see, ninety percent of the time if a patient is suffering from simple insomnia,
the doctor can prescribe one of these drugs for short-term relief and everything will be
just fine. The patient takes the medication at bedtime - exactly as directed. The
medication works perfectly. The patient’s sleep disorder resolves and the remaining pills
go stale in the patient’s bathroom cabinet over the next ten years – never touched again.
In nine out of ten patients you can do this and there is nothing to worry about. It is the
tenth patient – the addict - that has trouble. For these patients something other than
medications must be used.
Now this is where “Sleep Hygiene” comes in. Personally, I do not like the word
“Hygiene” because it implies that the patient with insomnia is somehow “Sleep Dirty.”
And I do not like “Sleep Discipline” either. But Sleep Hygiene is a form of structured
behaviors that, if practiced will clear up most sleep disorders, without medications. They
work in non-addicted patients and addicted patients alike, but because of the danger of
relapse in the addict with prescription medications they are especially important. I must
tell you, they are not easy – certainly not as easy as taking a pill – but they do work.
To learn Sleep Hygiene best, I recommend that you find a doctor that is an expert
in sleep disorders, undergo a sleep study, and work out a plan with that doctor that is
right for you. If that is impractical right now, they you might start with two books (yes, I
know, more books! Listen, I don’t have stock in Amazon.com, there really is a legitimate
reason for all these books. It is called bibliotherapy, and hey, twenty dollars for a book is
Kevin T. McCauley, M.D.
a lot cheaper than $2000 for an inpatient detox). The first is The Promise of Sleep, by
William Dement, M.D., Ph.D., and the second is Desperately Seeking Snoozin’ by John
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