Alcohol and Sleep Problems in Primary Care Patients: A Report from the AAFP National Research Network

Daniel C. Vinson; Brian K. Manning; James M. Galliher; L. Miriam Dickinson; Wilson D. Pace; Barbara J. Turner

doi:10.1370/afm.1175

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Responses to letters to the Annals of Family Medicine re alcohol and sleep paper
Daniel C. Vinson

Published on: 09 December 2010
The effects of alcohol on sleep.
Aleksandra E Zgierska, MD, PhD

Published on: 25 November 2010
Alcohol use near bedtime
Paul E. Peppard

Published on: 25 November 2010
Alcohol and Insomnia - More Definition Needed
John P. Muench

Published on: 23 November 2010

Published on: (9 December 2010)

Responses to letters to the Annals of Family Medicine re alcohol and sleep paper

Daniel C. Vinson, Columbia, MO

We agree with Dr. Muench. The lack of an association between hazardous and/or harmful drinking and sleep problems was not what we expected to find. Extensive further analyses found only small associations, and only between the frequency of drinking and overall sleep quality, initial insomnia, and late insomnia; and between the AUDIT-C sum with late insomnia (see Table below). These few weak associations found in bivariate analyses were all in the direction of greater alcohol consumption being associated with better sleep quality. In linear regression models controlling for sex, age, and educational attainment, none of the three AUDIT items were significantly associated with insomnia as assessed by initial insomnia, late insomnia, or overall sleep quality when the three AUDIT items were entered one at a time, when all three were entered as separate variables, or when the AUDIT-C sum was entered.

Alcohol variable	Sleep variable	Spearman’s rho	P value
Frequency of drinking	Overall sleep quality	-0.06	0.01
Frequency of drinking	Initial insomnia	-0.05	0.04
Frequency of drinking	Late insomnia	-0.07	0.006
AUDIT-C score	Late insomnia	-0.06	0.008

Dr. Peppard raises important points. We didn’t ask about the timing of drinking, and future research, even if using cross-sectional self-reported data, could explore these issues further.

Drs. Zgierska and Rabago raise concerns about the AUDIT-C misclassifying drinkers, which is indeed possible, as their example illustrates. However, as noted above, further analyses using the AUDIT-C items separately found only weak associations with measures of sleep quality. Their second point is well taken. We did not ask about a past history of alcohol use disorders.

Our study was limited by the design we chose, with a short questionnaire, self-reports of sleep problems (without attempts at confirmation by criterion standards), and use of alcohol screening questions to identify hazardous and harmful drinkers. Misclassification and other biases could have occurred.

Addressing alcohol use remains important in its own right. And our results suggest that in exploring a patient’s concerns about insomnia, a question about using alcohol for sleep may be useful in identifying hazardous and harmful drinking as well as addressing the patient’s main concern.

Competing interests: None declared

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Competing Interests: None declared.

Published on: (25 November 2010)

The effects of alcohol on sleep.
Aleksandra E Zgierska, MD, PhD, Madison, WI, USA
Other Contributors:
In their important cross-sectional study of primary care adult patients, Vinson et al. have carefully addressed a significant clinical and public health issue: the relationship between alcohol consumption and sleep problems.[1] Although this association in patients with alcohol dependence is well documented, the effect of alcohol on sleep in adults without alcohol use disorders is less clear.[2] While Vinson et al. foun...
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In their important cross-sectional study of primary care adult patients, Vinson et al. have carefully addressed a significant clinical and public health issue: the relationship between alcohol consumption and sleep problems.[1] Although this association in patients with alcohol dependence is well documented, the effect of alcohol on sleep in adults without alcohol use disorders is less clear.[2] While Vinson et al. found that hazardous drinkers were 4.5 times more likely to use alcohol as a sleeping aid than moderate drinkers, their analysis did not reveal significant associations between self-reported drinking and measures of insomnia symptoms.
These negative findings deserve cautious interpretation to avoid overselling the perception that alcohol, a commonly used sleeping aid, does not affect sleep. Two factors related to categorization of drinking status could have obscured the presence of a relationship between alcohol consumption and sleep-related problems. The first concerns the scoring rubric. Some drinkers defined as moderate by NIAAA* may have been categorized in this study as hazardous using the AUDIT-C criteria. This would have the effect of removing “higher-dose” patients from the moderate cohort, skewing it towards a lower average dose. For example, a man who consumes 1 drink 4 times/week would be categorized as “hazardous” on AUDIT -C in spite of falling far below the 14 drinks/week identified as “at- risk” by the NIAAA. If the relationship between alcohol and sleep problems follows a dose-response curve, the loss of heavier (though still “moderate” by NIAAA definition) drinkers from the moderate group would make detection of a relationship more difficult. Second, the authors do not state whether the group of non-drinkers included successfully- recovering alcoholics who reported abstinence. Such patients would be more likely to experience sleep problems than non-alcoholics[3] and skew this groups toward worse sleep, thus further decreasing the ability to detect real differences between groups with a given sample size. A larger sample size and/or more precise measures of outcomes of interest may be required to detect such potential associations.
While contributing to our understanding about effects of alcohol use on sleep, the present study does not provide definitive answers. Alcohol consumption prior to sleep can result in impaired daytime performance, even in well-rested people.[5] Sleep deprivation, compounded by alcohol use, may have devastating additive effects, including increased risk for accidents.[2] The authors rightly advocate further research. With alcohol being one of the leading causes of mortality, such research is particularly timely and clinically-relevant.
* National Institute for Alcohol Abuse and Alcoholism
References:
[1] Vinson DC, Manning BK, Galliher JM, Dickinson LM, Pace WD, Turner BJ. Alcohol and sleep problems in primary care patients: A report from the AAFP National Research Network. Ann Fam Med 2010;8:484-492.
[2] Stein MD, Friedmann PD. Disturbed sleep and its relationship to alcohol use. Subst Abus. 2005 Mar;26(1):1-13.
[3] Brower KJ, Aldrich MS, Robinson EAR, Zucker RA, Greden JF. Insomnia, self-medication, and relapse to alcoholism. Am J Psych 2001;1568:399–404.
[4] Rowshan Ravan A, Bengtsson C, Lissner L, Lapidus L, Björkelund C. Thirty-six-year secular trends in sleep duration and sleep satisfaction, and associations with mental stress and socioeconomic factors - results of the Population Study of Women in Gothenburg, Sweden. J Sleep Res. 2010 Sep;19(3):496-503. Epub 2010 Apr 30.
[5] Walsh JK, Humm T, Muehlbach MJ, Sugerman JL, Schweitzer PK. Sedative effects of ethanol at night. J Stud Alc. 1991;52(6):597-600.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (25 November 2010)

Alcohol use near bedtime
Paul E. Peppard, Madison, WI, USA
The excellent article of Vinson and colleagues [1] examining the cross-sectional association of alcohol use and patient- reported sleep in a large primary care patient population found little indication that moderate to “hazardous” alcohol consumption was related to sleep pathology. I would like to comment on one potentially clinically-important aspect of alcohol use patterns that the Vinson et al. study [1] (and previo...
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The excellent article of Vinson and colleagues [1] examining the cross-sectional association of alcohol use and patient- reported sleep in a large primary care patient population found little indication that moderate to “hazardous” alcohol consumption was related to sleep pathology. I would like to comment on one potentially clinically-important aspect of alcohol use patterns that the Vinson et al. study [1] (and previous observational studies of alcohol and sleep) has not been able to address: the possible effects of habitual near- bedtime alcohol use on sleep.
There have been a number of short term (one to a few nights) investigations of the impact of alcohol dose and/or timing on sleep integrity or respiratory stability that have demonstrated disrupted sleep architecture [2] and impaired nocturnal breathing [3,4] resulting from experimentally- consumed alcohol just prior to sleep. Thus, the question remains: despite limited evidence for an observational association of general alcohol consumption and sleep problems, should alcohol use near bedtime be discouraged? While the Vinson et al. study [1] was limited in its ability to answer this question, there was a suggestion in the presented data that acute alcohol use at bedtime may be a highly prevalent exposure: approximately 8% of the patients reported alcohol use to aid falling asleep at least once in the last month. Furthermore, this 8% prevalence of patients “self-medicating” with alcohol as a sleep aide is a lower bound on the overall prevalence of alcohol use near bedtime (i.e., it does not include alcohol use near bedtime that is not intended to assist with sleep initiation).
In patients who consume alcohol near bedtime, problems with sleep may not be recognized and reported. An association of alcohol use and problems with initiating sleep may be suppressed if alcohol is used as an acute sleep aide (i.e., if heavy alcohol users truly have more difficulty falling asleep in the absence of alcohol consumption just prior to bedtime, that association could be masked if further alcohol consumption is used to assist sleep initiation). Additionally, with respect to sleep apnea, if alcohol increases sleep apnea severity in patients who typically drink just prior to bedtime, clinical sleep laboratory- assessed sleep apnea would likely be under-detected because diagnostic polysomnography is likely to occur in an “alcohol free” environment in which alcohol-induced or exacerbated apneas would not be observed. Finally, patients may simply not recognize subtle but important effects of alcohol on sleep quality. Experimental administration of alcohol has been shown to alter sleep architecture, including early- night REM sleep suppression that may be linked to daytime functional decrements [2]. In the Vinson et al article [1], there was a non-statistically significant, but suggestively higher percentage of alcohol-using subjects reporting problems with daytime sleepiness. Compared to nondrinkers, hazardous drinkers had a 25% higher prevalence of “trouble staying awake” in situations where it would be inappropriate to fall asleep such as while driving or eating—27% of “hazardous” drinkers experienced such trouble staying awake in the previous month vs. 21% of non-drinkers; however, hazardous drinkers had only a 3% higher prevalence of sleeping less than 7 hours per night. Thus, patients who drink near bedtime may be experiencing negative functional outcomes of poor sleep quality, even if they do not recognize sleep problems in themselves or have lesser sleep durations (of course, the “excess” sleepiness could be due, in part, to alcohol per se).
Future epidemiologic investigations of the relationship between alcohol and sleep problems would be enhanced by a focus on alcohol consumption just prior to bedtime (whether used as an intentional sleep aide or not), as well as inclusion of broad measures of functional outcomes of poor sleep quality.
[1] Vinson DC, Manning BK, Galliher JM, Dickinson LM, Pace WD, Turner BJ. Alcohol and sleep problems in primary care patients: A report from the AAFP National Research Network. Ann Fam Med 2010;8:484-492.
[2] Smith C, Smith D. Ingestion of ethanol just prior to sleep onset impairs memory for procedural but not declarative tasks. SLEEP. 2003;26(2):185-191.
[3] Scanlan MF, Roebuck T, Little PJ, Redman JR, Naughton MT. Effect of moderate alcohol upon obstructive sleep apnoea. Eur Respir J. 2000;16:909–913.
[4] Mitler MM, Dawson A, Henriksen SJ, Sobers M, Bloom FE. Bedtime ethanol increases resistance of upper airways and produces sleep apneas in asymptomatic snorers. Alcohol Clin Exp Res. 1988;12:801-805.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (23 November 2010)

Alcohol and Insomnia - More Definition Needed
John P. Muench, Portland, OR
It’s clear that screening and brief intervention for alcohol misuse is both important and an effective means to help our patients live healthier lives.(1) It is also clear that it is one of the USPSTF advocated preventive practices that is most infrequently used by physicians.(2) Given the morbidity, mortality, and cost of alcohol abuse in this country, it is imperative that we better understand physician reluctance to...
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It’s clear that screening and brief intervention for alcohol misuse is both important and an effective means to help our patients live healthier lives.(1) It is also clear that it is one of the USPSTF advocated preventive practices that is most infrequently used by physicians.(2) Given the morbidity, mortality, and cost of alcohol abuse in this country, it is imperative that we better understand physician reluctance to discuss alcohol related problems with their patients and what we can do to overcome it.
At our institution, we're in the process of assessing a 3-hour residency curriculum concerning alcohol screening and brief intervention (SBI). Three months after the educational session we send the residents a survey that includes asking what they see to be the greatest challenges to carrying out SBI practices with their own patients. Sixty-six percent, (by far, the greatest number) list as a barrier the “lack of time to address substance abuse issues given the patient's other serious medical problems”. This perceived lack of time has been shown to be a barrier in other surveys as well.(3) Thus, one obvious strategy to overcome physician resistance to address alcohol with their patients is to point out possible associations between many patient presenting problems and use of alcohol.
The current paper by Vinson et. al. directly explored one of these possible associations. From the standpoint of finding ways to encourage alcohol screening, the results are disappointing. It does not appear that we can use the co-occurrence of alcohol misuse and patient complaints of insomnia as a reason to prioritize alcohol screening. The apparent disparity of the results of this study with previous studies is surprising and hard to understand. One possible explanation is that there might be a dose-response curve in which a threshold quantity of alcohol is required to negatively affect sleep patterns. The method used in this study to identify alcohol misuse may not have been sufficiently specific to identify those who drink enough alcohol to affect their sleep patterns. It would be helpful if the authors could revisit their data to assess an association between insomnia and higher AUDIT-C scores. Is there an AUDIT -C score at which insomnia becomes more prevalent? More investigation is needed to understand this association (or lack thereof) with greater clarity and specificity.
(1). Whitlock, E. P., M. R. Polen, et al. (2004). "Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force." Ann Intern Med 140(7): 557-68. (2). Solberg, L. I., M. V. Maciosek, et al. (2008). "Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness." Am J Prev Med 34(2): 143-152. (3). National Center on Addiction and Substance Abuse (2000). Missed Opportunity: CASA National Survey of Primary Care Physicians and Patients on Substance Abuse. New York, Columbia University, CASA.
Competing interests: None declared
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Competing Interests: None declared.