A review of sleep disturbance in adults prescribed medications for opioid use disorder: potential treatment targets for a highly prevalent, chronic problem

Phase 1b/2a safety study of lemborexant as an adjunctive treatment for insomnia to buprenorphine-naloxone for opioid use disorder: A randomized controlled trial

Background

Evidence supports the common incidence of sleep disturbance in opioid use disorder (OUD) as a potential marker of disrupted orexin system functioning. This study evaluated the initial safety and tolerability of a challenge dose of lemborexant, a dual orexin antagonist, as an adjunct to buprenorphine/naloxone.

Methods

Patients (18-65 years old) with OUD receiving sublingual buprenorphine/naloxone, with a Pittsburgh Sleep Quality Index total score of 6 or higher, were recruited from outpatient clinics. After randomization, while being monitored on an inpatient research unit over two 10-hour daytime periods, participants received a placebo or lemborexant (5 mg on day one and 10 mg on day two) along with buprenorphine/naloxone. Primary outcomes included safety and tolerability: adverse events, physiologic measures, sedation level assessments. Generalized linear mixed model analysis assessed the effect of study drug and time on outcomes.

Results

N=18 (14=male, 4=female) were randomized to lemborexant (n=12) or placebo (n=6). No unanticipated problems occurred; five adverse events occurred in the lemborexant group and two in the placebo group with no serious adverse events. None of the physiologic measures showed a significant interaction of time and placebo vs. lemborexant (5 or 10 mg): Pulse oximetry (F=0.6; p=0.84), End-tidal CO2 (F=0.5; p=0.91), Heart rate (F=0.6; p=0.82), Systolic blood pressure (F=0.7; p=0.73), Diastolic blood pressure (F=2.0; p=0.06). At 9 hours after study drug administration, all participants returned to baseline sedation levels and were discharged.

Conclusions

Findings support the initial safety and tolerability of lemborexant as an adjunctive treatment for insomnia in humans receiving buprenorphine for OUD. Future longitudinal work is warranted with larger samples.

Associations Among Sleep, Pain, and Medications for Opioid Use Disorder: a Scoping Review

Purpose of Review

We present current evidence on the associations among sleep, pain, and medications for opioid use disorder (MOUD) among individuals with opioid use disorder (OUD).

Recent Findings

We searched MEDLINE, Embase, PsycInfo, Web of Science, and Cochrane Library from inception until September 2023 for original research studies examining sleep, pain, and MOUD. We identified 19 manuscripts (14 were cross-sectional studies, four were prospective cohort studies, and one was a randomized controlled trial). Measures of sleep and pain varied. Sleep disturbance and pain were highly prevalent and associated. However, the associations between MOUD treatment characteristics (e.g., initiation, type, dose, and prior MOUD) and a) sleep and b) pain were mixed or unclear. Limited sample sizes and covariates such as opioid use disorder severity sometimes complicated the examination or interpretation of these associations. Few studies examined possible mediators underlying these associations.

Summary

While sleep and pain were consistently associated, it is unclear whether sleep and pain are associated with MOUD treatment characteristics or other covariates such as opioid use disorder severity. Future research on the associations among sleep, pain, and MOUD among individuals with OUD should consider a) comparing different MOUD treatments including formulations and dose schedules, b) qualitative and mixed methods studies to assess patient and provider preferences for the treatment of sleep and pain in OUD treatment settings, c) longitudinal studies that employ reliable and valid measures with sufficiently powered sample sizes to examine mediation and moderation, and d) testing whether interventions addressing pain or sleep among patients receiving MOUD improve pain, sleep, and MOUD outcomes.

Sleep apnea syndrome in patients with methadone or buprenorphine

OBJECTIVES

This work aimed to assess the association between sleep apnea syndrome (SAS) and opioid substitution treatments (OST) dose/timing of administration in patients receiving methadone or buprenorphine for an opioid use disorder (OUD).

METHODS

We conducted a retrospective cross-sectional study by including files of adult patients treated between November 2015 and January 2023 with methadone or buprenorphine and who had a nocturnal respiratory polygraphy. We collected information on treatments and polygraphical recording data such as the apnea-hypopnea index (AHI).

RESULTS

We enrolled 60 patients on methadone and 15 on buprenorphine. The sample encompassed 72% of males, and the mean age was 36±7.49years. Moderate to severe and severe SAS were significantly associated with the daily dose and the evening administration but was not predicted by the type of OST. However, the mean and median values of AIH were significantly greater with methadone. Contrary to methadone, there was no significant correlation between the buprenorphine daily dose and the AHI. The best sensitivities and specificities for the prediction of an AHI≥15 events/h and an AHI≥30 events/h were respectively obtained with methadone dose thresholds of 77.5mg/day.

CONCLUSIONS

In this sample, the methadone daily dose of 77.5mg was the best cut-point to predict moderate to severe SAS, especially while taken in the evening, and we found no correlation between buprenorphine and the AHI. These results draw clinicians' attention to buprenorphine use as an alternative for patients treated with methadone and having SAS.

Association between sleep problems and impulsivity mediated through regional homogeneity abnormalities in male methamphetamine abstainers

Sleep problems and impulsivity frequently occur in methamphetamine (MA) abstainers and are linked to aberrant brain function. However, the interplay between these factors remains poorly understood. This study aimed to investigate the relationship between sleep, impulsivity, and regional homogeneity (ReHo) through mediation analysis in MA abstainers. 46 MA abstainers and 44 healthy controls were included. Impulsivity and sleep problems were evaluated using the Barratt Impulsivity Scale and the Pittsburgh Sleep Quality Scale, respectively. ReHo, indicative of local brain spontaneous neural activity, was assessed using resting-state functional magnetic resonance imaging. Results unveiled correlations between different dimensions of impulsivity and ReHo values in specific brain regions. Motor impulsivity correlated with ReHo values in the left postcentral gyrus and left precentral gyrus, while non-planning impulsivity was only associated with ReHo values in the left precentral gyrus. Additionally, the need for sleep medications correlated with ReHo values in the left precentral gyrus and bilateral postcentral gyrus. Also, the need for sleep medications was positively correlated with cognitive impulsivity and motor impulsivity. Mediation analysis indicated that reduced ReHo values in the left precentral gyrus mediated the association between impulsivity and the need for sleep medications. These findings imply that addressing sleep problems, especially the need for sleep medications, might augment spontaneous neural activity in specific brain regions linked to impulsivity among MA abstainers. This underscores the importance of integrating sleep interventions into comprehensive treatment strategies for MA abstainers.

Post-traumatic stress disorder symptomatology is associated with insomnia among women engaged in opioid use disorder treatment with buprenorphine

This study aimed to explore the association between the degree of PTSD symptomatology and severity of insomnia symptoms in a clinical sample of women receiving buprenorphine for OUD. PTSD symptomatology was assessed via the PCL-5, and insomnia symptoms were determined via the Insomnia Severity Index. Analyses indicated that more participants experiencing clinically significant PTSD symptomatology also reported insomnia symptoms than their counterparts. Future work should investigate how holistic care (e.g., trauma-informed approaches) that addresses the overlap between trauma and sleep disturbance could inform gender-specific OUD treatment strategies in the overdose crisis.

Methadone Dose and Timing of Administration as Predictors of Sleep Apnea Syndrome During Methadone Maintenance Treatment: A Retrospective Cross-sectional Study

Background

This study aimed to assess the association of sleep apnea syndrome (SAS) with methadone dose and timing of administration in patients receiving methadone maintenance treatment (MMT) for opioid use disorder (OUD).

Methods

This retrospective cross-sectional study was conducted on adult patients receiving MMT who had a nocturnal respiratory polygraphy between November 2015 and December 2021. Data on methadone treatment and polygraph recording, including the apnea-hypopnea index (AHI) were collected.

Findings

A total of 40 patients, mostly male (72.5%), with a mean age of 35±6.7 years and a mean body mass index (BMI) of 25.1±4.5 kg/m2 were included. The daily dose of methadone was significantly associated with an AHI≥15 events/h as well as an AHI≥30 events/h, even after adjustment for age, gender, BMI, and benzodiazepine use. However, these associations were not preserved when the time of administration (day vs evening) was considered, while the evening administration was significantly associated with an AHI≥15 events/h. The best sensitivity and specificity for the prediction of AHI≥15 events/h and AHI≥30 events/h were obtained with daily methadone doses of≥72.5 mg and 77.5 mg, respectively.

Conclusion

In this sample of MMT patients, methadone doses of 72.5 mg and 77.5 mg were the best cut-off values for predicting AHI≥15 and≥30 events/h, respectively, especially when taken in the evening. These results should draw clinicians' attention to the importance of SAS screening, and further studies are needed, notably comparisons with buprenorphine.

Patient reported preferences for sleep interventions among women receiving buprenorphine for opioid use disorder

Aim

Among individuals receiving medication for OUD (MOUD), insomnia is highly prevalent and increases the risk for negative OUD outcomes. However, little is known about MOUD patient-reported preferences for insomnia treatments among women with OUD. This mixed-methods study explored acceptability of and patient preferences for sleep interventions among women in OUD treatment.

Methods

This is an analysis from an ongoing cross-sectional survey and interview study investigating the relationship between sleep and OUD recovery. The parent study is actively enrolling non-pregnant women between 18-45 years stabilized on buprenorphine from an outpatient program. Participants complete measures including the Insomnia Severity Index (ISI), with scores of ≥10 identifying clinically significant insomnia symptoms. A sub-sample who met this threshold completed semi-structured interviews. Descriptive statistics were generated for survey responses, and applied thematic analysis was used for interview data.

Results

Participants selected for the qualitative interview (n = 11) highlighted prior positive and negative experiences with sleep treatments, challenges with employing non-pharmacological sleep strategies, and preferences for both medical and behavioral sleep interventions while in recovery. Women emphasized the need for flexibility of sleep therapy sessions to align with ongoing social determinants (e.g., caregiving responsibilities) as well as for sleep medications without sedating effects nor risk of dependency.

Conclusions

Many women receiving MOUD have concomitant insomnia symptoms, and desire availability of both pharmacologic and behavioral sleep interventions within the OUD treatment setting. Qualitative findings underscore the need for evidence-based sleep interventions that account for the unique socioenvironmental factors that may impact strategy implementation in this population.

Benzodiazepine, Z-drug, and sleep medication prescriptions in male and female people with opioid use disorder on buprenorphine and comorbid insomnia: an analysis of multistate insurance claims

STUDY OBJECTIVES

In adult populations, women are more likely than men to be prescribed benzodiazepines. However, such disparities have not been investigated in people with opioid use disorder (OUD) and insomnia receiving buprenorphine, a population with particularly high sedative/hypnotic receipt. This retrospective cohort study used administrative claims data from Merative MarketScan Commercial and MultiState Medicaid Databases (2006-2016) to investigate sex differences in the receipt of insomnia medication prescriptions among patients in OUD treatment with buprenorphine.

METHODS

We included people aged 12-64 years with diagnoses of insomnia and OUD-initiating buprenorphine during the study timeframe. The predictor variable was sex (female versus male). The primary outcome was receipt of insomnia medication prescription within 60 days of buprenorphine start, encompassing benzodiazepines, Z-drugs, or non-sedative/hypnotic insomnia medications (e.g. hydroxyzine, trazodone, and mirtazapine). Associations between sex and benzodiazepine, Z-drug, and other insomnia medication prescription receipt were estimated using Poisson regression models.

RESULTS

Our sample included 9510 individuals (female n = 4637; male n = 4873) initiating buprenorphine for OUD who also had insomnia, of whom 6569 (69.1%) received benzodiazepines, 3891 (40.9%) Z-drugs, and 8441 (88.8%) non-sedative/hypnotic medications. Poisson regression models, adjusting for sex differences in psychiatric comorbidities, found female sex to be associated with a slightly increased likelihood of prescription receipt: benzodiazepines (risk ratio [RR], RR = 1.17 [1.11-1.23]), Z-drugs (RR = 1.26 [1.18-1.34]), and non-sedative/hypnotic insomnia medication (RR = 1.07, [1.02-1.12]).

CONCLUSIONS

Sleep medications are commonly being prescribed to individuals with insomnia in OUD treatment with buprenorphine, with sex-based disparities indicating a higher prescribing impact among female than male OUD treatment patients.

Effects of polyphenol-rich interventions on sleep disorders: A systematic review and meta-analysis

Epidemiology studies have indicated that polyphenol consumption was more likely to have higher sleep quality, but some results remain controversial. A general overview of polyphenol-rich interventions on sleep disorders still lacks in the existing literature. Eligible randomized controlled trials (RCT's) literature retrieval was performed in six databases. Sleep efficiency, sleep onset latency, total sleep time, and PSQI were included as objective measures to compare the effects of placebo and polyphenols in patients with sleep disorders. Subgroup-analyses were performed based on treatment duration, geographic location, study design, and sample size. The mean differences (MD) with 95% confidence intervals (CI) were adopted for four continuous variable data of outcomes in pooled analysis. This study is registered on PROSPERO, number CRD42021271775. In total, 10 studies of 334 individuals were included. Pooled data demonstrated that administration of polyphenols decreases sleep onset latency (MD, -4.38 min; 95% CI, -6.66 to -2.11; P = 0.0002) and increases total sleep time (MD, 13.14 min; 95% CI, 7.54 to 18.74; P＜0.00001), whereas they have no effect on sleep efficiency (MD, 1.04; 95% CI, -0.32 to 2.41; P = 0.13) and PSQI (MD, -2.17; 95% CI, -5.62 to 1.29; P = 0.22). Subgroup analyses further indicated that treatment duration, study design, and number of participants appeared to be responsible for the largest proportion of accountable heterogeneity. Polyphenols' potential importance is highlighted by these findings in treating sleep disorders. The development of large-scale, randomized, controlled trials is recommended to providing further evidence for therapeutic use of polyphenols in a variety of sleep difficulties.

Sleep and substance use: Practice considerations for social workers

Poor sleep health is consistently associated with the initiation of substance use, development of substance use disorders (SUDs), dropout from treatment, and return to use. Quality sleep health holds promise as a modifiable factor that can reduce the occurrence and severity of SUDs. Unfortunately, social workers typically receive little to no training in the assessment and evidence-based treatment of sleep disorders. This article, authored by an interdisciplinary team of clinicians and researchers, provides important sleep and SUD considerations for social workers. After providing a summary of the empirical literature surrounding the relationship between sleep and SUDs, we discuss the inclusion of the following in SUD treatment settings: (1) sleep health assessments, (2) psychoeducation on behaviors to promote healthy sleep, (3) referral to appropriate specialists when sleep disorders are suspected, (4) the promotion of a healthy sleep environment in residential treatment settings, and (5) evidenced-based behavioral interventions.

Associations between insomnia and central sensitization in cancer survivors undergoing opioid therapy for chronic cancer pain: A STROBE-compliant prospective cohort study

Several risk factors for insomnia in cancer patients have been recognized, including chronic pain and treatment with opioid. Although associations between insomnia and central sensitization were previously reported in patients with chronic non-cancer pain, those have not been elucidated among cancer survivors undergoing opioid therapy for chronic cancer pain. To investigate the associations between insomnia and central sensitization among cancer survivors undergoing opioid therapy for chronic cancer pain, consecutive patients undergoing chemotherapy with chronic cancer pain under opioid therapy on an outpatient basis were enrolled from September 2019 to August 2020 and answered questions from the Athens Insomnia Scale (AIS) for assessing insomnia. Pain characteristics, including pain intensity, neuropathic pain, central sensitization assessed using the central sensitization inventory (CSI), opioid use disorder, and pain-related psychological symptoms were also examined. Uni- and multivariate regression analyses were performed to elucidate correlations between the AIS score and these pain characteristics. Of 44 enrolled patients, 20 patients completed to answer all questions. Insomnia was identified in 9 patients (45%). Although AIS scores showed no significant associations with pain intensity, neuropathic pain, opioid use disorder, or psychological symptoms, multivariate regression analysis revealed that CSI scores showed a positive relationship with AIS scores (P = .004). Discrimination was assessed using linear regression analysis which confirmed a significant association between the AIS and CSI scores (P = .002). Insomnia appears to be associated with central sensitization in cancer survivors with chronic cancer pain under opioid therapy.

Characterisation of the genetic relationship between the domains of sleep and circadian-related behaviours with substance use phenotypes

Sleep problems and substance use frequently co-occur. While substance use can result in specific sleep deficits, genetic pleiotropy could explain part of the relationship between sleep and substance use and use disorders. Here we use the largest publicly available genome-wide summary statistics of substance use behaviours (N = 79,729-632,802) and sleep/activity phenotypes to date (N = 85,502-449,734) to (1) assess the genetic overlap between substance use behaviours and both sleep and circadian-related activity measures, (2) estimate clusters from genetic correlations and (3) test processes of causality versus genetic pleiotropy. We found 31 genetic correlations between substance use and sleep/activity after Bonferroni correction. These patterns of overlap were represented by two genetic clusters: (1) tobacco use severity (age of first regular tobacco use and smoking cessation) and sleep health (sleep duration, sleep efficiency and chronotype) and (2) substance consumption/problematic use (drinks per day and cigarettes per day, cannabis use disorder, opioid use disorder and problematic alcohol use) and sleep problems (insomnia, self-reported short sleep duration, increased number of sleep episodes, increased sleep duration variability and diurnal inactivity) and measures of circadian-related activity (L5, M10 and sleep midpoint). Latent causal variable analyses determined that horizontal pleiotropy (rather than genetic causality) underlies a majority of the associations between substance use and sleep/circadian related measures, except one plausible genetically causal relationship for opioid use disorder on self-reported long sleep duration. Results show that shared genetics are likely a mechanism that is at least partly responsible for the overlap between sleep and substance use traits.