Cocaine self-medication for insomnia

“Addicted people may take cocaine to improve sleep-related cognitive functioning deficits—unaware that they are abusing, in part, to ‘solve’ these problems.”

Huh? I suppose, if cocaine is part of one’s life, one might use it instrumentally when tired–the way many of us use caffeine. But “unaware”?

Also, isn’t this theory tautological? I go beyond his statement, but I think this speaks to much of the psychiatric conventional wisdom.

  • Sleep problems are widespread among addicts.
  • People self-medicate with stimulants to deal with impairments related to sleep problems.
  • People self-medicate with sedatives to help them sleep when experiencing sleep problems.

Under what conditions is their drug use not self-medication? If it is self-medication, why are they unaware? If what they really seek is relief from sleep problems and psychiatric symptoms, why are they non-compliant with professionally directed treatments? Yet, they are so consistent with illicit drugs as self-medication when these drugs are poor treatments for the problem.

Two quotes come to mind:

Their every truth is not quite true. Their two is not the real two, their four not the real four: so that every word they say chagrins us and we know not where to begin to set them right. — Ralph Waldo Emerson

If the only tool you have is a hammer, you tend to see every problem as a nail. — Abraham Maslow

At any rate, the study focuses only on the first 17 days of abstinence in a non-treatment population. NIDA summarizes their findings as follows:

  • Sleep deficits—After 14 to 17 days of abstinence, the study group exhibited sleep deficits on several measures, relative to healthy, age-matched peers who participated in prior studies. For example, they had less total sleep time (336 versus 421-464 minutes) and took longer to fall asleep (19 versus 6-16 minutes).
  • Declines in sleep quantity and quality—The time participants took to fall asleep and their total time asleep transiently improved during the first week of abstinence, but then reverted to the patterns recorded on days of cocaine taking. On abstinence days 14-17, participants took an average of 20 minutes to fall asleep (from a low of 11) and slept for 40 minutes less than their minimum. Slow-wave sleep—a deep sleep that often increases following sleep deprivation—rose during the binge and on abstinence days 10-17.
  • Lack of awareness of their sleep problems—In contrast to the evidence of objective measures, the study participants reported steadily improving sleep from the beginning to the end of their days of abstinence.
  • Impairments in learning and attention—As with sleep quality, participants’ performance on tests of alertness and motor-skills learning initially improved and then deteriorated. On abstinence day 17, they registered their lowest scores on alertness and ability to learn a new motor skill.

They then acknowledge the limitations of such a short study:

“Cocaine abusers who recognize their cognitive problems often report that it takes them 6 months to a year to turn the corner—a clinical observation that points to the need for longer term studies of sleep and treatment outcomes among this population.”

They argue that they are relevant because other studies have found that early sleep problems predict relapse 6 months later, but neglect to mention that other studies have found that distress about sleep problems is a better predictor of relapse than objective sleep measures.

Not surprisingly, they are researching medications for sleep:

Dr. Morgan and his team are currently testing two medications, tiagabine (an anticonvulsant) and modafinil (a stimulant), to see if they can improve cocaine abusers’ sleep and restore cognitive performance.

Why not try CBT (here and here) and looking at treatment populations?