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Volume 14 No. 09
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Accepted Papers





Scientific Investigations

Insomnia and Regulation of Sleep-Wake Cycle With Drugs Among Adolescent Risky Drinkers

Tina Lam, PhD1; Rowan P. Ogeil, PhD2; Steve Allsop, PhD1; Tanya Chikritzhs, PhD1; Jane Fischer, PhD3; Richard Midford, PhD4; William Gilmore, MSc1; Simon Lenton, PhD1; Wenbin Liang, PhD1; Belinda Lloyd, PhD2; Alexandra Aiken, MPH5; Richard Mattick, PhD5; Lucinda Burns, PhD5; Dan I. Lubman, PhD2
1National Drug Research Institute, Faculty of Health Sciences, Curtin University, Perth, Australia; 2Turning Point and Monash University, Melbourne, Australia; 3National Centre for Education and Training on Addiction, Flinders University, Adelaide, Australia; 4Charles Darwin University and the Menzies School of Health Research, Darwin, Australia; 5National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia

ABSTRACT

Study Objectives:

We aimed to explore symptoms of insomnia in a group of youths characterized as engaging in risky drinking, their use of drugs as sleep/ wake aids, and the relationships between alcohol and other drug use and insomnia.

Methods:

Face-to-face interviews were conducted with 596 Australian 14 to 19-year-olds identified as engaging in regular risky drinking. They completed the Insomnia Severity Index and were assessed for recent alcohol and other drug use, including drugs used specifically as sleep aids or to stay awake. Alcohol-related problems, emotional distress, self-control, and working outside of traditional hours were also assessed using validated scales.

Results:

More than one-third of the study participants (36%) reported moderate to very severe sleep-onset insomnia, and 39% screened positive for clinical insomnia using adolescent criteria. Three-fourths used drugs in the past 2 weeks to regulate their sleep cycle (65% used stimulants to stay awake, mainly caffeine, and 32% used a depressant to get to sleep, mainly cannabis). Regression analyses showed that after controlling for variables such as sex, emotional distress, self-control, alcohol use problems, and past 6-month illicit or non-prescribed drug use, those who used drugs specifically to get to sleep or to stay awake were 2.0 (P < .001) and 1.7 (P = .02) times more likely to report clinical insomnia, respectively.

Conclusions:

Insomnia was commonly reported in this community sample of adolescents characterized as engaging in risky drinking. Those with symptoms of insomnia appeared to be managing their sleep-related symptoms through alcohol and other drug use, which may have further exacerbated their sleep issues.

Citation:

Lam T, Ogeil RP, Allsop S, Chikritzhs T, Fischer J, Midford R, Gilmore W, Lenton S, Liang W, Lloyd B, Aiken A, Mattick R, Burns L, Lubman DI. Insomnia and regulation of sleep-wake cycle with drugs among adolescent risky drinkers. J Clin Sleep Med. 2018;14(9):1529–1537.


BRIEF SUMMARY

Current Knowledge/Study Rationale: There is a bidirectional relationship between sleep disturbance and alcohol and other drug-related problems. To date, however, there has been limited exploration of the experience of adolescents engaging in risky drinking with sleep problems, and their use of drugs to regulate their sleep-wake cycle.

Study Impact: Controlling for various psychological and behavioral confounders, use of drugs specifically identified as sleep/wake aids was associated with higher odds of insomnia among teenagers in the risky drinking group. Contrary to their intended function of regulating sleep-wake cycles, these drugs may actually be compounding sleeping problems. Interventions to improve sleep quality may have positive flow-on effects in other health areas such as heavy alcohol use.

INTRODUCTION

Prevalence and Outcomes of Adolescent Insomnia/Sleep Problems

Risky alcohol consumption and self-reported sleep problems including “feeling sleepy during the day,” “difficulty falling asleep” and “difficulty waking in the morning”1 are some of the most common and also most modifiable risk factors influencing adolescent health.2 Approximately 1 in 10 teenagers in the general population experience clinical insomnia,35 and up to one-third of school-age children and half of adolescents in countries including the United States report subclinical but substantive sleep problems.68 In adolescents, sleep problems have been associated with heavy alcohol use, smoking, cannabis use, depression, impaired immune function, and risky sexual behaviors.9,10

Bidirectional Relationship Between Sleep and Alcohol and Other Drug Use

There is burgeoning evidence that there is a bidirectional relationship between sleep disturbance and alcohol and other drug (AOD) use issues. Problems with sleep routines during childhood or early adolescence predict later risky AOD use.3,1113 In addition, AOD use can impair young adults' sleep maintenance and total sleep time,14,15 and insomnia can predict relapse into alcohol dependence in adults.16

Previous studies suggest a common sleep/AOD trajectory is that of childhood sleep difficulties, earlier initiation into AOD use, then of AOD-related problems such as higher risk drinking, illicit drug use, and driving under the influence of alcohol during adolescence and young adulthood.12,17,18 As sleep difficulties appear to continue in parallel with the adolescent AOD trajectory, youth engaging in risky drinking are more likely to be experiencing sleep problems than their peers who abstain or who are low-risk drinkers, and their overall well-being may be compromised along two dimensions. To date, however, there has been limited exploration of sleep problems in adolescents who engage in risky drinking, and their use of drugs to regulate their sleep-wake cycle.

Recently, the work of Miller et al.19 confirmed this pattern by assessing the sleeping patterns of 829 substance-naïve 12-year-olds and examined their AOD use at age 16 years. They found that shorter sleep duration and greater sleepiness during the day prospectively predicted the onset of alcohol use, risky drinking, and alcohol-related problems. For example, for every extra hour of sleep reported, the odds of having ever had a full alcoholic drink was reduced by 15%. These sleep indicators retained their predictive capacity even after controlling for psychiatric symptoms, which commonly co-occur with sleep and AOD disorders.19

Hasler et al. recruited children aged 9–13 years who had a father with a substance use disorder, and surveyed them until age 30 years.20 Their findings were consistent with the previous cross-sectional and longitudinal findings, and extended the temporal reach of the literature with disturbed childhood sleep predicting substance use disorders in early adulthood. Furthermore, they found that restless sleep predicted earlier onset of alcohol and cannabis use, but not cocaine. They speculated this may be related to the sedative effects of alcohol and cannabis, though similar to study results from Miller et al., the specific function of the drugs was not assessed (that is, if they were used recreationally or as a sleep aid).

Risk Factors Associated With Poor Sleep Outcomes

The risk factors in the sleep-alcohol nexus may be interactive,21 working within a broader framework of risk factors. For example, up to 73% of depressed adolescents report sleep problems,22 and a meta-analysis with 172,000 participants found that depression was twice as likely to develop in individuals with insomnia.23 The inclusion of psychiatric variables such as internalizing problems (eg, depression and anxiety), and externalizing problems (eg, aggression) reduce the association between adolescent risky alcohol use and sleep problems.24 Recently, Miller et al.21 examined college students who were heavy drinkers and found that their alcohol-related consequences were elevated when both poor sleep quality and psychiatric symptoms were present. However, students who reported only poor sleep, or only a positive psychiatric screen, had a similar number of alcohol-related harms to the students who reported neither risk factor.21

Trait impulsivity and self-control have been associated with both risky alcohol use and sleep problems, and it has been suggested that executive functioning may be a mediating factor that is common to sleep, AOD use, and psychiatric problems.18,19,25 Premorbid deficits in working memory and impulse control may be the common origin for a range of dysregulations, and in turn, the distress of these dysregulations may further impair psychological resources for inhibitory processes.26,27 For example, diminished executive control may impede the establishment of a regular sleep schedule, and the resulting sleep deprivation can reduce reaction time, which individuals may in turn compensate for through more impulsive behavior.28

Shift work, which can include nontraditional work hours, is a risk factor for insomnia among adults.29 Despite 15 to 19-year-olds reporting the highest rates (18%) of shift work of all age brackets,30 there has also been limited examination of the potential effect of shift work on adolescent sleeping patterns. This issue may be of increasing importance as being a full-time student while engaged in paid work appears to be increasing, from 34% of Australian students ages 15 to 24 years in 1990 to 43% in 2016.31

Rationale

Similar to other designs,21,32 this study targeted a higher risk adolescent sample as a more efficient means of examining the central alcohol-sleep relationship. These young people were identified as being at high risk of alcohol-related harms, but underrepresented in current national AOD surveys.3336 They were recruited from the community on the basis of their drinking patterns, not from any engagement in a sleep clinic (so were not presumed to have a preexisting issue). Our 596 adolescents reported engagement in a range of study-based and other occupations, which is a broader selection compared to Miller et al.'s 385 heavy-drinking college students. Further, unlike in the study by Hasler et al., our participants were selected specifically as risky drinkers, as opposed to being at risk of AOD use by virtue of their father's history of dependence.

Although there is a body of literature that suggests sleep difficulties and risky AOD use are likely to co-occur, how adolescents behaviorally regulate this comorbidity is an area this study sought to explore. To our knowledge, this is the first study to examine the potential effect of drugs used specifically for the means of regulating the sleep-wake cycle on symptoms of insomnia in a sample of adolescents who engage in risky drinking.

We aimed to estimate the association between insomnia symptoms and alcohol use in a sample of adolescents who engage in risky drinking, assess their consumption of drugs used to regulate their sleep-wake cycle, and examine the effect of these AOD sleep-wake regulators on insomnia, while controlling for a range of potential confounding influences including psychological distress, self-control, alcohol-related problems, illicit drug use, and nontraditional work hours.

METHODS

Participants

Participants were 596 Australian adolescent risky drinkers aged 14–19 years (mean age 17.20 years, standard deviation 1.38; 14–15 years [n = 88]; 16–17 years [n = 237]; 18–19 years [n = 271]). Almost half of the participants (48%) were female. Most were students (grade or high school 46%; university 33%; technical college 4%; employed full time 3%; trade apprentices 2%; unemployed 2%). One in 10 participants were born overseas and 14% spoke a language other than English at home (n = 594). Few participants (n = 5; < 1%) were in any form of alcohol or other drug treatment. More than one-third (43%) worked outside of traditional “9 to 5” hours (eg, night or overtime shifts) in the past 2 weeks. One-fourth had worked 1 to 4 days and 18% worked 6 or more days over a 2-week period (n = 588).

Consistent with previous Australian surveys, risky drinking was defined as consuming Australian standard drinks (ASD) of alcohol (1 ASD = 10 g of alcohol) in patterns consistent with the top 25% of drinkers from their age and sex cohort.3739 Screening criteria for risky drinking by age and sex were as follows:

  • 14 to 15-year-olds: ≥ 1 ASD in a single sitting at least once a month

  • 16 to 17-year-olds: ≥ 5 ASD per single occasion at least twice a month

  • 18 to 19-year-old females: ≥ 7 ASD in a single sitting at least twice a month

  • 18 to 19-year-old males: ≥ 9 ASD per occasion at least twice month.

Across age and sex groupings, 59% of participants consumed ≥ 9 ASD in a single session at least twice a month (n = 596).

Measures

Sleep Characteristics

This study reports on the sleep-related variables of insomnia, nontraditional work hours, and the use of drugs either as sleep aids, or to stay awake, assessed with a reference period of the 2 weeks immediately prior to interview.

Clinically relevant insomnia was identified using the seven-item Insomnia Severity Index (ISI).40 Consistent with recommendations for administration to adolescents, the item “waking up too early” was expanded to read “waking up too early and not being able to go back to sleep.”41,42 ISI items were summed with scores ≥ 9 indicating clinical insomnia in adolescents.42 For adult populations, scores of 8–14 suggest subthreshold insomnia, scores of 15–21 are indicative of moderate severity clinical insomnia, and scores of 22–28 indicate severe clinical insomnia.40

Respondents were asked “How often have you worked outside of traditional ‘9–5’ hours? (over the past 2 weeks) eg, night or overtime shifts” (5–7 days a week, 3–4 days a week, 1–2 days a week, once every 2 weeks, not at all).

They were also asked whether they had used any of a list of depressant drugs to “help you get to sleep” (cannabis, drugs bought over the counter at the pharmacy where no prescription was required, alcohol, prescription medications, specified other drug), or used any of a list of stimulant drugs to “to stay awake” (caffeinated soft drinks, coffee/tea, energy drinks, cigarettes, dexamphetamine, methamphetamine, specified other drug). These items were dichotomized into the use of a drug specifically used to “get to sleep” or to “stay awake” in the past 2 weeks.

Emotional Distress and Self-Control

Emotional distress experienced in the past 30 days was assessed using Kessler et al.'s six-item psychological distress scale (K6). K6 scores of 0–7 denote no to low distress, 8–12 moderate distress and scores of 13 and higher are indicative of high distress and probable mental illness.43

Self-control was assessed across the domains of self-discipline, deliberate/nonimpulsive action, healthy habits, work ethic, and reliability using the validated Brief Self-Control (BSC) Scale.26 The 13 B-SC items were summed, the resulting total scores appeared broadly consistent with general population norms, and the scores were split into quartiles for regression analyses.

Alcohol Use and Other Drug Use

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening tool developed by the World Health Organization to detect risky drinking patterns.44 Because this was a purposive risky drinking sample all respondents were “at risk” using adolescent criteria.45,46 For the regression analyses, participants were categorized using adult guidelines with scores of 8–15 indicating medium levels of alcohol problems (appropriate for simple advice focused on the reduction of hazardous drinking); scores 16–19 indicating high levels of problems (suggesting the need for brief counselling and continued monitoring); and scores ≥ 20 indicating very high problems (strongly suggesting further diagnostic evaluation for alcohol dependence).

Participants also indicated whether they had used any of 10 identified illicit or nonprescribed drugs in the past 6 months (cannabis, ecstasy, hallucinogens, inhalants, pain killers [not used as prescribed], benzodiazepines or sleeping pills [not used as prescribed], dexamphetamine [not used as prescribed], cocaine, methamphetamine or amphetamine, ketamine). This was dichotomized into the use of an illicit or nonprescribed drug (yes/no). So, this item reflected the use of an illicit drug in the past 6 months, irrespective of reason for use (eg, recreational, sleep-wake regulation, or other reason).

Procedure

Participants were a convenience sample recruited primarily through paid social media advertisements. The advertisements were targeted to 14 to 19-year-old Australians, and included the question “do you drink regularly?” to further select for alcohol users. Adolescents interested in the study could email, SMS or telephone their nearest research unit for initial screening and interview booking. Eligibility was confirmed during the interview using selection criteria items relating to alcohol use frequency and quantity. More than one-half of the participants (59%) had responded to a social media advertisement, one-third (37%) were referred through a friend, 5% saw a poster at their educational facility, and 4% were recruited through a youth service they used (n = 584). After informed consent was obtained, the confidential and anonymous face-to-face interviews took approximately 45 minutes. Participants were reimbursed 40 Australian dollars (approximately 30 United States dollars) for their time and travel costs. Interviews occurred in all eight Australian capital cities with institutional ethics approval granted from all participating locations (Curtin University, University of New South Wales, Monash University, University of Tasmania, Flinders University, Australian Capital Territory Health Research Records and Governance Office, Charles Darwin University, University of Queensland).

Data Analyses

Relevant data are described as percentages, and correlations were calculated using Spearman rho due to non-normal distribution of the ISI scores.

A three-stage hierarchical multiple logistic regression was conducted to assess nine factors on the likelihood of a positive screen for clinical insomnia using adolescent criteria. The first stage included the variables sex, age, psychological distress, and self-regulation. The second stage included assessments of alcohol-related problems and illicit or nonprescribed drug use. The final stage included sleep-related variables of working outside of traditional hours, use of a drug to stay awake, and use of a drug to get to sleep.

Analyses were computed in IBM SPSS version 24 (IBM Corp, Armonk, New York, United States).

RESULTS

ISI Scores

Using adolescent criteria (ISI score ≥ 9), 39% of the participants reported symptoms suggestive of clinical insomnia.42 Using adult criteria, 33% had symptoms of subthreshold insomnia (ISI score 8–14), 11% had scores indicative of moderate severity clinical insomnia (ISI score 15–21), and 2% with severe clinical insomnia (ISI score 22–28).40 The mean total ISI score was 7.60 (standard deviation = 5.57, n = 595), and the endorsement of each ISI item are more specifically presented in Table 1.

Endorsement rate on the Insomnia Severity Index.

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Table 1

Endorsement rate on the Insomnia Severity Index.

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Use of Drugs for Sleep-Wake Cycle

Almost three-fourths of this group (72%) appeared to be self-regulating their sleep-wake cycles with drugs, and 21% were using an illicit drug to do so.

To stay awake, 65% reported using a stimulant in the past 2 weeks. The most commonly reported drugs used to stay awake were coffee/tea (56%), energy drinks (22%), caffeinated soft drinks (21%), cigarettes (11%), and dexamphetamine (3%), and 3% used another drug (n = 595).

One-fifth of the participants (22%) reported having used alcohol in their lifetime to help get to sleep (n = 593). In the past 2 weeks, 32% had used a depressant drug to help them get to sleep (cannabis 19%, alcohol 10%, prescription medications 10%, over-the-counter medications 6%; n = 588).

Almost half of the participants (43%) worked outside of traditional “9 to 5” hours (eg, night or overtime shifts) in the past 2 weeks. One-fourth had worked 1 to 4 days and 18% worked 6 or more days over a 2-week period (n = 588). Although not significant in our regression model, we note that shift work may affect sleep as engagement in both full-time study and casual work can affect total sleep time, and second, the timing of that casual work (eg, night shifts) may affect sleep via disruption of a sleep onset routine.

Correlations Between ISI and Other Variables

ISI scores indicative of more severe symptoms of insomnia were significantly more likely to occur among females, and were correlated with higher psychological distress in the past 4 weeks, lower self-control, higher AUDIT scores, illicit or nonprescribed drug use in the past 6 months, use of a drug to stay awake, and use of a drug to get to sleep in the past 2 weeks (Table 2).

Demographic, lifestyle, and clinical characteristics of participants included in the logistic regression model.

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Table 2

Demographic, lifestyle, and clinical characteristics of participants included in the logistic regression model.

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Regression Analysis

Step 1 of the model with the variables age, sex, psychological distress, and self-regulation was statistically significant, explained 21.9% of variance in insomnia status, and correctly classified 71.8% of cases (Table 3). Higher distress and lower self-regulation uniquely contributed to reports of insomnia. Those with the highest distress scores and moderate distress scores were respectively 7.9 and 3.7 times more likely to report insomnia compared to those with no or low psychological distress. Participants with the lowest self-control scores were twice as likely to report insomnia compared to those in the quartile with highest self-control scores.

Three stage hierarchical logistic regression analysis of factors associated with insomnia.

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Table 3

Three stage hierarchical logistic regression analysis of factors associated with insomnia.

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In the second step, AUDIT scores for alcohol use problems, and use of other drugs were added to the model. In this statistically significant six-variable model, sex, psychological distress, and alcohol-related problems uniquely contributed to reports of insomnia. Females were 1.5 times more likely, more distressed respondents were 3.9 to 7.2 times more likely, and participants who had a “very high” alcohol problems were 2.1 times more likely than those who had a “medium” alcohol problems to report insomnia.

In the final model, drugs used to stay awake and to get to sleep were added. Five variables made a unique statistically significant contribution to this nine-variable model: sex, psychological distress, alcohol use, drugs used to stay awake, and drugs used to get to sleep. Females were 1.6 times more likely, more distressed participants were 3.7 to 6.0 times more likely, and those with very high alcohol problems were twice as likely as those who had medium problems to report insomnia. Participants who used a drug to stay awake were 1.7 times more likely, and those who reported using a drug to get to sleep were 2.2 times more likely to report symptoms of clinical insomnia compared to those who did not use a drug to stay awake or get to get to sleep, respectively.

In recognition that tea, coffee, and caffeinated soft drinks may be consumed in small quantities as part of a typical diet or also consumed in larger quantities to maximize their stimulant properties, these products were analyzed as a group separate from all the other stimulants used to stay awake. This analysis appeared broadly similar to model 3 with tea/coffee/caffeinated soft-drink consumers 1.8 times more likely to report adolescent insomnia (P = .007), controlling for all other factors in the model. In contrast, the smaller group of energy drink/cigarette/ amphetamine type stimulant users did not demonstrate significantly higher odds (P = .95).

DISCUSSION

Our study examined insomnia among adolescent risky drinkers. We found that clinically significant insomnia and psychological distress symptoms were common and that participants reported a broad range of psychoactive substances to sleep and to stay awake. Risky drinking, psychological distress, and sleep problems may each independently inhibit adolescent development, but in combination, as was prevalent in this group, may place adolescents who engage in risky alcohol use at an elevated risk of harm. For example, deficiencies in these domains may all uniquely diminish working memory capacity, and therefore impair decision-making processes around further behavioral regulation.47

Consistent with both adolescent and adult literature, participants' insomnia symptoms were associated with sex,48,49 emotional distress,22,50 self-control,25 and AOD use problems.18,22 Furthermore, given the same psychological and behavioral profile (emotional distress, self-control, drug use), the use of drugs explicitly described as used to help them get to sleep or to stay awake was associated with even greater rates of insomnia. That is, contrary to their intended function of regulating sleep-wake cycles, these drugs may actually be compounding sleeping problems.

Insomnia among study participants was higher than for adolescents in the Australian general population. More than one-third of study participants (39%) screened positive for clinical insomnia using adolescent-appropriate ISI criteria. Using stricter adult criteria, 33% of participants had subthreshold insomnia and 13% had clinical insomnia. In comparison, an Australian general population study of 1,512 individuals found that 2% of 14 to 17-year-olds and 11% of 18 to 24-year-olds had clinical insomnia according to ISI adult criteria.51 The mean ISI score for this study (mean = 7.6, standard deviation = 5.6) was only slightly higher, and contained higher variance than the largest adolescent general population survey available, 1,516 Chinese 12 to 19-year-olds (ISI score = 7.4, standard deviation = 4.6).42 This finding is consistent with international literature that associates poorer adolescent sleep with higher alcohol use.3,52

This study extends the work within the field, particularly in the examination of the effects of AOD use to regulate sleep-wake behaviors during adolescence. Almost three-fourths of this risky drinking sample used drugs to regulate their sleep-wake cycles over the past 2 weeks (mostly caffeine, with 21% reporting using an illicit drug). The final model revealed that those who reported insomnia were twice as likely to have used a drug in the past 2 weeks to stay awake or to get to sleep. Though this drug use could be a consequence of insomnia, due to the cross-sectional nature of the dataset, it is possible that the drug use could have also been in turn affecting insomnia symptoms.

One-third of participants had used a depressant drug, most commonly cannabis (19%), to help them get to sleep in the past 2 weeks. In contrast, 14% of general population 14 to 19-year-olds used cannabis for any reason in the past 12 months.53 Adolescents commonly report cannabis use for general relaxation.54 The few studies that specifically focused on cannabis use and sleep suggest that cannabis can reduce sleep latency in the short term, but can have mixed longer-term effects, especially among recreational users.55 Lifetime cannabis use is a risk factor for shorter sleep durations in a young adult general population,56 withdrawal among dependent cannabis users keeps the user awake,57 and shorter sleep duration predicts the onset of cannabis use.19 Therefore, the use of cannabis as a sleep aid may have had unintended, opposite effects that compounded sleep issues.

Almost two-thirds of participants reported using a stimulant, most commonly caffeine, over a 2-week period to stay awake. In contrast, an estimated 26% of general population 14 to 16-year-old Australians consumed caffeinated beverages on the day prior to survey,58 and 14 to 18-year-olds consumed a mean of 39–52 mg/d of caffeine.59 Despite discrepancies in reference time frame, the study samples' use of caffeine was likely more pronounced compared to general population adolescents, in line with their generally higher AOD use. Given that caffeine has previously been implicated in sleep issues in the general population, how caffeine is related to insomnia symptoms (including assessment of caffeine quantity) among adolescents engaging in risky drinking could be explored in greater detail in the future.

As a cohort, it is interesting to note that most study participants were students and 40% also worked. The increasing trend of simultaneous engagement in full-time education and employment,31 nontraditional work hours, and the availability of energy drinks may influence choices around the use of drugs that promote wakefulness and productivity. In turn, the use of stimulants such as caffeine is associated with almost double the likelihood of difficulty sleeping.60,61 That is, similar to alcohol, there could be a bidirectional relationship between caffeine and sleep problems.60 Furthermore, it is of note that because sleep deprivation can affect decision making,47 the risk of work-related injuries may be elevated in this group.

The aforementioned issues are of concern, but evidence-based interventions regarding adolescent risky drinking, insomnia, psychological distress, and sleep/awakening management are available. Brief interventions can improve the sleep quality of adolescents,62,63 and some argue that independent treatment of sleep disorders may have positive flow-on effects in other health areas such as alcohol use. For example, Fucito et al. engaged college drinkers who were experiencing sleep problems and a brief intervention on sleep hygiene and other health strategies resulted in a variety of health benefits, including reductions in alcohol consumption.64 Similarly, because sleep deprivation and fragmentation can affect executive functions and risk taking,47 treating insomnia in adolescents can also improve executive function.65 This adolescent comorbidity may also be framed as an opportunity for intervention engagement. Seeking help for sleep problems may be a more acceptable avenue through which related AOD issues can be addressed. The rise of anonymous online cognitive behavioral therapy interventions may further reduce adolescent barriers to engagement.60

Limitations

Because this study was designed to recruit adolescents who were underrepresented in current national health surveys and were at higher risk of both alcohol and sleep-related problems, this sample is not representative of young people in general.3336 The results presented here are likely indicative of the upper limits of the range in levels of use and harms.

This study reports associations between AOD use and sleep outcomes in a cross-sectional sample of adolescents and therefore cannot be used to infer causality. However, the population examined includes a broad range of adolescents with respect to age, types of students and nonstudents, and specifically recruited a community-based sample rather than a clinically based sample, suggesting that there is a degree of robustness or generalizability to other risky drinking populations of young people. Together, these qualities of the sample provide a broader understanding of the AOD-sleep relationship.

Importantly, this study builds on the limited range of Australian sleep studies on adolescents.4,6,51,66,67 It is of note that the Australian legal purchase age for alcohol is 18 years, compared to age 21 years in the United States where the bulk of sleep studies are conducted, suggesting the comorbidity between sleep and alcohol may be occurring at a younger age.

This study relied on self-report on sleep characteristics as opposed to objective measures within a sleep laboratory setting. Though adolescents' self-reported sleep patterns correlate with actigraphy and sleep readings,68 future studies could make use of these measures and ask for further detail such as bedtime, wake time, daytime sleepiness, use of technology or other light-emitting devices, and preexisting sleep conditions.

CONCLUSIONS

This study used a series of validated scales to assess the effect of constructs such as mood, self-control, and AOD use on insomnia among a large community sample of nontreatment-seeking adolescents engaging in risky drinking. Other than insomnia symptoms being commonly reported by the sample, the most significant finding was that most study participants reported the use of depressants and stimulants specifically to get to sleep/stay awake. The regular use of such drugs to regulate sleep-wake cycles may be compounding the sleep disruption that they are meant to be addressing.

DISCLOSURE STATEMENT

All authors have contributed to and reviewed the manuscript. This work was supported by the Australian Department of Health (D16-451850). The National Drug Research Institute of the Health Sciences Faculty at Curtin University, the National Drug and Alcohol Research Centre at the University of New South Wales and the National Centre for Education and Training on Addiction, Flinders University are supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvement Grants Fund. Tina Lam is supported by a Western Australian Health Promotion Foundation Research Fellowship (24106). The authors report no conflicts of interest.

ABBREVIATIONS

AOD

alcohol and other drugs

ASD

Australian standard drink (1 ASD = 10 g of alcohol)

AUDIT

Alcohol Use Disorders Identification Test

B-SC

Brief Self-Control Scale

ISI

Insomnia Severity Index

K6

Kessler 6-item psychological distress scale

ACKNOWLEDGMENTS

Thanks are extended to all the organizations that helped coordinate research implementation in each Australian jurisdiction. These include but are not limited to staff members at the National Drug Research Institute (NDRI), Curtin University, Turning Point and Monash University, National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Alcohol and Other Drug Policy Unit, ACT Health, School of Psychology, University of Tasmania, National Centre for Education and Training on Addiction (NCETA), Flinders University, Charles Darwin University and the Menzies School of Health Research, Institute of Social Science Research, University of Queensland. Last, we would like to thank the young people themselves for their enthusiastic contributions.

REFERENCES

1 

National Sleep Foundation. 2006 Sleep in America poll: summary of findings. https://sleepfoundation.org/sleep-polls-data/sleep-in-america-poll/2006-teens-and-sleep. Accessed January 2016.

2 

Gore FM, Bloem PJN, Patton GC, et al. Global burden of disease in young people aged 10-24 years: a systematic analysis. Lancet. 2011;377(9783):2093–2102. [PubMed]

3 

Roane BM, Taylor DJ. Adolescent insomnia as a risk factor for early adult depression and substance abuse. Sleep. 2008;31(10):1351–1356. [PubMed Central][PubMed]

4 

Dohnt H, Gradisar M, Short MA. Insomnia and its symptoms in adolescents: comparing DSM-IV and ICSD-II diagnostic criteria. J Clin Sleep Med. 2012;8(3):295–299. [PubMed Central][PubMed]

5 

Johnson EO, Roth T, Schultz L, Breslau N. Epidemiology of DSM-IV insomnia in adolescence: lifetime prevalence, chronicity, and an emergent gender difference. Pediatrics. 2006;117(2):e247–e256. [PubMed]

6 

Waters KA, Suresh S, Nixon GM. Sleep disorders in children. Med J Aust. 2013;199(8):S31–S35. [PubMed]

7 

Carskadon M, Mindell J, Drake C. Contemporary sleep patterns of adolescents in the USA: Results of the 2006 National Sleep Foundation Sleep in America poll [abstract]. J Sleep Res. 2006;15(Suppl 1):42

8 

Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh A. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006;29(10):1263–1276. [PubMed]

9 

Hasler BP, Soehner AM, Clark DB. Sleep and circadian contributions to adolescent alcohol use disorder. Alcohol. 2015;49(4):377–387. [PubMed]

10 

Besedovsky L, Lange T, Born J. Sleep and immune function. Pflugers Archiv. 2012;463(1):121–137. [PubMed]

11 

Mike TB, Shaw DS, Forbes EE, Sitnick SL, Hasler BP. The hazards of bad sleep-sleep duration and quality as predictors of adolescent alcohol and cannabis use. Drug Alcohol Depend. 2016;168:335–339. [PubMed Central][PubMed]

12 

Wong MM, Brower KJ, Fitzgerald HE, Zucker RA. Sleep problems in early childhood and early onset of alcohol and other drug use in adolescence. Alcohol Clin Exp Res. 2004;28(4):578–587. [PubMed]

13 

Hasler BP, Martin CS, Wood DS, Rosario B, Clark DB. A longitudinal study of insomnia and other sleep complaints in adolescents with and without alcohol use disorders. Alcohol Clin Exp Res. 2014;38(8):2225–2233. [PubMed Central][PubMed]

14 

Van Reen E, Roane BM, Barker DH, McGeary JE, Borsari B, Carskadon MA. Current alcohol use is associated with sleep patterns in first-year college students. Sleep. 2016;39(6):1321–1326. [PubMed Central][PubMed]

15 

Stein MD, Friedmann PD. Disturbed sleep and its relationship to alcohol use. Subst Abus. 2005;26(1):1–13. [PubMed Central][PubMed]

16 

Brower KJ, Aldrich MS, Robinson EA, Zucker RA, Greden JF. Insomnia, self-medication, and relapse to alcoholism. Am J Psychiatry. 2001;158(3):399–404. [PubMed Central][PubMed]

17 

Wong MM, Brower KJ, Nigg JT, Zucker RA. Childhood sleep problems, response inhibition, and alcohol and drug outcomes in adolescence and young adulthood. Alcohol Clin Exp Res. 2010;34(6):1033–1044. [PubMed Central][PubMed]

18 

Wong MM, Roberson G, Dyson R. Prospective relationship between poor sleep and substance-related problems in a national sample of adolescents. Alcohol Clin Exp Res. 2015;39(2):355–362. [PubMed Central][PubMed]

19 

Miller MB, Janssen T, Jackson KM. The prospective association between sleep and initiation of substance use in young adolescents. J Adolesc Health. 2017;60(2):154–160. [PubMed]

20 

Hasler BP, Kirisci L, Clark DB. Restless sleep and variable sleep timing during late childhood accelerate the onset of alcohol and other drug involvement. J Stud Alcohol Drugs. 2016;77(4):649–655. [PubMed Central][PubMed]

21 

Miller MB, Van Reen E, Barker DH, et al. The impact of sleep and psychiatric symptoms on alcohol consequences among young adults. Addict Behav. 2017;66:138–144. [PubMed]

22 

Lovato N, Gradisar M. A meta-analysis and model of the relationship between sleep and depression in adolescents: Recommendations for future research and clinical practice. Sleep Med Rev. 2014;18(6):521–529. [PubMed]

23 

Li L, Wu C, Gan Y, Qu X, Lu Z. Insomnia and the risk of depression: a meta-analysis of prospective cohort studies. BMC Psychiatry. 2016;16:375[PubMed Central][PubMed]

24 

Johnson EO, Breslau N. Sleep problems and substance use in adolescence. Drug Alcohol Depend. 2001;64(1):1–7. [PubMed]

25 

Telzer EH, Fuligni AJ, Lieberman MD, Galván A. The effects of poor quality sleep on brain function and risk taking in adolescence. NeuroImage. 2013;71:275–283. [PubMed]

26 

Tangney JP, Baumeister RF, Boone AL. High self-control predicts good adjustment, less pathology, better grades, and interpersonal success. J Pers. 2004;72(2):271–324. [PubMed]

27 

Pilcher JJ, Morris DM, Donnelly J, Feigl HB. Interactions between sleep habits and self-control. Front Hum Neurosci. 2015;9:284[PubMed Central][PubMed]

28 

Demos KE, Hart CN, Sweet LH, et al. Partial sleep deprivation impacts impulsive action but not impulsive decision-making. Physiol Behav. 2016;164(Pt A):214–219. [PubMed Central][PubMed]

29 

Vallières A, Azaiez A, Moreau V, LeBlanc M, Morin CM. Insomnia in shift work. Sleep Med. 2014;15(12):1440–1448. [PubMed]

30 

Australian Bureau of Statistics. 6105.0 - Australian Labour Market Statistics. Oct 2010. http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/6105.0Oct%202010?OpenDocument. Accessed October 10, 2017.

31 

Australian Bureau of Statistics. 6202.0 - Labour Force, Australia, Aug 2017. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/6202.0Main+Features1Aug%202017?OpenDocument. Accessed October 10, 2017.

32 

Hasler BP, Franzen PL, de Zambotti M, et al. Eveningness and later sleep timing are associated with greater risk for alcohol and marijuana use in adolescence: initial findings from the national consortium on alcohol and neurodevelopment in adolescence study. Alcohol Clin Exp Res. 2017;41(6):1154–1165. [PubMed Central][PubMed]

33 

Lam T, Lenton S, Burns L, et al. Alcohol policy impact on young risky drinkers and their support for proposed measures. Aust N Z J Public Health. 2015;39(2):129–134. [PubMed]

34 

Lam T, Lenton S, Ogeil R, et al. Most recent risky drinking session with Australian teenagers. Aust N Z J Public Health. 2017;41(1):105–110. [PubMed]

35 

Ogeil RP, Lloyd B, Lam T, et al. Pre-drinking behavior of young heavy drinkers. Subst Use Misuse. 2016;51(10):1297–1306. [PubMed]

36 

Wilson J, Ogeil RP, Lam T, et al. Re-thinking pre-drinking: Implications from a sample of teenagers who drink in private settings. Int J Drug Policy. 2018;52:20–24. [PubMed]

37 

Victorian Drug and Alcohol Prevention Council. 2009 Victorian Youth Alcohol and Drug Survey Final Report. Melbourne, Australia: Victorian Department of Health; 2010.

38 

Australian Institute of Health and Welfare. National Drug Strategy Household Survey detailed report: 2013. Drug statistics series no. 28. Cat. no. PHE 183. Canberra, Australia: Australian Institute of Health and Welfare; 2014.

39 

Government of Western Australia Mental Health Commission. Alcohol Trends in Western Australia: Australian School Students Alcohol and Drug Survey 2014. 2016. Government of Western Australia;

40 

Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601–608. [PubMed Central][PubMed]

41 

Kanstrup M, Holmstrom L, Ringstrom R, Wicksell RK. Insomnia in paediatric chronic pain and its impact on depression and functional disability. Eur J Pain. 2014;18(8):1094–1102. [PubMed]

42 

Chung K-F, Kan K, Yeung W-F. Assessing insomnia in adolescents: Comparison of Insomnia Severity Index, Athens Insomnia Scale and Sleep Quality Index. Sleep Med. 2011;12(5):463–470. [PubMed]

43 

Kessler RC, Green JG, Gruber MJ, et al. Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative. Int J Methods Psychiatr Res. 2010;19 Suppl 1:4–22. [PubMed Central][PubMed]

44 

Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care. 2nd ed. Geneva, Switzerland: World Health Organization; 2001.

45 

Adger H, Saha S. Alcohol use disorders in adolescents. Pediatr Rev. 2013;34(3):103–114. [PubMed Central][PubMed]

46 

Chung T, Colby SM, Barnett NP, Rohsenow DJ, Spirito A, Monti PM. Screening adolescents for problem drinking: performance of brief screens against DSMIV alcohol diagnoses. J Stud Alcohol. 2000;61(4):579–587. [PubMed]

47 

Thomas AG, Monahan KC, Lukowski AF, Cauffman E. Sleep problems across development: a pathway to adolescent risk taking through working memory. J Youth Adolesc. 2015;44(2):447–464. [PubMed]

48 

Gerber M, Lang C, Lemola S, et al. Validation of the German version of the insomnia severity index in adolescents, young adults and adult workers: results from three cross-sectional studies. BMC Psychiatry. 2016;16:174[PubMed Central][PubMed]

49 

Chahoud M, Chahine R, Salameh P, Sauleau EA. Reliability, factor analysis and internal consistency calculation of the Insomnia Severity Index (ISI) in French and in English among Lebanese adolescents. eNeurologicalSci. 2017;7:9–14. [PubMed Central][PubMed]

50 

Wirz-Justice A. Biological rhythm disturbances in mood disorders. Int Clin Psychopharmacol. 2006;21:S11–S15

51 

Hillman DR, Lack LC. Public health implications of sleep loss: the community burden. Med J Aust. 2013;199(8):7–10

52 

Hasler BP, Clark DB. Circadian misalignment, reward-related brain function, and adolescent alcohol involvement. Alcohol Clin Exp Res. 2013;37(4):558–565. [PubMed]

53 

Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2016: Detailed Findings. Drug Statistics series no. 31. Cat. no. PHE 214. Canberra, Australia: Australian Institute of Health and Welfare; 2017.

54 

Lee CM, Neighbors C, Woods BA. Marijuana motives: Young adults' reasons for using marijuana. Addict Behav. 2007;32(7):1384–1394. [PubMed]

55 

Gates PJ, Albertella L, Copeland J. The effects of cannabinoid administration on sleep: a systematic review of human studies. Sleep Med Rev. 2014;18(6):477–487. [PubMed]

56 

Glozier N, Martiniuk A, Patton G, et al. Short sleep duration in prevalent and persistent psychological distress in young adults: the DRIVE study. Sleep. 2010;33(9):1139–1145. [PubMed Central][PubMed]

57 

Bolla KI, Lesage SR, Gamaldo CE, et al. Polysomnogram changes in marijuana users who report sleep disturbances during prior abstinence. Sleep Med. 2010;11(9):882–889. [PubMed Central][PubMed]

58 

Beckford K, Grimes CA, Riddell LJ. Australian children's consumption of caffeinated, formulated beverages: a cross-sectional analysis. BMC Public Health. 2015;15:70[PubMed Central][PubMed]

59 

Australian Bureau of Statistics, Food Standards Australia New Zealand. Australian Health Survey: Usual Nutrient Intakes, 2011-12. 4364.0.55.008. Canberra, Australia: Commonwealth of Australia; 2005.

60 

de Zambotti M, Goldstone A, Colrain IM, Baker FC. Insomnia disorder in adolescence: diagnosis, impact, and treatment. Sleep Med Rev. 2018;39:12–24. [PubMed]

61 

Ogeil RP, Rajaratnam SMW, Broadbear JH. Ecstasy and sleep disturbance: Progress towards elucidating a role for the circadian system. Sleep Biol Rhythms. 2012;10(1):3–13

62 

Meltzer LJ, Mindell JA. Systematic review and meta-analysis of behavioral interventions for pediatric insomnia. J Pediatr Psychol. 2014;39(8):932–948. [PubMed]

63 

Paavonen EJ, Huurre T, Tilli M, Kiviruusu O, Partonen T. Brief behavioral sleep intervention for adolescents: an effectiveness study. Behav Sleep Med. 2016;14(4):351–366. [PubMed]

64 

Fucito LM, DeMartini KS, Hanrahan TH, Yaggi HK, Heffern C, Redeker NS. Using sleep interventions to engage and treat heavy-drinking college students: a randomized pilot study. Alcohol Clin Exp Res. 2017;41(4):798–809. [PubMed Central][PubMed]

65 

de Bruin EJ, Dewald-Kaufmann JF, Oort FJ, Bögels SM, Meijer AM. Differential effects of online insomnia treatment on executive functions in adolescents. Sleep Med. 2015;16(4):510–520. [PubMed]

66 

Short MA, Gradisar M, Gill J, Camfferman D. Identifying adolescent sleep problems. PLoS One. 2013;8(9):e75301[PubMed Central][PubMed]

67 

Lovato N, Gradisar M, Short M, Dohnt H, Micic G. Delayed sleep phase disorder in an Australian school-based sample of adolescents. J Clin Sleep Med. 2013;9(9):939–944. [PubMed Central][PubMed]

68 

Wolfson AR, Carskadon MA, Acebo C, et al. Evidence for the validity of a sleep habits survey for adolescents. Sleep. 2003;26(2):213–216. [PubMed]