Abstract
Background and Objectives.
Drug-related dreams are commonly reported by individuals in treatment for substance use disorders, and may be distressing. Existing evidence suggests that dream recollection may be influenced by clinically relevant phenomena, such as opioid use and withdrawal, general sleep disturbance, affective symptoms, and chronic pain. However, very few studies have explored drug-related dreams among individuals who screened positive for opioid use disorder.
Methods.
Adults recruited from Amazon Mechanical Turk (MTurk) who screened positive for opioid use disorder (N=154) completed a questionnaire about drug-related dreams, as well as measures assessing sleep, opioid use history, stress, anxiety, and chronic pain. Chi-square analyses, one-way ANOVA, and bivariate correlations, correcting for the false discovery rate, were used as appropriate to explore correlates of 1) recollecting a drug-related dream, and 2) experiencing post-dream craving and distress.
Results.
Individuals who recollected a past-week drug-related dream were more likely to report other recent sleep disturbances, including poorer sleep quality, greater insomnia symptoms, and higher risk for sleep apnea. Post-dream craving and distress were both associated with greater insomnia symptoms, poor sleep hygiene behaviors, and greater anxiety symptoms. Individuals who had ever experienced a drug-related dream (recently, or in their lifetime) were more likely to report history of severe withdrawal, overdose, and intravenous opioid use.
Conclusions and Scientific Significance.
Drug-related dreams were common among individuals in the present sample, and were related to other clinically-relevant phenomena. Interventions that treat co-occurring OUD, pain, sleep symptoms, and affective symptoms may improve overall well-being in this population.
Background and Objectives
Dreaming has been a subject of fascination and speculation throughout history1, and the functional meaning of dreaming remains a topic of interest in behavioral health. Dreaming about drug-related content is often reported by patients in substance use treatment2–4, but remains poorly understood.
Modern theories posit that dreaming may be involved in memory consolidation5,6, and may result from memory activation and recombination7. Laboratory studies have demonstrated that participants self-report dreaming about spatial tasks (e.g., a virtual maze task) performed before sleep, and incorporation appears to influence post-sleep task performance8, as well as daily diary studies suggesting that personally significant events, major daily activities, and major concerns are frequently incorporated into dream content9,10. Threat simulation theory11 has also posited that dreaming functions, in-part, as threat simulation by incorporating recent and past threating experiences into dream content, and nightmares are influenced by cross-state factors (i.e., factors that also influence waking states, such as affect load and dispositional distress7). In fact, literature suggests that nightmares often occur within the context of affective distress, other sleep disturbance, and health behavior problems7.
Individuals with opioid use disorder (OUD) (i.e., individuals with a diagnosis based on ICD-9 codes12 or individuals in outpatient opioid-agonist treatment13) may have increased likelihood of exposure to threat experiences, such as experiencing drug-related illness or injury or overdose, and may experience greater environmental stress. Individuals who meet diagnostic criteria for OUD also appear prone to greater dispositional factors that may influence dreaming, such as psychiatric comorbidity14, chronic pain15, and sleep disorders and disturbance16. Further, opioid use can have physiological effects that may increase the likelihood of dreaming. Dreaming in REM and stage N3 sleep, where dreams are most likely to occur17, have both been shown to decrease following acute opioid administration18, and increases in REM sleep or “REM rebound” has been observed during opioid withdrawal19. Thus, increases in dreaming would be expected after opioid cessation, and during nights of rebound REM as a consequence of persistent sleep disturbances that are exacerbated by opioid use.
Early research found that drug-related dreams containing distressing content are relatively common in patients in treatment for substance use2. Results from a nationally-representative sample of individuals with a past alcohol or drug problem suggested that recollection of drug-related dreams was associated with use of a greater number of substances, history of both inpatient and outpatient treatment, current and past mutual-help and 12-step group attendance, and considering oneself to be in recovery4. Moreover, the frequency of alcohol or drug-related dreams declined after a period of sustained abstinence4. In a separate study, patients in substance use treatment experienced greater craving and negative affect following drug-related dreams than they did after having regular dreams and after not dreaming. Active dream content related to searching for drugs, experiencing temptation, and resisting use was strongly associated with negative affect3. However, neither of these studies focused exclusively on patients with OUD. Because opioids may exert specific neurobiological effects on sleep16, further examination among a population of patients in treatment for OUD is warranted.
There is currently a lack of research examining clinically-relevant correlates of drug-related dreams among individuals with OUD. Although a key aim of this study was to facilitate hypothesis generation, we expected that drug-related dream recollection would be higher among 1) individuals with a history of greater opioid use-related problems, such as history of severe withdrawal and history of overdose, 2) individuals with disturbed sleep who may be more prone to awaken and recollect dreams, and 3) among individuals with common OUD-related dispositional factors that influence dreaming, such as chronic pain and affective symptoms. Further, we expected that among individuals who experienced a recent drug-related dream, individuals with greater dispositional distress would also report greater post-dream craving and distress.
Method
Participants
Participants were sourced from the Amazon Mechanical Turk (AMT) registry platform from 5/22/2020–8/8/2020. AMT is an online crowd-sourcing platform used in biomedical research to target difficult-to-reach populations20. The study was advertised as a brief health survey, and only individuals with an approval rating ≥ 90% on AMT who had not previously completed the survey and who were living in the United States were eligible to enroll. Persons completed a screening survey that blinded eligibility criteria through distractor questions (i.e., demographics, and treatment/recovery status of other health conditions, such as cancer and chronic pain). Access to the survey was reserved to persons aged ≥ 18 years, who endorsed being currently in treatment or recovery from OUD. Each participant that responded to the screener received a $0.10 payment, and participants who completed the entire survey received $3.50 and a $0.50 bonus for answering an open-ended question. Participants were informed that participation was voluntary and anonymous. Due to the nature of data collection, the study was submitted to and acknowledged by the Johns Hopkins School of Medicine Institutional Review Board as exempt from IRB review based on category 2 of the Common Rule.
Measures
Demographic characteristics and opioid use history.
Information was collected regarding age, sex, race, marriage status (recoded into married/remarried vs. single/divorced widowed), and income. The standard diagnostic and statistical manual for mental disorders (DSM-5) self-report checklist for OUD was used to assess OUD severity in the time-period leading up to their most recent treatment. Individuals were assessed using a self-reported checklist rather than clinician assessment due to the method of data collection (anonymous survey), similar to other work21,22. Participants endorsed symptoms (range 0–11) and were non-diagnostically assigned to an OUD severity class: none (0–1), mild (2–3), moderate (4–5), severe (<6).
Participants were also asked about their age of first opioid use, preferred route of administration [orally, nasally, intravenously (IV), subcutaneously, transdermal, smoked, or other], current OUD treatment medications [sublingual buprenorphine or buprenorphine/naloxone (e.g., Suboxone ®), extended-release buprenorphine (e.g., Probuphine®, Sublocade®) methadone, oral naltrexone (e.g., Revia®), extended-release naltrexone (e.g., Vivitrol®)], as well as other medications that they had been prescribed in the past 30 days (ADHD medications, such as Ritalin, Adderall, and Strattera; Anxiety medications such as Valium, Klonopin, Xanax, and Ativan; Smoking cessation medications, such as Chantix, Zyban, Wellbutrin, or bupropion). Participants also responded to questions about overdose history, defined in the present study as loss of consciousness, overdose requiring hospitalization, and/or needing to be revived via Narcan®. The Subjective Opioid Withdrawal Scale (SOWS)23 was adapted to measure past withdrawal severity when abruptly stopping opioid use.
Sleep Measures
Drug-related Dream Recollection.
Participants were asked whether they recalled experiencing a drug-related dream (e.g., “In recovery, have you had any dreams about using drugs?”). Those who reported recollection of a drug-related dream answered follow-up questions related to frequency, content, and consequences of the dream. Individuals who reported a recent drug-related dream (in the past week) were asked to 1) provide a description of their most recent drug-related dream recollection, and 2) indicate how much they had wanted to use following the drug-related dream on a Visual Analogue Scale anchored at 0 (“No desire”) and 100 (“Extreme desire”), and 3) indicate whether they had experienced distressing symptoms associated with the dream (Guilt, Anguish, Anger, Fear, Terrified or afraid, Anxious, Disappointment, Depressed, Faint/lightheaded, Hot/cold sweats, Unable to relax, Heart pounding/racing, Shaky/unsteady) on a four-point scale (Not at all, Mildly – it didn’t bother me much, Moderately-it wasn’t pleasant at times, Severely – it bothered me a lot) which were summed to create a measure or overall distress. The items showed good internal consistency (α = .89).
Sleep Quality.
The Pittsburg Sleep Quality Index (PSQI)24 was used to assess sleep disturbance over the past month. Items include statements such as “During the past month, how would you rate your sleep quality overall”. A total score was used in the present study. Reliability of component scores was acceptable in the present sample (α = .71).
Insomnia.
Symptoms of insomnia over the past 2 weeks was characterized via the Insomnia Severity Index (ISI)25, which reports the nature and symptoms of sleep disturbance (e.g., “Difficulty falling asleep”). using a 0–4-point Likert scale, resulting in a total score. Reliability was good in the present sample (α = .88).
Sleep Apnea Risk.
To index the risk of obstructive sleep apnea (OSA), the snoring, tiredness, observed apnea, high BP, BMI, age, and male gender (STOP-BAG)26 questionnaire was administered. Participants were classified as low risk (0–2), moderate risk (3–4), or severe risk (5–7) based on a total score. The measure utilizes all items from the STOP-BANG, a well-validated and widely used measure of OSA, with the exception of neck circumference. The measure has been shown in other studies to successfully predict OSA27. Sample items include statements assessing risk factors for sleep apnea (e.g., BMI, high blood pressure), as well as items assessing self-report of breathing problems during sleep.
Poor Sleep Hygiene Habits.
Participants were also asked several questions on a 5-point Likert-scale (anchored at 0 [never] and 4 [always]), which reflect how often they engage in positive and negative sleep hygiene habits. Sleep hygiene refers to healthy sleep behaviors. Examples of reverse-coded positive sleep hygiene behaviors included items “How often do you wake-up and go to bed at the same time.” Examples of negative sleep hygiene behaviors included items such as “How often do you partake in prolonged screen time before bed (ex. Looking at phones, computers or watching TV)”. Higher scores indicate worse sleep hygiene. Reliability was acceptable in the present sample (α = .72).
Physical and Mental Health Outcomes
Chronic Pain Screening.
The Graded Chronic Pain Scale, Revised (GCPS-R)28 was used to index the presence of chronic pain over the past 3 months. Individuals who reported pain most days or every day in the past 3 months were classified as having at least mild chronic pain, whereas individuals who reported never or sometimes having pain in the past three months were chronic pain absent. Thus, a Cronbach’s alpha was not calculated for this scale.
Stress.
The Perceived Stress Scale (PSS)29 was used to characterize how persons have appraised stressful situations over the past month. The PSS collected self-reported symptoms of stress (e.g., “How often have you felt nervous or stressed?”) using a 4-point Likert scale extending from 0 (never) to 3 (very often). Reliability was good in the present sample (α = .81).
Anxiety.
The Beck Anxiety Inventory (BAI)30 was administered to determine the degree to which persons were bothered by physiological symptoms of anxiety over the past month. Symptoms (e.g., numbness or tingling, heart pounding/racing) were self-reported using a 4-point Likert scale anchored at 0 (not at all) to 3 (severely-it bothered me a lot). Reliability was excellent (α = .95).
Data analysis
Data were screened for normality and outliers. The post-dream emotional distress scale was negatively skewed and square-root transformed. Analyses were performed using transformed and non-transformed values and no differences were found; thus, non-transformed values are reported in order to increase interpretability.
Chi-square tests and one-way ANOVA with follow-up Tukey HSD post-hoc tests were used to explore correlates of recent drug-related dream recollection. Among those who reported experiencing a recent drug-related dream, correlates of post-dream craving and distress were explored using bivariate correlations. In cases where homogeneity of variance was not observed, we also conducted tests that do not make assumptions about equal variance (i.e., unequal variance t-tests, Brown-Forsythe test) to examine stability of the results. As a secondary analysis, we explored relationships between demographic and opioid use characteristics and returning to use as a result of a drug-related dream (i.e., individuals who reported that they had returned to use vs. those who reported that they hadn’t or did not know), among the subset of individuals who reported experiencing a drug-related dream in their lifetime.
Due to the exploratory nature of the analyses, the Benjamini-Hochberg procedure31 was used to correct for the false-discovery rate. Due to the conceptual overlap between independent variables and risk of multicollinearity (i.e., insomnia and sleep quality), we did not conduct multivariate analyses. Analyses were considered significant at p<.05 and were conducted using SPSS version-26.
Results
Sample characteristics
Descriptive demographic information is presented in Table 1. The majority of the sample reported symptoms consistent with severe OUD. Over half of the sample was taking a medication for OUD, slightly over half had overdosed, and around a third reported IV use.
Table 1.
Demographic characteristics of the sample
| Variable | N(%) or M(SD) |
|---|---|
|
| |
| Sex (Female) | 61 (39.6%) |
| Employment (% Employed full or part time) | 135 (87.7%) |
| Hispanic Ethnicity | 31 (20.1%) |
| Race | |
| White/Caucasian | 109 (70.8%) |
| Black/African American | 19 (12.3%) |
| American Indian | 7 (4.5%) |
| Asian | 9 (5.8%) |
| Native Hawaiian/Pacific Islander | 5 (3.2%) |
| More than one race | 5 (3.2%) |
| Marital status | |
| Married or remarried | 98 (63.6%) |
| Never married | 46 (29.9%) |
| Divorced/separated | 9 (5.8%) |
| Widowed | 1 (0.6%) |
| Income | |
| $0–$30,000 | 54 (35.1%) |
| $30,001–$60,000 | 55 (35.7%) |
| $60,001–$90,000 | 23 (14.9%) |
| $90,001+ | 22 (14.3%) |
| Age - M(SD) | 35.13 (8.42) |
| Participant-reported Opioid of Choice | |
| Heroin | 50 (32.5%) |
| Fentanyl | 7 (4.5%) |
| Hydrocodone | 15 (9.7%) |
| Hydrocodone/acetaminophen | 14 (9.1%) |
| Hydromorphone | 8 (5.2%) |
| Meperidine | 4 (2.6%) |
| Methadone | 8 (5.2%) |
| Morphine | 10 (6.5%) |
| Oxycodone | 19 (12.3%) |
| Oxycodone/acetaminophen | 7 (4.5%) |
| Oxycodone/naloxone | 5 (3.2%) |
| Codeine | 7 (4.2%) |
Drug-related dreams
Descriptive information about drug-dreams is presented in Table 2. Fifty-four percent of participants reported that they had experienced a drug-related dream, with 29.2% (n = 45) reporting a drug-related dream prior to the past week, but not in the past week, and 24.5% of the sample reporting a drug-related dream within the past week. Approximately a quarter of the participants that had drug-related dreams indicated that they had drug-related dreams every night or almost every night (i.e., 3–6 nights per week). The most common type of dream involved using drugs, although smaller proportions of participants reported more distressing content, such as overdosing, others overdosing, being forced to use, dying due to drug use, or others dying due to drug use.
Table 2.
Descriptive information – drug-related dreams
| Variable | N(%) |
|---|---|
|
| |
| Most recent drug dream | |
| Within the last week | 38 (24.5%) |
| Prior to the past week, but not in the past week | 45 (29.2%) |
| Never | 71 (46.1%) |
| How long had drug dreams | |
| For the past week | 4 (2.6%) |
| For the past month | 22 (14.3%) |
| For the past three months | 21 (13.6%) |
| For the past six months | 9 (5.8%) |
| For the past year | 13 (8.4%) |
| Longer than one year | 14 (9.1%) |
| No drug dreams | 71 (46.1%) |
| Frequency of drug dreams | |
| Every night | 3 (1.9%) |
| 3–6 nights per week | 18 (11.7%) |
| 1–2 nights per week | 32 (20.8%) |
| 1–2 nights per month | 15 (9.7%) |
| Once per month or next | 15 (9.7%) |
| No drug-related dreams | 71 (46.1%) |
| Ever relapsed because of a drug dream | |
| Yes | 34 (22.1%) |
| No (one or more drug-related dreams, never relapsed as result) | 46 (29.9%) |
| No (no drug-related dreams) | 71 (46.1%) |
| I don’t know | 3 (1.9%) |
| Drug dream content (% endorsed content) | |
| Using drugs (the act of shooting up, snorting, etc.) | 73 (47.4%) |
| Trying to obtain or seek drugs and failing | 55 (35.7%) |
| Trying to obtain or seek drugs and succeeding | 38 (37.7%) |
| The feeling of being high | 55 (35.7%) |
| Being around people who are using drugs | 56 (36.4%) |
| Conflict involving drugs | 34 (22.1%) |
| Overdosing | 32 (20.8%) |
| Others overdosing | 25 (16.2%) |
| Being forced to use drugs | 22 (14.3%) |
| Being offered drugs | 51 (33.1%) |
| Refusing to do drugs | 38 (24.7%) |
| Dying due to drug use | 22 (14.3%) |
| Others dying due to drug use | 31 (20.1%) |
| Accidentally using drugs or alcohol | 32 (20.8%) |
Correlates of drug-related dreams
Correlates of recollecting a recent drug-related dream are presented in Table 3. Individuals who reported having a drug-related dream in the past week reported significantly worse sleep quality on the PSQI than individuals reporting non-recent drug-related dreams (Mean Difference = 2.12, p = .029) and individuals who had never experienced a drug-related dream (Mean Difference = 2.32, p = .006). Individuals who experienced a past-week drug-related dream reported greater insomnia symptoms on the ISI than individuals who had experienced a non-recent drug-related dream (Mean Difference = 4.30, p = .004) and those who never experienced a drug-related dream (Mean Difference = 2.88, p = .045). Finally, individuals who reported a past-week drug-related dream were more likely to screen positive for being high risk for sleep apnea than individuals reporting a non-recent drug-related dream and individuals who never experienced a drug-related dream (23.7% vs. 4.4% and 7.0%, respectively).
Table 3.
Correlates of experiencing a drug-related dream
| No drug-related dreams (n = 71) | Drug-related dreams prior to past week (n = 45) | Drug-related dreams in past week (n = 38) | χ2 or F | p-value | |
|---|---|---|---|---|---|
|
| |||||
| Demographics | |||||
| Age, M(SD) | 36.34 (7.92) | 33.53 (8.89) | 34.76 (8.64) | 1.59 | .208 |
| Male, N(%) | 47 (66.2%) | 24 (53.3%) | 22 (57.9%) | 2.04 | .361 |
| Married/partnered, N(%) | 57 (80.3%) | 19 (42.2%) | 22 (57.9%) | 17.96 | <.001* |
| Hispanic, N(%) | 9 (12.7%) | 14 (31.1%) | 8 (21.1%) | 5.85 | .054 |
| Income, N(%) | 10.21 | .116 | |||
| $0–30,000 | 20 (28.2%) | 20 (44.4%) | 14 (36.8%) | ||
| $30–60,000 | 29 (40.8%) | 10 (22.2%) | 16 (42.1%) | ||
| $60–90,000 | 14 (19.7%) | 5 (11.1%) | 4 (10.5%) | ||
| $90,000+ | 8 (11.3%) | 10 (22.2%) | 4 (10.5%) | ||
| Opioid Use History | |||||
| History of Overdose, N(%) | 26 (36.6%) | 28 (62.2%) | 28 (73.7%) | 15.72 | <.001* |
| History of IV use, N(%) | 9 (12.7%) | 18 (40.0%) | 18 (47.4%) | 17.98 | <.001* |
| SOWS/History of severe withdrawal, M(SD) | 33.30 (13.95) | 39.09 (12.79) | 39.37 (11.31) | 3.97 | .021* |
| DSM OUD Severity, N(%) | NT3 | NT3 | |||
| Mild | 2 (2.8%) | 0 (0.0%) | 1 (2.6%) | ||
| Moderate | 14 (19.7%) | 2 (4.4%) | 0 (0.0%) | ||
| Severe | 55 (77.5%) | 43 (95.6%) | 37 (97.4%) | ||
| OUD Medication, N(%) | 13.38 | .037* | |||
| None | 22 (31.0%) | 23 (51.1%) | 10 (26.3%) | ||
| Methadone | 19 (26.8%) | 11 (24.4%) | 8 (21.1%) | ||
| Buprenorphine1 | 7 (9.9%) | 7 (15.6%) | 7 (18.4%) | ||
| Naltrexone2 | 23 (32.4%) | 4 (8.9%) | 13 (34.2%) | ||
| Other Medications (Past 30 days) | |||||
| ADHD medication | 31 (43.7%) | 15 (33.3%) | 19 (50.0%) | 2.46 | .292 |
| Anti-anxiety medication | 40 (56.3%) | 21 (46.7%) | 24 (63.2%) | 2.34 | .311 |
| Anti-smoking medication | 34 (47.9%) | 14 (28.9%) | 21 (55.3%) | 6.56 | .038* |
| Sleep Measures | |||||
| ISI (past 2W), M(SD) | 13.49 (5.57) | 12.07 (7.38) | 16.37 (4.56) | 5.55 | .005* |
| PSQI (PM), M(SD) | 8.89 (3.11) | 9.09 (4.19) | 11.21 (4.17) | 5.24 | .006* |
| Sleep Apnea Risk, N(%) | 17.33 | .002* | |||
| Low risk | 39 (54.9%) | 32 (71.1%) | 12 (31.6%) | ||
| Moderate risk | 27 (38.0%) | 11 (24.4%) | 17 (44.7%) | ||
| High risk | 5 (7.0%) | 2 (4.4%) | 9 (23.7%) | ||
| Poor sleep hygiene, M(SD) | 18.76 (7.76) | 18.20 (6.09) | 21.29 (5.68) | 2.41 | .093 |
| Pain | |||||
| GCPS (PW), N(%) | 6.08 | .048* | |||
| Grade 0 : Absent | 60 (84.5%) | 31 (68.9%) | 25 (65.8%) | ||
| Grade 1–3: Present | 11(15.5%) | 14 (31.1%) | 13 (34.2%) | ||
| Mental Health Symptoms | |||||
| Anxiety (BAI), M(SD) | 26.49 (14.60) | 23.42 (15.01) | 30.26 (12.49) | 2.38 | .096 |
| Stress (PSS), M(SD) | 19.69 (6.24) | 19.09 (8.53) | 20.26 (4.60) | 0.32 | .725 |
Includes ER buprenorphine
Includes ER naltrexone
Not tested due to small cell sizes
= p<.05.
A higher proportion of individuals who recalled drug-related dreams prior to or during the past week screened positive for chronic pain than those who reported never experiencing a drug-related dream (34.2% and 31.1% vs. 15.5%, respectively). Experiencing a recent drug-related dream was not significantly related to scores on measures of anxiety or stress (ps > .096).
Correlates of post-dream distress and craving
Among those who had experienced a recent drug-related dream (N = 38), post-dream craving was positively associated with greater insomnia symptoms on the ISI (r = .37, p = .021), poor sleep hygiene behaviors (r = .37 p = .019), and greater anxiety symptoms (r = .36, p = .027). Post-dream distress was also related to insomnia symptoms on the ISI (r = .46, p = .003), poor sleep hygiene behaviors (r = .48, p = .002), and greater anxiety symptoms (r = .66, p < .001). Post-dream distress and post-dream craving were unrelated to demographic characteristics (ps > .258), opioid-use variables (ps > .232), and perceived stress (ps > .085).
Correlates of Lapse to Use Following a Drug-Related Dream
Among participants who reported that they experienced a drug-related dream, 41.0% (n = 34) reported that they had relapsed in their lifetime as a result of a drug-related dream. Individuals who indicated that a drug-related dream had caused a lapse to use were more likely to describe their ethnicity as Hispanic/Latino (χ2(1, N = 83) = 6.36, p = .012), to be married (χ2(1, N = 83) = 25.02, p < .001), and to have experienced overdose (χ2(1, N = 83) = 11.32, p = .001). Sex, age, income, race, history of severe withdrawal, and history of IV use were unrelated to experiencing a lapse to use from a drug-related dream. Among those reporting a past-week drug-related dream, individuals reporting return to use associated with a drug-related dream reported higher post-dream distress (t(36) = −2.36, p = .024), but did not report greater post-dream craving (t(36) = 01.28, p = .210).
Discussion
Drug-related dreams are commonly reported among individuals screening positive for OUD, but have received limited attention. The purpose of the present study was to contextualize drug-related dreams in relation to other clinically-relevant phenomena known to occur in OUD. As expected, individuals who reported current sleep disturbance and chronic pain, and past severe opioid use symptoms (e.g., history of severe withdrawal, IV use, overdose) were more prone to recollect drug-related dreams. Contrary to expectations, affective symptoms were not related to drug-related dreams.
Consistent with previous work2–4, drug-related dreams were common in this study, with over half recalling at least one prior drug-related dream. Drug-related dreams were particularly prevalent among individuals experiencing other sleep disturbances, such as symptoms of insomnia and sleep apnea. One possible explanation for these findings is that persistent sleep disturbance leads to nights of “rebound REM” sleep, which have been associated with vivid dreams in other populations32 and could partially account for the drug-related dreams experienced by persons screening positive for OUD. Alternatively, difficulties sleeping may increase the likelihood of waking up and recollecting a dream, and post-dream distress may lead to difficulties returning to sleep. Supporting this possibility, we found post-dream distress and craving were associated with insomnia symptom severity. If future investigations suggest that drug-related dreams reinforce maladaptive sleep health behaviors in OUD, cognitive-behavioral sleep interventions could be appropriately tailored to the needs of this vulnerable population. Currently, the literature has not examined the frequency with which opioid treatment providers assess for and treat sleep disturbance. Some opioid treatment programs (i.e., methadone and buprenorphine treatment providers33) require frequent contact with patients, particularly during the early stabilization period before take-home privileges are earned, allowing providers an opportunity to routinely assess and respond to sleep disturbance.
Previous work suggests that distress stemming from nightmares is associated with dispositional affect distress7. Although individuals experiencing drug-related dreams in this study did not report greater anxiety or stress, individuals with anxiety were more likely to experience post-dream distress and craving. Thus, it may be beneficial for providers to normalize the experience of drug-related dreams, and to provide psychoeducation about changes in sleep following abstinence from opioid use (e.g., possible increases in dreaming resulting from increased stage 4 and REM sleep). Some evidence also suggests anxiety symptoms improve following treatment of insomnia and other sleep disorders34. Thus, adjunctive treatments for sleep, such as cognitive behavioral therapy for insomnia (CBT-I) may be beneficial in reducing the emotional impact of drug-related dreams, in addition to having three-fold beneficial effects on those with co-occurring insomnia, chronic pain, and mood disorders35,36. Finally, future studies should also examine whether the usage, timing, or dosage of antidepressant medications influence drug-related dreams, as many of these medications can impact REM consolidation generally37.
Contrary to expectations, perceived stress was unrelated to post-dream craving or distress. It is possible that the relationship between stress and post-dream craving or distress is a dynamic process unable to be captured by the cross-sectional design of the study. Future work should consider daily diary methodology to explore whether changes in affective load and perceived stress are associated with 1) likelihood of experiencing drug-related dreams, and 2) the extent to which drug-related dreams are perceived as distressing. Daily diary methodology may also be useful in capturing whether the experience of drug-related dreams changes during periods of use and non-use, particularly in early recovery. Additionally, future work should test whether drug-related dreams resolve following continued abstinence from opioids and/or stabilization on a medication, as information about the typical time course of drug-related dreams may be beneficial for patients who are experiencing distressing dreams.
There were some limitations in the present study. Due to the lack of literature on drug-related dreams, many of the present analyses were exploratory and should be validated in future studies. We used a convenience sample of individuals who screened positive for OUD, although it should be noted that we used distractor questions when assessing eligibility to minimize the likelihood of individuals misrepresenting symptoms. Individuals were allowed to participate regardless of how long they had been in treatment. Further, we did not examine how other substance use is related to recollection of drug-related dreams, a topic that should be explored in future work. The sample size in the present study was small, particularly for some of the sub-analyses, which may limit generalizability. Additionally, future studies should examine the role of cultural factors in drug-related dreams, as contextual differences in dreaming have been observed in different cultures, including the perceived meaningfulness of dreaming38.
Conclusions
This was among the first examinations of drug-related dreams among individuals who screened positive for OUD. Results suggest that drug-related dreams are common and often occur in the context of other sleep disturbances, such as poor sleep quality, insomnia symptoms, risk for sleep apnea, as well as chronic pain. Individuals experiencing anxiety may be more likely to experience drug-related dreams as distressing, or to experience craving after experiencing a drug-related dream. Assessment and treatment of sleep-related disturbance and co-occurring disorders among individuals with OUD may improve well-being among this population.
Acknowledgments
This study was supported by the National Institute on Drug Abuse T32 DA007209 (Bigelow) and the National Heart, Lung, and Blood Institute U01 HL150835 01 (Huhn/Finan).
Footnotes
Declaration of Interest
ASH receives research funding from Ashley Addiction Treatment through his university. JDE, JLM, CEG, & PHF report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.
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