Codeine Is Not Safe for Treating Insomnia
Codeine is not recommended as a safe option for treating insomnia due to significant risks of respiratory depression, dependence, and lack of supporting evidence. 1 Instead, evidence-based approaches should be utilized.
First-Line Treatment: Non-Pharmacological Approaches
Cognitive Behavioral Therapy for Insomnia (CBT-I)
- Recommended as first-line treatment by multiple guidelines including the American Academy of Sleep Medicine and American College of Physicians 1
- Components include:
- Stimulus control
- Sleep restriction therapy
- Relaxation training
- Cognitive therapy addressing negative thoughts about sleep
- Sleep hygiene education
Other Non-Pharmacological Interventions
- Regular physical activity (30 minutes daily, preferably morning or afternoon) 1
- Morning exposure to bright light to regulate circadian rhythm 1
- Sleep hygiene practices 2
Second-Line Treatment: Evidence-Based Pharmacological Options
If non-pharmacological approaches are insufficient, consider these medications based on insomnia type:
For Sleep Onset Insomnia:
- Zolpidem: 10mg (adults), 5mg (elderly)
- Zaleplon: 10mg
- Ramelteon: 8mg 1
For Sleep Maintenance Insomnia:
- Doxepin: 3-6mg
- Eszopiclone: 2-3mg
- Temazepam: 15mg
- Suvorexant: 10-20mg 1
Other Appropriate Options:
- Trazodone: 50-100mg at bedtime (preferred over quetiapine due to better evidence and fewer metabolic risks) 1
- Melatonin, including extended-release formulations 3
Why Codeine Is Not Appropriate for Insomnia
Respiratory Depression Risk: As an opioid, codeine can cause dangerous respiratory depression, especially when used for sleep 4
Dependence and Addiction: Opioids like codeine carry significant risk of dependence and addiction 5
Association with Sleep Problems: Research shows opioid use is actually associated with increased insomnia (42% higher likelihood) 5
Not Recommended in Guidelines: No major sleep medicine guidelines recommend opioids for insomnia treatment 3, 1
Better Alternatives Exist: Multiple safer and more effective options are available, as outlined above 1
Special Considerations
Elderly Patients: Use lower doses of any sedating medications due to increased risk of falls and cognitive impairment 1
Patients with Substance Use History: Avoid potentially addictive medications; prefer non-scheduled options like ramelteon or doxepin 1
Monitoring: Schedule follow-up within 2-4 weeks after initiating any treatment to evaluate effectiveness and monitor for side effects 1
Common Pitfalls to Avoid
Inappropriate Use of Antipsychotics: Medications like quetiapine should not be prescribed solely for sleep disturbances due to significant side effects including metabolic syndrome 3
Prolonged Medication Use: Limit pharmacological treatment to 4-5 weeks when possible 1
Ignoring Underlying Causes: Ensure proper evaluation of potential underlying causes of insomnia before initiating treatment 3
Overlooking Non-Pharmacological Options: Many providers jump directly to medications without trying evidence-based non-pharmacological approaches first 2