What sleep medication is recommended for individuals with alcohol use disorder (AUD) experiencing sleep disturbances?

Sleep Medication Recommendations for Alcohol Use Disorder

For patients with alcohol use disorder experiencing sleep disturbances, trazodone is the recommended first-line pharmacological intervention, while cognitive behavioral therapy for insomnia (CBT-I) should be implemented concurrently as the foundation of treatment. 1, 2

First-Line Approach

Non-Pharmacological Interventions

• CBT-I should be the initial foundation of treatment for all patients with AUD and sleep disturbances
  • Includes stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring
  • Should be attempted for at least 4-6 weeks before considering medication changes 1
• Sleep hygiene practices are essential:
  • Maintain consistent bed and wake times
  • Avoid alcohol completely (critical for recovery)
  • Avoid caffeine and nicotine, especially in the afternoon/evening
  • Create a restful bedroom environment
  • Limit daytime napping 1

First-Line Pharmacological Options

• Trazodone (sedating antidepressant) is the preferred medication, chosen by 38% of addiction medicine physicians 2
  • Typical starting dose: 25-50mg at bedtime
  • Can be titrated up as needed
  • Duration of therapy typically exceeds one month
  • Does not have cross-dependence potential with alcohol

Important Considerations and Cautions

Medications to Avoid

• Benzodiazepines and benzodiazepine receptor agonists (BzRAs) should be strictly avoided due to:

  • Cross-dependence with alcohol 3
  • High risk of abuse potential
  • Risk of respiratory depression when combined with alcohol relapse
  • FDA warnings regarding complex sleep behaviors 4

• Avoid eszopiclone and other Z-drugs (zolpidem, zaleplon) due to:

  • Risk of abnormal thinking and behavioral changes
  • Potential for physical dependence and withdrawal symptoms
  • Increased risk of next-day impairment 5, 4

Second-Line Options

If trazodone is ineffective or poorly tolerated:

• Other sedating antidepressants (12% of addiction specialists prefer these) 2
  • Mirtazapine (15mg at bedtime)
  • Low-dose doxepin (3-6mg)
• Antihistamines (12% of specialists use these) 2
  • However, these have limited evidence and may cause daytime sedation

Monitoring and Follow-Up

• Sleep disturbances in AUD patients may persist for weeks to years during abstinence 6
• Regular assessment of sleep quality using validated tools like the Short Sleep Index (SSI) 7
• Schedule follow-up within 7-10 days of any treatment change 1
• Monitor for:
  • Treatment effectiveness
  • Side effects
  • Signs of relapse (poor sleep is a major risk factor for drinking relapse) 8

Special Considerations

• Sleep disturbances independently increase relapse risk, making effective treatment crucial for maintaining sobriety 3
• Cognitive impairments from both alcohol use and sleep disturbances can compound each other, potentially hindering recovery 8
• Treatment duration may need to be longer than for primary insomnia, as IAAC (Insomnia Associated with Alcohol Cessation) can persist long-term 6

Remember that addressing sleep disturbances is not just about improving sleep quality but is also a critical component of relapse prevention in alcohol recovery.