Can Suboxone (buprenorphine) cause insomnia?

Can Suboxone Cause Insomnia?

Yes, Suboxone (buprenorphine/naloxone) can cause insomnia as a significant side effect, with studies showing that 46-68% of patients on buprenorphine maintenance therapy experience clinically significant insomnia symptoms.

Evidence for Suboxone-Related Sleep Disturbances

Research clearly demonstrates that sleep disturbances are common among patients receiving buprenorphine:

• A 2017 study found that 71% of persons receiving buprenorphine treatment reported sleep difficulties 1
• Another study reported that 46-68% of patients on buprenorphine maintenance treatment (BMT) experienced clinically significant insomnia as measured by the Athens Insomnia Scale 2
• A 2024 study showed approximately 60% of participants on buprenorphine reported clinically significant insomnia symptoms 3

Mechanisms and Risk Factors

Several factors may contribute to insomnia in patients taking Suboxone:

• Pharmacological properties: Buprenorphine is a partial μ-opioid agonist that can affect sleep architecture
• Gender differences: Women may be at higher risk, as men were significantly less likely to report disturbed sleep (OR = 0.57) 1
• Treatment duration: Persons reporting sleep disturbance had shorter time in buprenorphine treatment compared to those without sleep difficulty 1
• Comorbid conditions: Insomnia symptoms were strongly associated with depression and anxiety 1, 3

Sleep-Disordered Breathing

Beyond insomnia, Suboxone may cause other sleep disturbances:

• A 2013 study found that 63% of patients on buprenorphine/naloxone had at least mild sleep-disordered breathing 4
• Moderate to severe sleep apnea was present in 33% of patients 4
• Hypoxemia during sleep was observed in 38.6% of patients despite buprenorphine's supposed "ceiling effect" on respiratory depression 4

Management Options

For patients experiencing insomnia while on Suboxone:

1. Non-pharmacological approaches:

   • Cognitive behavioral therapy for insomnia (CBT-I) has been shown to be highly effective 5
   • Implement strict sleep hygiene practices 6

2. Pharmacological options (if non-pharmacological approaches are insufficient):

   • Trazodone: A 2023 double-blind, placebo-controlled trial showed trazodone (50-150mg) was effective and well-tolerated for improving sleep in patients on buprenorphine 7
   • Sedating antidepressants: Mirtazapine may be used for sleep and offers additional benefits like appetite stimulation 5
   • Melatonin: May be considered as it has a small improvement in sleep quality 5

3. Medications to avoid:

   • Benzodiazepines: The FDA label for buprenorphine warns that profound sedation, respiratory depression, coma, and death may result from concomitant use with benzodiazepines 8
   • Other CNS depressants: Similar risks exist with non-benzodiazepine sedatives/hypnotics 8

Clinical Approach

When a patient on Suboxone reports insomnia:

1. Assess severity using validated tools like the Insomnia Severity Index or Pittsburgh Sleep Quality Index 6
2. Rule out other causes of sleep disturbance (sleep apnea, restless legs syndrome)
3. Start with CBT-I and sleep hygiene as first-line treatment
4. Consider trazodone if non-pharmacological approaches are insufficient (based on recent evidence) 7
5. Monitor closely for adverse effects and interactions

Important Considerations

• Sleep disturbances may negatively impact opioid use disorder treatment outcomes 3
• Patients with insomnia on buprenorphine often report that poor sleep interferes with their treatment 3
• The insomnia may improve with longer duration of buprenorphine treatment 1

Remember that addressing sleep disturbances is an important component of successful opioid use disorder treatment and may help improve overall treatment outcomes and quality of life.