What are the non-pharmacologic and pharmacologic treatment recommendations for a patient with anxiety, insomnia, and substance use issues?

Non-Pharmacologic Recommendations for Insomnia with Anxiety and Substance Use Issues

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for MJ's insomnia due to its superior long-term efficacy, minimal adverse effects, and effectiveness in patients with substance use disorders. 1, 2

Primary Non-Pharmacologic Interventions

• CBT-I has been shown to be more effective than pharmacotherapy in the long-term management of chronic insomnia and should be implemented before considering medication options 1
• CBT-I is particularly valuable for patients with substance use disorders as it avoids introducing potentially addictive medications 3, 4
• Key components of effective CBT-I include:
  • Sleep restriction therapy - limiting time in bed to match actual sleep time to improve sleep efficiency 1
  • Stimulus control - breaking negative associations between the bed/bedroom and wakefulness 1, 2
  • Cognitive restructuring - addressing maladaptive thoughts and beliefs about sleep 1, 2

Specific Behavioral Techniques

• Sleep restriction therapy: Based on sleep logs, limit time in bed to the actual sleep time (but not less than 5 hours), then gradually increase as sleep efficiency improves above 85% 1
• Stimulus control instructions:
  • Go to bed only when sleepy
  • Use the bed only for sleep
  • Leave the bed if unable to fall asleep within approximately 20 minutes
  • Return to bed only when sleepy again
  • Maintain a regular wake-up time regardless of sleep duration 1
• Relaxation training: Progressive muscle relaxation to reduce somatic and cognitive arousal that interferes with sleep 1

Additional Non-Pharmacologic Approaches

• Regular exercise, particularly aerobic activities like walking or jogging, can help reduce anxiety symptoms and improve sleep quality 1, 5
• For anxiety management, incorporate specific techniques:
  • Deep breathing exercises
  • Mindfulness practices
  • Problem-solving skills 1, 5
• Sleep hygiene education (as part of comprehensive treatment, not as standalone therapy):
  • Avoid caffeine, alcohol, and nicotine, especially in the evening
  • Create a comfortable sleep environment
  • Establish consistent sleep-wake times
  • Avoid daytime napping 1, 2

Special Considerations for Substance Use

• The relationship between insomnia and substance use disorders is bidirectional - each can exacerbate the other 3, 4
• Regular reassessment of sleep patterns throughout substance use treatment is essential 3
• For patients with substance use disorders, non-pharmacological approaches should be strongly emphasized to avoid triggering or worsening substance use issues 4, 6

Implementation Considerations

• While CBT-I is highly effective, access to trained practitioners may be limited 7
• Self-help CBT-I materials (such as weekly booklets providing information on components of CBT-I) have shown clinically significant improvements in insomnia severity, sleep efficiency, and sleep quality 1
• Brief, focused CBT interventions that include psychoeducation, exercise prescription, and psychosocial support can be effective when delivered in primary care settings 5

Common Pitfalls to Avoid

• Relying solely on sleep hygiene education, which is insufficient as a standalone treatment for chronic insomnia 1, 2
• Using sedating substances (including alcohol) to self-medicate sleep problems, which can worsen both insomnia and substance use issues in the long term 4, 6
• Failing to address underlying anxiety that may be contributing to sleep difficulties 1
• Neglecting to provide adequate follow-up and support during implementation of behavioral techniques 2