What are the non-narcotic treatment options for insomnia?

Non-Narcotic Treatment for Insomnia

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I should be the initial treatment for all patients with chronic insomnia, as it is recommended by the American Academy of Sleep Medicine, American College of Physicians, and VA/DoD as the standard of care with superior long-term efficacy compared to any pharmacological option. 1, 2, 3

Why CBT-I is Superior

• CBT-I provides sustained benefits for up to 2 years without risk of tolerance, dependence, or adverse effects that are inherent to medications 2, 3, 4
• The therapy produces clinically meaningful improvements: sleep onset latency reduces by approximately 19 minutes, wake after sleep onset decreases by 26 minutes, and sleep efficiency improves by nearly 10% 4
• CBT-I is effective in 70-80% of patients with chronic insomnia 5

Core Components of Effective CBT-I

The American Academy of Sleep Medicine recommends that CBT-I must include these critical behavioral and cognitive components 1, 2:

• Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep 2
• Stimulus control therapy: Breaks the association between bed/bedroom and wakefulness through specific instructions (go to bed only when sleepy, use bed only for sleep and sex, leave bed if unable to sleep within 15-20 minutes) 1, 2
• Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, and behavioral experiments 2
• Sleep hygiene education: Addresses environmental and behavioral factors, though this alone is insufficient as monotherapy 1, 3

Treatment Delivery

• Standard CBT-I is delivered over 4-8 sessions with a trained specialist 2
• Brief Therapies for Insomnia (BTIs) are abbreviated versions emphasizing behavioral components when resources are limited 2
• Internet-based CBT-I has shown clinically significant improvements and can be used when in-person therapy is unavailable 1

Second-Line Treatment: Pharmacotherapy (Only When CBT-I Fails or Is Unavailable)

Medications should only be considered when patients cannot participate in CBT-I, still have symptoms despite CBT-I, or as a temporary adjunct to CBT-I. 1, 3

FDA-Approved Non-Narcotic Medications

The American Academy of Sleep Medicine identifies these non-narcotic options 1, 3:

• Ramelteon: Melatonin receptor agonist indicated for sleep onset insomnia, reduces latency to persistent sleep without abuse potential at doses up to 20 times the recommended therapeutic dose 6
• Low-dose doxepin: Selective histamine H1 antagonist for sleep maintenance insomnia 3
• Suvorexant/Lemborexant: Orexin receptor antagonists (newer non-narcotic options) 7

Benzodiazepine Receptor Agonists (BzRAs)

While technically non-narcotic, these carry significant risks 1, 3:

• Eszopiclone, zolpidem, zaleplon, triazolam, and temazepam may be considered for sleep onset and maintenance
• Critical caveat: These medications carry risks of falls, cognitive impairment, tolerance, and dependence, particularly in older adults 3
• Short-term use only is recommended due to concerns about long-term adverse effects 3

Treatment Algorithm

1. Start with CBT-I as primary intervention for all patients with chronic insomnia 1, 2, 3
2. Monitor progress using sleep diary data collected before and during treatment 2, 3
3. Consider pharmacotherapy only if CBT-I is ineffective, unavailable, or patient cannot participate 1, 3
4. If medication is necessary, select based on primary complaint:
   • Sleep onset difficulty: Ramelteon 6
   • Sleep maintenance difficulty: Low-dose doxepin 3
   • Short-term use of BzRAs only when other options fail 1, 3
5. Regular follow-up until insomnia stabilizes, then every 6 months 2

Common Pitfalls to Avoid

• Never use sleep hygiene education alone as primary treatment—it is insufficient for chronic insomnia and should only be an adjunct to CBT-I 1, 8
• Avoid melatonin for chronic insomnia treatment—the American Academy of Sleep Medicine specifically recommends against it due to insufficient evidence 2
• Do not use antihistamines (over-the-counter sleep aids) as they lack demonstrated efficacy and have safety concerns 1
• Exercise extreme caution with medications in older adults due to increased risk of falls, cognitive impairment, and adverse effects 3
• Avoid long-term benzodiazepine use due to tolerance, dependence, and cognitive risks 3
• Sleep restriction may be contraindicated in patients with high-risk occupations, predisposition to mania/hypomania, or poorly controlled seizure disorders 2

Special Populations

For pregnant women: CBT-I remains the first-line treatment with the same core components (sleep restriction, stimulus control, cognitive restructuring), as it has a favorable benefit-to-risk ratio without medication exposure 9