Treatment of Insomnia in Persons with Addiction Issues
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the definitive first-line treatment for insomnia in patients with substance use disorders, as it avoids the risks of dependence, tolerance, and relapse associated with pharmacotherapy while demonstrating effectiveness in this population. 1, 2, 3
Primary Treatment Approach
CBT-I as Essential First-Line Therapy
CBT-I must be the initial intervention for all patients with addiction issues and insomnia, as it provides sustained benefits for up to 2 years without risks of tolerance, dependence, or adverse effects inherent to medications. 1, 2
CBT-I has demonstrated effectiveness specifically in patients with substance use disorders, with 80% of participants achieving insomnia remission (ISI ≤8) compared to 25% with standard care in outpatient SUD treatment settings. 3
The therapy must include four critical components: sleep restriction therapy (limiting time in bed to match actual sleep duration), stimulus control therapy (breaking bed-wakefulness associations), cognitive therapy (targeting maladaptive sleep beliefs), and sleep hygiene education. 1
Face-to-face CBT-I with at least four sessions is more effective than self-help interventions or briefer treatments, which is particularly important for patients with comorbid conditions like addiction. 4
Pharmacotherapy Considerations (Second-Line Only)
When Medications May Be Considered
Pharmacotherapy should only be considered if CBT-I is ineffective, unavailable, the patient cannot participate, or as a temporary adjunct during severe symptoms. 1, 2
In patients with addiction issues, benzodiazepines and benzodiazepine receptor agonists (BzRAs) should be avoided due to high risk of dependence, cross-tolerance with alcohol, and potential for relapse. 5, 6
Safer Pharmacological Options for Addiction Populations
Ramelteon (8 mg) is the preferred pharmacological option when medication is necessary, as it has no abuse potential even at doses 20 times the therapeutic dose and is specifically indicated for sleep onset insomnia. 5, 7, 6
Mirtazapine exhibits moderate evidence for treating insomnia in alcohol use disorder patients and may be particularly useful when comorbid depression exists. 6
Gabapentin immediate release shows moderate evidence for insomnia in AUD populations and may provide dual benefits for both sleep and substance use symptoms. 6
Low-dose doxepin (3-6 mg) is an alternative for sleep maintenance insomnia without significant abuse potential. 1, 5
Trazodone has low-level evidence but may be considered when other options are contraindicated, though it is not formally recommended by guidelines. 5, 6
Critical Pitfalls to Avoid
Never use benzodiazepines (including lorazepam, temazepam, triazolam) or Z-drugs (zolpidem, zaleplon, eszopiclone) in patients with active or recent substance use disorders due to cross-addiction risk and potential for relapse. 5, 6
Avoid over-the-counter antihistamines (diphenhydramine) as they lack efficacy data, cause problematic daytime sedation, and have no role in treating insomnia in any population. 1, 5, 2
Do not prescribe antipsychotics like quetiapine as first-line treatment despite their common off-label use, as they carry problematic metabolic side effects. 1, 2
Pay particular attention to patients who use alcohol to help fall asleep, as they have higher relapse risk after stopping treatment. 6
Treatment Algorithm for Addiction Populations
Initiate CBT-I immediately as primary intervention with at least 4 face-to-face sessions including all core components. 1, 2, 4
Support abstinence or reduction in substance use, as this alone may improve insomnia symptoms. 6
If CBT-I insufficient after adequate trial (typically 4-8 weeks), consider ramelteon 8 mg as first pharmacological choice due to zero abuse potential. 5, 7
For persistent symptoms or comorbid depression/anxiety, consider mirtazapine or gabapentin as second-line options with moderate evidence in addiction populations. 6
Provide regular follow-up every 1-2 weeks initially, then every 6 months once stabilized, to monitor both insomnia and substance use outcomes. 1
Special Considerations
Insomnia has been implicated in the development, maintenance, worsening, and relapse of alcohol use disorder, making aggressive treatment essential for recovery. 6
CBT-I shows larger effects on psychiatric comorbidities (common in addiction) compared to medical conditions, with small to medium positive effects across comorbid outcomes. 8
Coordination with addiction treatment staff is essential for successful implementation of sleep interventions in SUD treatment settings. 3