What are the treatment options for insomnia in patients with Post-Acute Withdrawal Syndrome (PAWS)?

Treatment of Insomnia in Post-Acute Withdrawal Syndrome (PAWS)

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for insomnia in PAWS, with melatonin or trazodone as preferred pharmacological adjuncts if needed, while avoiding benzodiazepines due to the high risk of dependence in this population. 1, 2

Understanding PAWS-Related Insomnia

Insomnia is extremely common in post-acute withdrawal syndrome, affecting approximately 31.7% of individuals with lifetime alcohol dependence and up to 50% of those who experienced acute withdrawal symptoms. 3 Importantly, impaired sleep can persist well beyond the acute withdrawal period, with some patients experiencing insomnia peaks as late as 160-169 days after abstinence, suggesting it represents a protracted withdrawal symptom. 4

First-Line Treatment: CBT-I

CBT-I must be initiated as the foundation of treatment before or alongside any pharmacotherapy, as it provides superior long-term outcomes and addresses the underlying mechanisms maintaining insomnia without risk of dependence. 1, 5

Core CBT-I Components to Implement:

• Stimulus control therapy: Go to bed only when sleepy, maintain regular sleep-wake schedule, avoid naps, use bed only for sleep, leave bed after 20 minutes if unable to sleep 6, 5
• Sleep restriction therapy: Track total sleep time for 1-2 weeks, then limit time in bed to match actual sleep time to consolidate sleep 6, 5
• Cognitive therapy: Address distorted beliefs about sleep that perpetuate insomnia 6, 5
• Relaxation training: Progressive muscle relaxation and other techniques 6

CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats show effectiveness. 1, 5 Treatment typically requires 4-8 sessions over 6 weeks, with improvements being gradual but sustained for up to 2 years. 5

Pharmacological Treatment Algorithm

First-Line Pharmacological Options (Only After or Alongside CBT-I):

For PAWS patients, avoid benzodiazepines and benzodiazepine receptor agonists (BzRAs) as first-line agents due to the substantial risk of dependence and withdrawal symptoms in this population. 2, 7

Preferred initial pharmacological options:

• Ramelteon 8 mg: Non-DEA-scheduled medication particularly appropriate for patients with substance use history, effective for sleep onset difficulty 2, 6
• Melatonin (extended-release formulation): Should be considered for sleep initiation, though evidence is limited in general insomnia populations 1
• Trazodone: Commonly used as second-choice treatment (57% of clinicians), particularly when comorbid depression/anxiety is present 1

Second-Line Options (If First-Line Fails):

• Low-dose doxepin 3-6 mg: Specifically for sleep maintenance insomnia 2
• Mirtazapine: Sedating antidepressant that may be appropriate when comorbid depression exists 1

Medications to AVOID in PAWS:

Benzodiazepines (lorazepam, alprazolam, temazepam, triazolam) should be avoided due to risk of respiratory depression, ataxia, excessive sedation, memory impairment, paradoxical disinhibition, and critically—dependence and withdrawal symptoms that can perpetuate the cycle of substance use. 1

Non-benzodiazepine BzRAs (zolpidem, eszopiclone, zaleplon) should be used with extreme caution or avoided as they carry similar dependence risks. Studies show that 10.5% of patients develop clinically relevant withdrawal symptoms even after 24 weeks of eszopiclone at standard doses, with dependence and poor compliance being significant predictors. 7

Second-generation antipsychotics (quetiapine) should not be prescribed for insomnia alone due to significant metabolic side effects including metabolic syndrome. 1

Over-the-counter antihistamines (diphenhydramine, hydroxyzine) are not recommended due to lack of efficacy data, daytime sedation, and risk of delirium. 1, 2

Implementation Strategy

1. Initiate CBT-I immediately as the cornerstone of treatment 1, 5
2. If CBT-I alone is insufficient after 2-4 weeks, add ramelteon or melatonin while continuing CBT-I 2, 6
3. If sleep disturbance persists, consider trazodone or low-dose doxepin based on symptom pattern (sleep onset vs. maintenance) 1, 2
4. Use the lowest effective dose for the shortest duration possible, with regular reassessment every few weeks 1
5. Attempt medication tapering when conditions allow, facilitated by concurrent CBT-I 6

Critical Pitfalls to Avoid

• Never prescribe benzodiazepines or BzRAs as first-line treatment in PAWS patients—this violates best practice and creates substantial risk of perpetuating substance dependence 2, 7
• Do not rely on sleep hygiene education alone—it lacks efficacy as a single intervention and must be combined with other CBT-I components 5
• Avoid combining multiple sedative medications, which significantly increases risks of cognitive impairment, falls, and complex sleep behaviors 2
• Do not continue pharmacotherapy long-term without periodic reassessment and attempts at tapering 2, 6
• Never use antipsychotics for insomnia treatment alone due to problematic metabolic side effects 1

Monitoring and Follow-Up

• Reassess patients every 1-2 weeks initially to evaluate efficacy on sleep latency, sleep maintenance, daytime functioning, and monitor for adverse effects 2, 6
• Educate patients about treatment goals, realistic expectations (gradual improvement), safety concerns, and the importance of behavioral treatments 6, 5
• Screen for underlying sleep disorders (sleep apnea, restless legs syndrome) if insomnia persists beyond 7-10 days of treatment 2
• Monitor for relapse risk, as insomnia during both acute and post-acute withdrawal is strongly associated with relapse to substance use 3