What alternative sleep aids can be considered for an adult patient with a history of insomnia and substance abuse, currently taking Ativan (lorazepam) 1mg, Suboxone (buprenorphine/naloxone) 2mg, Hydroxyzine 25mg, and Synthroid (levothyroxine), who has tried Ambien (zolpidem) but experienced residual sedation and is considering increasing Ativan to 2mg for sleep?

Alternative Sleep Medications for This Patient

Given this patient's history of substance use disorder (on Suboxone), increasing Ativan to 2mg is contraindicated—instead, prioritize low-dose doxepin 3-6mg or a dual orexin receptor antagonist (DORA) like suvorexant, lemborexant, or daridorexant, while simultaneously implementing Cognitive Behavioral Therapy for Insomnia (CBT-I). 1, 2

Critical Safety Concerns with Current Plan

Do not increase Ativan (lorazepam) to 2mg in this patient. The combination of:

• Benzodiazepines (Ativan)
• Opioids (Suboxone/buprenorphine)
• Sedating antihistamines (hydroxyzine)

...creates dangerous polypharmacy with significantly increased risks of respiratory depression, cognitive impairment, falls, complex sleep behaviors, and overdose. 1

Why Benzodiazepines Are Problematic Here

• Lorazepam is considered second or third-line for insomnia, not first-line 1
• Patients with substance use disorders should avoid benzodiazepines entirely when possible 1
• The American Academy of Sleep Medicine specifically recommends against using benzodiazepines as first-line treatment 1
• Long-term benzodiazepine use carries risks of dependence, withdrawal, cognitive impairment, and falls 1

First-Line Pharmacologic Alternatives

Option 1: Low-Dose Doxepin (Preferred for Sleep Maintenance)

Start doxepin 3-6mg at bedtime 1, 2, 3

• Specifically FDA-approved for sleep maintenance insomnia 3
• Reduces wake after sleep onset by 22-23 minutes and increases total sleep time by 26-32 minutes 3
• Minimal abuse potential—critical for patients with substance use history 1
• Does not interact significantly with Suboxone 1
• Lower risk profile than benzodiazepines 1, 2

Option 2: Dual Orexin Receptor Antagonists (DORAs)

Consider suvorexant 10-20mg, lemborexant, or daridorexant 1, 4

• Work by inhibiting wakefulness rather than inducing sedation 4
• No evidence of rebound insomnia, withdrawal, or abuse potential—making them ideal for patients with substance use disorders 4
• Suvorexant reduces wake after sleep onset by 16-28 minutes 1, 3
• Daridorexant has an ideal 8-hour half-life with demonstrated 12-month efficacy 4
• Lemborexant offers pharmacokinetic advantages over suvorexant 1
• Specifically recommended for patients with substance abuse history 1

Option 3: Alternative BzRAs (If Above Options Fail)

Try eszopiclone 2-3mg or low-dose zolpidem 5mg (only if doxepin and DORAs are ineffective) 1, 2

• Eszopiclone addresses both sleep onset and maintenance, improving total sleep time by 28-57 minutes 3
• Zolpidem 5mg (lower than standard 10mg) may reduce next-day grogginess that occurred with Ambien 1, 5
• However, zolpidem still carries FDA warnings about complex sleep behaviors, driving impairment, and falls 5, 6
• These agents have lower abuse potential than benzodiazepines but still require caution in substance use disorder 1

What NOT to Use

Avoid these options entirely: 1, 2

• Trazodone: Not recommended by American Academy of Sleep Medicine despite common use 2
• Over-the-counter antihistamines (diphenhydramine): Lack efficacy data, cause daytime sedation and delirium risk 1, 2
• Melatonin/valerian/herbal supplements: Insufficient evidence of efficacy 1, 2
• Long-acting benzodiazepines: Increased risks without clear benefit 1

Essential Non-Pharmacologic Component

Implement CBT-I immediately alongside any medication change 1, 2

• CBT-I is the gold standard first-line treatment for chronic insomnia with superior long-term efficacy compared to medications alone 1, 2
• Components include stimulus control therapy, sleep restriction therapy, cognitive restructuring, and relaxation techniques 7, 1
• Can be delivered via individual therapy, group sessions, telephone-based programs, or web-based modules—all showing effectiveness 1
• Pharmacotherapy should supplement, not replace, CBT-I 1, 2

Specific CBT-I Techniques to Implement

• Stimulus control: Go to bed only when sleepy; use bed only for sleep; if unable to sleep within 20 minutes, leave bed and return when drowsy 7
• Sleep restriction: Limit time in bed to actual sleep time, gradually increasing as sleep efficiency improves 7
• Cognitive therapy: Address beliefs like "I can't sleep without medication" or "My life will be ruined if I can't sleep" 7
• Sleep hygiene: Avoid excessive caffeine, evening alcohol, late exercise; optimize sleep environment 1

Recommended Treatment Algorithm

1. Immediately begin CBT-I (can start while adjusting medications) 1, 2

2. Taper and discontinue or minimize Ativan (do not increase to 2mg) 1

3. Start low-dose doxepin 3-6mg as first-line pharmacotherapy 1, 2, 3

   • If sleep onset is the primary problem, consider adding ramelteon 8mg 1
   • If doxepin alone is insufficient after 1-2 weeks, consider adding a DORA 1

4. If doxepin fails, switch to a DORA (suvorexant, lemborexant, or daridorexant) 1, 4

5. Only if both fail, consider eszopiclone 2-3mg or low-dose zolpidem 5mg 1, 2

6. Reassess after 1-2 weeks to evaluate efficacy on sleep latency, sleep maintenance, daytime functioning, and adverse effects 1

7. If insomnia persists beyond 7-10 days of treatment, evaluate for underlying sleep disorders like sleep apnea or restless legs syndrome 1, 5

Critical Monitoring Points

• Monitor for respiratory depression given the combination of Suboxone and any sedating medications 1
• Assess for morning sedation, cognitive impairment, and complex sleep behaviors with any hypnotic 1, 5
• Use the lowest effective dose for the shortest duration possible 1
• Follow up every few weeks initially to assess effectiveness and side effects 2
• Periodically reassess need for ongoing medication and attempt to taper when conditions allow 1

Common Pitfalls to Avoid

• Failing to implement CBT-I alongside medication—behavioral interventions provide more sustained effects than medication alone 1
• Polypharmacy with multiple sedatives—significantly increases risks of falls, cognitive impairment, and respiratory depression 1
• Using benzodiazepines as first-line in patients with substance use disorders—high risk of dependence and abuse 1
• Continuing pharmacotherapy long-term without reassessment—increases risk of adverse effects and dependence 1
• Ignoring underlying sleep disorders—sleep apnea is common with opioid use and can worsen with sedatives 8