Sleep Medication for Alcohol Cravings: Limited Direct Evidence
Sleep medications are not established treatments for reducing alcohol cravings, though treating insomnia in patients with alcohol use disorder (AUD) is critical for preventing relapse. The relationship is indirect: improving sleep may reduce relapse risk, but medications specifically targeting sleep do not directly reduce alcohol cravings 1.
The Evidence on Specific Medications
Medications That May Help Both Sleep and Cravings
Baclofen is the only medication with evidence for both reducing alcohol cravings and improving sleep in patients with alcoholic liver disease. A 12-week course effectively maintained abstinence by reducing craving for alcohol in patients with liver cirrhosis 1.
Acamprosate reduces withdrawal effects and craving for alcohol, reaching therapeutic concentration within 1-2 weeks. While primarily an anti-craving medication (1,998 mg/day for ≥60 kg body weight), it may improve sleep continuity and architecture measured by polysomnography, though it shows little effect on self-reported sleep 1, 2.
Gabapentin (immediate release) and mirtazapine have moderate-level evidence for treating insomnia in AUD patients, though their effect on cravings is not well-established 3.
Sleep Medications to Avoid in AUD
Benzodiazepines and benzodiazepine receptor agonists (BzRAs) should be avoided in patients with AUD due to cross-tolerance with alcohol, addiction potential, and risk of withdrawal symptoms similar to alcohol withdrawal 1, 3, 4. The FDA warns about additive effects on psychomotor performance with concomitant CNS depressants and alcohol use 1.
Naltrexone, while effective for reducing alcohol cravings and excessive drinking, has detrimental effects on sleep—significantly increasing both insomnia and somnolence compared to placebo 1, 2. It is also contraindicated in patients with alcoholic liver disease due to hepatotoxicity risk 1.
The Correct Treatment Algorithm
First-Line: Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I is the recommended first-line treatment for insomnia in patients with AUD, with high-level evidence showing large reductions in insomnia severity (ISI reduction of -5.51 points post-treatment) that persist at 6-month follow-up 3, 5, 6, 4. This therapy includes stimulus control, sleep restriction, relaxation strategies, and cognitive restructuring 1, 5.
CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, or web-based modules—all showing effectiveness 1, 7, 5.
Second-Line: Pharmacotherapy (When CBT-I Insufficient)
If CBT-I is unavailable or insufficient, consider medications with evidence in AUD populations:
- Mirtazapine: Moderate evidence for insomnia in AUD; sedating antidepressant particularly useful with comorbid depression/anxiety 7, 3
- Gabapentin immediate release: Moderate evidence for insomnia in AUD 3
- Quetiapine: Moderate evidence, though concerns about metabolic side effects 3
- Trazodone: Low evidence; modest improvements in sleep parameters but no improvement in subjective sleep quality 1, 7, 3
- Melatonin: Low evidence 3
Medications That Address Both Conditions
Acamprosate may be the most suitable choice when patients with AUD report sleep problems, as it reduces alcohol cravings while potentially improving objective sleep measures without worsening self-reported sleep 1, 2. Dosing: 1,998 mg/day for patients ≥60 kg, reduced by one-third for <60 kg, for 3-6 months 1.
Critical Pitfalls to Avoid
Do not use alcohol to treat insomnia—patients who use alcohol to help fall asleep have a higher risk of relapse after stopping treatment 1, 3.
Do not prescribe benzodiazepines or Z-drugs (zolpidem, eszopiclone, zaleplon) as they have cross-tolerance with alcohol and addiction potential 1, 3, 4.
Do not assume treating insomnia will prevent relapse—while insomnia is associated with relapse risk, firm evidence that treating insomnia prevents relapse has not been established. Insomnia and AUD should be treated as co-occurring disorders, each requiring its own treatment 4.
Abstinence or decreased alcohol use is necessary first-line treatment—most patients will have some improvement in insomnia with sobriety alone 4.