What is the best approach to treat insomnia in a patient with a history of alcohol use disorder (AUD)?

Treatment of Insomnia in Alcohol Use Disorder

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for insomnia in patients with alcohol use disorder, demonstrating large and sustained reductions in insomnia severity without worsening drinking outcomes. 1, 2

First-Line Treatment: CBT-I

CBT-I should be initiated as the primary intervention for all patients with AUD and comorbid insomnia, regardless of whether pharmacotherapy is being considered. 1, 3, 2

Evidence for CBT-I in AUD Population

• Meta-analysis of 8 RCTs (426 adults with AUD) demonstrates that CBT-I produces a large reduction in insomnia severity (ISI reduction of -5.51 points) post-treatment, with sustained benefits at 1-3 months (ISI reduction of -4.39) and 6 months (ISI reduction of -4.55) 2
• CBT-I is effective across the entire spectrum of AUD severity, from heavy drinking to varying levels of alcohol dependence 2
• Brief behavioral therapies show long-lasting benefit without worsening drinking outcomes, making them particularly suitable for this population 4

Core CBT-I Components for AUD Patients

• Sleep restriction therapy: Limit time in bed to match actual sleep time, consolidating sleep and increasing sleep drive 1
• Stimulus control therapy: Re-establish the bed as a cue for sleep rather than wakefulness; leave bed if unable to sleep within 15-20 minutes 1
• Cognitive restructuring: Address unhelpful sleep-related beliefs and anxiety about sleep that perpetuate insomnia 1
• Sleep hygiene education: Avoid evening alcohol (critical in AUD), excessive caffeine, late exercise, and optimize sleep environment, though insufficient as monotherapy 1, 5

Delivery Modalities

• CBT-I can be delivered effectively through in-person individual therapy, group sessions, telephone-based programs, web-based modules (such as SHUTi), or self-help books 1, 6
• Internet-based CBT-I shows particular promise for AUD populations given accessibility barriers and can be initiated during inpatient treatment and continued outpatient 6

Pharmacological Treatment Algorithm

Pharmacotherapy should only supplement—never replace—CBT-I, and should be considered when CBT-I is insufficient, unavailable, or while CBT-I is being implemented. 5, 3

First-Line Pharmacological Options (Moderate Evidence)

When pharmacotherapy is necessary, the following agents have demonstrated efficacy in AUD populations:

1. Gabapentin (immediate release): Moderate level of evidence for treating insomnia in AUD; also addresses alcohol cravings 3

2. Mirtazapine: Moderate level of evidence; particularly appropriate when comorbid depression/anxiety is present; requires nightly scheduled dosing (not PRN) due to 20-40 hour half-life 5, 3

3. Quetiapine: Moderate level of evidence, though should not be first-line due to metabolic side effects 3

Second-Line Pharmacological Options (Low Evidence)

• Trazodone: Low level of evidence; the American Academy of Sleep Medicine explicitly recommends against trazodone for general insomnia populations, though it may be considered in AUD when first-line options fail 5, 3
• Melatonin/Ramelteon (8 mg): Low level of evidence in AUD; ramelteon is suggested for sleep onset insomnia in general populations 5, 3
• Topiramate: Low level of evidence; may address both insomnia and alcohol cravings 3
• Acamprosate: Low level of evidence for sleep benefits 3

Medications to AVOID in AUD

Benzodiazepines and other GABA-A agonists (including zolpidem, eszopiclone, zaleplon) should be avoided in patients with AUD due to cross-tolerance, abuse potential, and risk of relapse. 3, 4, 7

• These agents carry significant risks including dependence, withdrawal reactions, cognitive impairment, and complex sleep behaviors 5
• The shared mechanism of action with alcohol creates particular concern for cross-addiction and relapse 3, 4

Treatment Implementation Strategy

Step 1: Establish Sobriety as Foundation

• Abstinence or significant reduction in alcohol use is a necessary first-line intervention, as most patients will experience some improvement in insomnia with sobriety alone 4
• Insomnia-specific treatment should be initiated after 4 or more weeks of sobriety to distinguish persistent insomnia from acute withdrawal effects 4

Step 2: Comprehensive Assessment

Before initiating treatment, assess for:

• Other sleep disorders: Polysomnography is indicated when sleep apnea or periodic limb movement disorder is suspected, or when insomnia is treatment-resistant 4
• Psychiatric comorbidities: Depression and anxiety are common and influence medication selection 3, 4
• Premorbid insomnia: Determine if insomnia preceded alcohol use 4
• Medication and substance use: Review all substances and medications that may affect sleep 4
• Sleep hygiene practices: Identify modifiable environmental and behavioral factors 4

Step 3: Initiate CBT-I

• Begin CBT-I immediately through the most accessible delivery format (in-person, group, telephone, or internet-based) 1, 2, 6
• Set realistic expectations: CBT-I improvements are gradual but durable, with benefits sustained beyond treatment end 5
• Monitor for initial side effects (mild sleepiness, fatigue) which typically resolve quickly 5

Step 4: Consider Pharmacotherapy Adjunct

If CBT-I alone is insufficient after 4-6 weeks, or if severe symptoms/psychiatric comorbidities require faster intervention, add pharmacotherapy while continuing CBT-I. 3, 4

• Start with gabapentin or mirtazapine (if comorbid depression/anxiety present) 3
• Use the lowest effective dose for the shortest duration possible 5
• Avoid benzodiazepines and Z-drugs entirely in this population 3, 4

Step 5: Monitor and Reassess

• Reassess every 2-4 weeks during active treatment 8
• Monitor both insomnia severity (using Insomnia Severity Index) and alcohol-related outcomes 2
• Taper medications when conditions allow to prevent discontinuation symptoms 5

Critical Considerations Specific to AUD

High-Risk Subgroup: Alcohol as Sleep Aid

Patients who historically used alcohol to help fall asleep have a higher risk of relapse after stopping treatment and require closer monitoring. 3

• These patients may be particularly vulnerable during medication discontinuation 3
• Emphasize CBT-I techniques that provide alternative sleep-promoting strategies 3

Timing of Intervention

• CBT-I can be initiated during inpatient treatment and continued in outpatient settings, maximizing engagement during the critical early recovery period 6
• Internet-based delivery facilitates this transition and improves accessibility 6

Relapse Prevention

• While treating insomnia is assumed to help prevent alcohol relapse, this has not been firmly established in controlled trials 4
• Insomnia and AUD should be conceptualized as co-occurring disorders, each requiring its own evidence-based treatment 4

Common Pitfalls to Avoid

• Starting with medications before attempting CBT-I: This violates guideline recommendations and deprives patients of more effective, durable therapy 1, 3, 2
• Prescribing benzodiazepines or Z-drugs: These agents have unacceptable risk in AUD populations due to cross-tolerance and abuse potential 3, 4
• Relying on sleep hygiene education alone: Sleep hygiene lacks efficacy as single-component therapy and must be combined with other CBT-I components 1, 5
• Failing to assess for other sleep disorders: Sleep apnea and periodic limb movements are common and require specific treatment 4
• Treating insomnia during acute withdrawal: Wait at least 4 weeks of sobriety to distinguish persistent insomnia from withdrawal effects 4
• Using trazodone as first-line: Despite common clinical use, evidence is limited and the American Academy of Sleep Medicine recommends against it for general insomnia 5, 3