Treatment of Sleep Disturbances in Substance Use Disorder
Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for sleep disturbances in patients with substance use disorders, with pharmacological options reserved for severe symptoms, insufficient CBT-I response, or when CBT-I is unavailable. 1, 2
First-Line Treatment: Behavioral Interventions
Cognitive Behavioral Therapy for Insomnia (CBT-I)
- CBT-I should be initiated immediately as the primary treatment, with effects sustained for up to 2 years without risk of dependence or withdrawal 1
- Group-based CBT-I has demonstrated effectiveness in outpatient SUD treatment programs, with 80% of participants achieving insomnia remission (ISI ≤8) compared to 25% with standard care 3
- CBT-I addresses perpetuating factors like conditioned arousal and maladaptive sleep behaviors that are particularly problematic during substance withdrawal 1
Essential Sleep Hygiene Components
Implement these foundational strategies immediately 1:
- Regular sleep-wake schedule with consistent bed and wake times
- Morning or afternoon exercise and daytime bright light exposure
- Avoid heavy meals, alcohol, and caffeine (last caffeine dose before 4:00 PM)
- Dark, quiet, comfortable sleep environment
- Short naps (15-20 minutes) around noon if needed for daytime sleepiness
Patient Education
- Educate patients that withdrawal-related sleep disturbances typically resolve within 14 days of cessation 1
- Explain that abstinence or decreased substance use may improve insomnia symptoms, though sleep problems often persist and require independent treatment 2, 4
Pharmacological Treatment Algorithm
When to Consider Pharmacotherapy
Add medications only when 1, 2:
- Severe daytime impairment persists beyond 1 week despite behavioral interventions
- CBT-I is unavailable or insufficient
- Severe symptoms or psychiatric comorbidities are present
- CBT-I requires several weeks to become effective and bridging therapy is needed
First-Choice Pharmacological Agent: Trazodone
Trazodone 50-100mg at bedtime is the most appropriate pharmacological choice for substance use disorder-related insomnia 1:
- Start with 50mg at bedtime
- Titrate to 100mg if insufficient response after 3-5 days
- Lower abuse potential compared to hypnotics
- Dual benefit for comorbid anxiety or depression common in SUD
- Avoid benzodiazepine-related risks in this vulnerable population
Alternative Pharmacological Options (Moderate Evidence)
If trazodone is contraindicated or ineffective, consider 2:
- Mirtazapine: Particularly effective in patients with depression and anorexia; sedating antidepressant properties 5, 2
- Gabapentin immediate release: Moderate evidence for insomnia in alcohol use disorder 2
- Quetiapine: Can be considered but use with caution due to metabolic side effects 5, 2
Medications with Limited Evidence (Use Cautiously)
The following have low-level evidence but may be considered in specific circumstances 2:
- Melatonin (particularly safe with few side effects)
- Topiramate
- Acamprosate (may have dual benefit in alcohol use disorder)
Critical Medications to AVOID
Benzodiazepines and Z-Drugs
Never prescribe benzodiazepines or benzodiazepine receptor agonists (zolpidem, eszopiclone) as first-line treatment in SUD patients 1:
- High risk of dependence and abuse, particularly problematic in patients with substance use history
- Risk of falls, confusion, and cognitive impairment
- Withdrawal seizure risk upon discontinuation
- Long-acting benzodiazepines are especially problematic due to accumulation and prolonged sedation
- Zolpidem and eszopiclone carry risks of complex sleep behaviors (sleep-driving, sleep-eating) and next-day impairment 6, 7
Other Medications to Avoid
- Antihistamines (e.g., diphenhydramine): Cause daytime sedation, delirium risk, and anticholinergic effects 1
- Ramelteon: While FDA-approved for insomnia, lacks specific evidence in SUD populations and may have limited efficacy 8
Special Considerations by Substance Type
Alcohol Use Disorder
- Insomnia resurges during detoxification and may lead to relapse if untreated 4, 9
- Pay particular attention to patients who use alcohol to help fall asleep, as they have higher relapse risk after stopping treatment 2
- Gabapentin and mirtazapine have moderate evidence specifically in alcohol withdrawal-related insomnia 2
Opioid Use Disorder
- Sleep fragmentation and circadian rhythm dysfunction are profound during withdrawal 4
- Insomnia during detoxification requires aggressive treatment to prevent relapse 4
Cannabis Use Disorder
- Sleep disturbance occurs within 3 days of cessation and typically lasts up to 14 days 1
- Trazodone 50-100mg is preferred over hypnotics due to lower abuse potential 1
Monitoring and Duration of Treatment
Follow-Up Schedule
- Reassess sleep quality weekly during the first month using validated tools like the Insomnia Severity Index 1
- Monitor for medication side effects
- Evaluate for substance use relapse, as insomnia is a known relapse trigger 2, 4
Medication Tapering
- Plan medication taper after 4-8 weeks if sleep normalizes 1
- Never prescribe hypnotics for longer than 4 weeks without reassessment 1
- Continue CBT-I even after medication discontinuation to maintain gains 1
Critical Pitfalls to Avoid
Never start with pharmacotherapy alone without concurrent behavioral interventions—this creates medication dependence without addressing perpetuating factors 1
Do not assume sobriety will resolve insomnia—comorbid insomnia requires independent treatment as sleep problems often persist despite abstinence 4
Avoid prescribing medications that lower seizure threshold or interact with other medications used in SUD treatment 10
Do not underestimate the bidirectional relationship—untreated insomnia increases relapse risk, and active substance use worsens sleep 4, 11
Screen for obstructive sleep apnea in patients with snoring, observed apneas, or excessive daytime drowsiness, as this requires different treatment (CPAP) 5, 10