How to manage insomnia in a patient with Post-Acute Withdrawal Syndrome (PAWS) and a history of substance use?

Managing Insomnia in Post-Acute Withdrawal Syndrome (PAWS)

Cognitive-behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia in patients with PAWS and substance use history, as benzodiazepines and other controlled substances carry unacceptable relapse risk in this population. 1, 2

Initial Assessment and Red Flags

Before initiating treatment, distinguish true insomnia from other sleep disorders that commonly masquerade as insomnia in this population:

• Rule out excessive daytime sleepiness (involuntary sleep episodes), which suggests obstructive sleep apnea, narcolepsy, or periodic limb movement disorder rather than primary insomnia 3
• Expect fatigue, not sleepiness as the daytime consequence—fatigue manifests as low energy, tiredness, and weariness, whereas sleepiness is the tendency to fall asleep involuntarily 3
• Screen for substance contributions: stimulants (caffeine, amphetamines, cocaine), antidepressants (SSRIs, SNRIs), cardiovascular agents (β-blockers), and alcohol use or withdrawal all perpetuate insomnia 3
• Assess for comorbid psychiatric conditions, particularly depression and anxiety, which occur in 50-75% of patients with insomnia and require bidirectional treatment 3

First-Line Treatment: Cognitive-Behavioral Therapy for Insomnia (CBT-I)

CBT-I should be implemented immediately upon recognition of chronic insomnia in PAWS patients, as it addresses the perpetuating factors without relapse risk. 1, 4

Core CBT-I Components

Sleep Restriction Therapy 1:

• Calculate mean total sleep time (TST) from 1-2 weeks of sleep logs
• Set time in bed (TIB) to match TST, maintaining minimum 5 hours
• Target sleep efficiency >85% (TST/TIB × 100%)
• Adjust TIB weekly: increase by 15-20 minutes if efficiency >85-90%; decrease by 15-20 minutes if <80%

Stimulus Control Therapy 1:

• Use bed only for sleep and sex
• Leave bedroom if unable to sleep within 15-20 minutes
• Return only when sleepy
• Maintain consistent wake time regardless of sleep duration
• Eliminate daytime napping

Cognitive Therapy 1:

• Address maladaptive beliefs: "I can't sleep without medication," "My life will be ruined if I can't sleep," "I have a chemical imbalance"
• Challenge catastrophic thinking about sleep loss consequences
• Reduce performance anxiety around sleep

Sleep Hygiene Education 1:

• Regular sleep-wake schedule
• Avoid caffeine, nicotine, alcohol, and stimulating activities before bed
• Quiet, dark sleep environment
• No clock-watching

Evidence in Substance Use Populations

Group-based CBT-I in outpatient SUD treatment programs shows 80% of completers achieving ISI scores ≤8 (below clinical threshold) compared to 25% with standard care 4. More severe insomnia at treatment entry predicts lower SUD treatment completion rates, making early intervention critical 5.

Pharmacological Considerations: Proceed with Extreme Caution

Avoid benzodiazepines entirely in PAWS patients due to respiratory depression risk, abuse potential, memory impairment, and paradoxical disinhibition. 1

Safer Pharmacological Options (When CBT-I Insufficient)

First Choice: Melatonin 1:

• Standard or extended-release formulations
• No abuse potential
• Minimal side effects
• Particularly useful for sleep initiation

Second Choice: Low-Dose Sedating Antidepressants 1:

• Trazodone: 25-100 mg at bedtime; minimal anticholinergic activity; most commonly used second-line agent (57% of clinicians) 1
• Mirtazapine: 7.5-15 mg at bedtime; warning—associated with weight gain 1
• Doxepin: Low doses (3-6 mg); more anticholinergic effects than trazodone 1

Note: These doses are subtherapeutic for depression treatment; if comorbid major depression exists, full antidepressant dosing is required with separate insomnia management 1

Third Choice: Non-Benzodiazepine Hypnotics (Use Sparingly) 1, 6:

• Zolpidem: 5-10 mg (5 mg in elderly); short-acting for sleep-onset insomnia; Schedule IV controlled substance with abuse potential 1, 6
• Eszopiclone: 2-3 mg (1 mg in elderly); intermediate-acting for sleep maintenance; no short-term usage restriction but still Schedule IV 1

Critical caveat: These remain controlled substances with dependence risk. Reserve for refractory cases after CBT-I failure and only with close monitoring 1, 6.

Avoid Entirely 1:

• Benzodiazepines (lorazepam, alprazolam, clonazepam)
• Quetiapine and other antipsychotics (metabolic syndrome risk; not indicated for insomnia alone)

Treatment Algorithm for PAWS Insomnia

1. Week 1-2: Comprehensive sleep assessment with sleep logs; rule out sleep apnea, restless legs syndrome, periodic limb movements 1, 3
2. Week 3-10: Implement full multicomponent CBT-I (sleep restriction, stimulus control, cognitive therapy, sleep hygiene) 1, 4
3. Week 11+: If insomnia persists despite adherent CBT-I:
   • Add melatonin for sleep initiation 1
   • If insufficient, add trazodone 25-100 mg 1
   • Consider sleep medicine specialist referral if refractory 1

Critical Pitfalls to Avoid

Do not assume insomnia will resolve with sobriety alone—this is a dangerous misconception; insomnia during detoxification often worsens and requires independent treatment to prevent relapse 7. Insomnia severity during early abstinence directly predicts treatment dropout 5.

Do not prescribe benzodiazepines or Z-drugs as first-line therapy in patients with substance use history, despite their efficacy in general populations 1. The relapse risk outweighs sleep benefits.

Do not overlook comorbid depression—if neurovegetative symptoms (insomnia, fatigue, appetite changes, psychomotor changes) cluster with depressed mood and anhedonia for ≥2 weeks, treat the underlying major depressive disorder with full-dose antidepressants, not just sleep aids 8.

Reassess throughout recovery phases—insomnia presentation changes from acute withdrawal through PAWS; what works in early recovery may need adjustment months later 2, 9.