What is the best treatment for insomnia in a 50-year-old patient with hypertension (high blood pressure), a history of alcohol use, and sleep problems?

Treatment of Insomnia in a 50-Year-Old with Hypertension and Alcohol Use History

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the mandatory first-line treatment for this patient, and benzodiazepines must be completely avoided given the alcohol use history. 1, 2

Critical Context: Alcohol Use and Insomnia

This patient's alcohol use history fundamentally changes the treatment approach. Patients with alcohol use disorder have a significantly higher risk of relapse when using GABA-A agonists (benzodiazepines and Z-drugs), and these medications should be strictly avoided. 3, 4 Additionally, patients who use alcohol to help sleep have particularly elevated relapse risk after stopping treatment. 3

First-Line Treatment: CBT-I

CBT-I must be implemented before or alongside any pharmacotherapy, as it provides superior long-term outcomes with sustained benefits after discontinuation and addresses the underlying mechanisms maintaining insomnia. 1, 2 This is especially critical in patients with substance use history, where behavioral interventions avoid the risks of cross-addiction and dependence. 3, 4

CBT-I Components to Implement:

• Sleep restriction therapy: Limit time in bed to match actual sleep time to increase sleep drive 1, 2
• Stimulus control: Use bedroom only for sleep; leave bed if unable to sleep within 15-20 minutes 1, 2
• Cognitive restructuring: Address maladaptive thoughts and anxiety about sleep 2
• Sleep hygiene optimization: Avoid caffeine after early afternoon, eliminate evening alcohol (critical for this patient), avoid late exercise, optimize sleep environment 1, 2

CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, or web-based modules—all showing effectiveness. 2

Pharmacotherapy Options (If CBT-I Insufficient)

Given this patient's alcohol use history, medication selection is severely restricted. Traditional first-line agents (benzodiazepine receptor agonists like zolpidem, eszopiclone, zaleplon) should be avoided due to cross-addiction potential and relapse risk. 2, 3

Recommended Pharmacotherapy Options:

1. Ramelteon 8 mg (First Choice)

• Ramelteon is the safest option for patients with substance abuse history, as it has no abuse potential and works through melatonin receptors rather than GABA-A receptors. 2, 3
• Effective for sleep onset insomnia with minimal adverse effects and no dependency risk 1, 2
• Does not interact with alcohol or worsen hypertension 3

2. Low-dose Doxepin 3-6 mg (Alternative for Sleep Maintenance)

• Doxepin 3-6 mg is specifically recommended for sleep maintenance insomnia with moderate-quality evidence showing 22-23 minute reduction in wake after sleep onset. 1, 2
• No abuse potential, making it appropriate for patients with substance use history 2
• At these low doses, anticholinergic effects are minimal 1

3. Suvorexant or Lemborexant (Orexin Receptor Antagonists)

• For patients with substance abuse history, orexin receptor antagonists are preferred over benzodiazepine receptor agonists due to different mechanism of action and lower abuse potential. 2, 3
• Suvorexant reduces wake after sleep onset by 16-28 minutes with moderate-quality evidence 1, 2
• Works through a completely different mechanism than GABA-A agonists 2

Medications with Moderate Evidence in Alcohol Use Disorder:

Mirtazapine 7.5-15 mg (If Comorbid Depression/Anxiety)

• Has moderate level of evidence specifically in patients with alcohol use disorder 3
• Must be taken nightly on scheduled basis, not PRN, as it requires consistent dosing with half-life of 20-40 hours 2
• Particularly appropriate when comorbid depression or anxiety is present 1, 2

Gabapentin immediate release (Alternative)

• Has moderate level of evidence in alcohol use disorder patients 3
• May also help with alcohol cravings 3

Medications to AVOID:

Absolutely Contraindicated:

• All benzodiazepines (lorazepam, temazepam, clonazepam, diazepam, triazolam): High risk of cross-addiction, dependence, and relapse 2, 3, 4
• Z-drugs (zolpidem, eszopiclone, zaleplon): GABA-A agonists with abuse potential and relapse risk 3, 4
• Trazodone: Explicitly not recommended by AASM due to insufficient efficacy evidence 1, 2
• Over-the-counter antihistamines (diphenhydramine): Lack efficacy data, cause daytime sedation and anticholinergic effects 1, 2, 5

Hypertension Considerations

Sleep apnea must be screened for, as it is commonly encountered in patients with resistant hypertension and can worsen both insomnia and blood pressure control. 1 Non-restorative sleep, snoring, and daytime sleepiness are clinical clues to pursue this diagnosis. 1

Evening alcohol consumption worsens both hypertension and sleep quality and must be eliminated. 1 The ACC/AHA guidelines recommend moderation of alcohol intake (≤2 drinks per day in men, ≤1 per day in women) as part of lifestyle modifications for hypertension. 1

Treatment Algorithm

1. Assess alcohol use status: Determine if patient is currently drinking, in recovery, or has history of alcohol use disorder 3, 4
2. Screen for sleep apnea: Evaluate for snoring, witnessed apneas, daytime sleepiness 1
3. Initiate CBT-I immediately: All components simultaneously, not sequentially 2, 3
4. If CBT-I insufficient after 4 weeks: Add ramelteon 8 mg as first-line pharmacotherapy 2, 3
5. If ramelteon ineffective: Consider low-dose doxepin 3-6 mg or orexin antagonist 2, 3
6. If comorbid depression/anxiety: Consider mirtazapine 7.5-15 mg nightly 2, 3
7. Reassess after 2-4 weeks: Evaluate efficacy, adverse effects, and alcohol use status 2

Critical Safety Monitoring

• Monitor for alcohol relapse: Insomnia is both a trigger for and consequence of relapse 3, 4
• Assess blood pressure control: Ensure antihypertensive regimen is optimized 1
• Screen for depression/suicidal ideation: Insomnia in alcohol use disorder is associated with increased suicidal thoughts 4
• Evaluate for other sleep disorders: Restless legs syndrome, circadian rhythm disorders 2

Common Pitfalls to Avoid

• Prescribing benzodiazepines or Z-drugs to patients with alcohol use history: This significantly increases relapse risk and creates cross-addiction 2, 3, 4
• Failing to implement CBT-I alongside medication: Behavioral interventions provide more sustained effects than medication alone 1, 2
• Using trazodone despite widespread off-label use: AASM explicitly recommends against it due to insufficient efficacy evidence 1, 2
• Ignoring underlying sleep apnea: This worsens both insomnia and hypertension 1
• Continuing pharmacotherapy long-term without periodic reassessment: Medications should be tapered when conditions allow, with CBT-I facilitating successful discontinuation 1, 2