After stopping his Vyvanse (lisdexamfetamine) for ADHD, what can be given to help him sleep?

Sleep Management After Stopping Vyvanse

Start with Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment, combined with strict sleep hygiene measures; if pharmacotherapy is needed, use trazodone 50-100mg at bedtime rather than benzodiazepines or hypnotics. 1

Immediate Non-Pharmacological Interventions (Start These First)

The most effective approach for sleep disturbances after stimulant discontinuation is CBT-I, which provides sustained effects for up to 2 years without risk of dependence. 1 This should be initiated immediately as the primary treatment. 1

Essential Sleep Hygiene Measures

Implement these evidence-based sleep hygiene practices immediately:

• Maintain a consistent sleep-wake schedule every day, including weekends, with the same rise time regardless of sleep quality the night before. 2
• Seek bright light exposure in the morning and avoid bright light, especially from electronic devices, in the evening (screens suppress melatonin and increase alertness). 2
• Keep the bedroom cool, dark, and comfortable. 2
• Avoid caffeine for at least 6 hours before bedtime (no coffee, energy drinks, certain sodas or teas). 2
• Avoid heavy meals and excessive liquids at night to prevent reflux and bathroom trips. 2
• Use the bed only for sleep and sex - no watching TV, working, or other activities in bed. 2

Stimulus Control Therapy

If he cannot fall asleep within 20-30 minutes, he should get out of bed and return only when sleepy. 2 This practice has strong evidence for preventing insomnia and improving sleep quality over time. 2

Avoid obsessive clock-watching, as this increases mental activity rather than decreasing it. 2

Pharmacological Options (If Behavioral Interventions Are Insufficient)

First-Line Medication: Trazodone

Trazodone 50-100mg at bedtime is the most appropriate pharmacological choice for sleep disturbances after stimulant discontinuation, with lower abuse potential compared to hypnotics. 1

• Start with 50mg at bedtime
• Titrate to 100mg if insufficient response after 3-5 days 1
• This is particularly appropriate given the context of recent stimulant use (Vyvanse discontinuation)

Alternative Pharmacological Option

Mirtazapine may be considered as an alternative, especially if he has comorbid depression or poor appetite. 2, 1

Second-Line Options (Use With Caution)

If trazodone and behavioral interventions fail:

• Short-acting benzodiazepine (lorazepam) - but avoid in older patients or those with cognitive impairment due to decreased cognitive performance 2
• Nonbenzodiazepine hypnotic (zolpidem) - use lower doses (5mg immediate-release, 6.25mg extended-release) due to next-morning impairment risk 2
• Sedating antipsychotics (quetiapine, olanzapine) for refractory cases 2

Critical Medications to AVOID

Do NOT prescribe benzodiazepines or z-drugs as first-line treatment in patients recently discontinuing stimulants due to high risk of dependence and abuse. 1

Avoid antihistamines (like diphenhydramine) due to daytime sedation, delirium risk, and anticholinergic effects. 1

Managing Stimulant-Related Sleep Onset Delay

The sleep difficulty after stopping Vyvanse may represent either:

1. Rebound insomnia from stimulant discontinuation (typically resolves within days to weeks)
2. Pre-existing sleep problems that were masked or worsened by the stimulant 2

During active stimulant treatment, clinicians typically manage sleep onset delay by lowering the last dose or moving it earlier in the day, or implementing a bedtime routine. 2 Since Vyvanse has been stopped, focus on the behavioral interventions above.

Monitoring and Follow-Up

• Reassess sleep quality weekly during the first month using validated tools like the Insomnia Severity Index 1
• Plan medication tapering after 4-8 weeks if sleep normalizes 1
• Continue CBT-I even after medication discontinuation to maintain gains 1
• Screen for obstructive sleep apnea if he has snoring, observed apneas, or excessive daytime drowsiness, as this requires CPAP rather than sleep medications 2, 1

Common Pitfall to Avoid

Never start with pharmacotherapy alone without concurrent behavioral interventions, as this creates medication dependence without addressing the perpetuating factors like conditioned arousal and maladaptive sleep behaviors. 1 The combination of CBT-I plus trazodone (if needed) is superior to either alone.