Management of insomnia in alcohol use disorder

ABSTRACT

Introduction: Insomnia has been implicated in the development, maintenance, worsening, and relapse of alcohol use disorder (AUD).

Areas covered: The authors review the possible pharmacological and non-pharmacological treatment options of insomnia for patients with alcohol-use disorder and provide their expert opinion.

Expert opinion: Abstinence, or at least a decrease in alcohol use, may improve insomnia symptoms. Second, sleep education is a cornerstone intervention that should be completed by more structured behavioral therapies or Cognitive Behavioral Therapy for Insomnia (CBT-I). CBT-I is the recommended first-line treatment of combined insomnia and AUD (high level of evidence). Third, in case of insufficient response or non-availability of CBT-I, pharmacological treatments might be added. In addition, CBT-I may take several weeks to be effective, and these medications could be proposed to patients with severe symptoms or psychiatric comorbidities. Mirtazapine, gabapentin immediate release, and quetiapine exhibit a moderate level of evidence. Melatonin, topimarate, trazodone, and acamprosate, have a low level of evidence. Benzodiazepines and other GABA-A agonists should be avoided. A particular attention should be provided to patients who use alcohol to help fall asleep as a higher risk of relapse exists after stopping treatment.

KEYWORDS:

• Insomnia
• alcohol
• sleep
• addictive disorders
• circadian rhythms
• mental disorders

Article highlights

• The abstinence, or at least a decrease of consumption, may improve insomnia symptoms.

• CBT-I is the recommended first-line treatment for insomnia disorder in AUD, with a high level of evidence.

• Pharmacological treatments should be introduced in second-line or at least added to CBT-I, especially in patients with severe symptoms or psychiatric comorbidities.

• Benzodiazepines and other GABA-A agonists should be avoided.

• There is a moderate level of evidence for mirtazapine, gabapentin immediate release, and quetiapine.

• There is also a low level of evidence for melatonin, topimarate, trazodone, and acamprosate.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.