Insomnia in patients with addictions: A safer way to break the cycle
Fight relapse by improving sleep with nonaddictive agents and behavior therapy.
Other sedating antidepressants such as mirtazapine and doxepin have not been studied in patients with substance use disorders.
Quetiapine is a second-generation antipsychotic with sedating properties. When quetiapine, 25 to 200 mg/d, was given to alcohol-dependent veterans with sleep complaints, they remained abstinent more days and had fewer hospitalizations than veterans not receiving quetiapine.25 Both groups had high rates of psychiatric comorbidity, and 90% had posttraumatic stress disorder. Improved abstinence was thought to result from improved sleep, but no sleep measures were included to test this hypothesis.
A recently published, randomized controlled pilot study reported significantly reduced drinking and craving in severely alcohol-dependent patients receiving quetiapine vs placebo, although sleep data were not included.26
Other options. Tricyclic antidepressants carry risks of cardiotoxicity and other side effects but can be useful when other options have not worked or patients have comorbidities such as neuropathic pain or migraine headaches. Combinations of agents also may be considered for treatment-resistant insomnia.
Nonprescription remedies such as antihistamines, valerian root extract (from the herb Valeriana officinalis), and melatonin are commonly used for sleep, although data are limited in substance-abusing patients.
Table 3
Noncontrolled sedating agents for treating insomnia
in patients with a history of substance abuse
| Agent | Dose range (mg) | TMAX (hr) | T½ (hr) |
|---|---|---|---|
| Melatonin receptor agonist | |||
| Ramelteon | 8 | 0.5 to 1.5 | 1 to 2.6 |
| Sedating anticonvulsant | |||
| Gabapentin | 300 to 1,500 | 2 to 3 | 6 to 7 |
| Sedating antidepressants | |||
| Amitriptyline† | 25 to 150 | 2 to 8 | 5 to 45 |
| Doxepin† | 25 to 150 | 2 to 8 | 10 to 30 |
| Mirtazapine | 7.5 to 45‡ | 1 to 3 | 20 to 40 |
| Nefazodone | 50 to 150 | 1 | 6 to 18* |
| Nortriptyline† | 10 to 75§ | 2 to 8 | 20 to 55 |
| Trazodone | 25 to 300 | 1 to 2 | 3 to 9¶ |
| Sedating second-generation antipsychotic | |||
| Quetiapine | 25 to 100 | 1.5 | 6 |
| TMAX: time to reach maximal plasma concentrations; T½: elimination half-life (all values are approximate for any given individual) | |||
| * Including active metabolites | |||
| † Tricyclic antidepressants | |||
| ‡ Antihistaminergic effects predominate at low doses (7.5 to 15 mg) | |||
| § Can be titrated to morning serum level (50 to 150 mcg/mL) 12 hr after bedtime dose if no effect at lower doses | |||
| ¶ Major metabolite, mCPP, has 14-hour half-life | |||
- American Academy of Sleep Medicine. www.sleepeducation.com.
- National Sleep Foundation. Sleep logs for downloading. www.sleepfoundation.org.
- Restless Legs Syndrome Foundation. www.rls.org.
- Brower KJ. Insomnia, alcoholism and relapse. Sleep Med Rev 2003;7:523-39.
- Amitriptyline • Elavil, Endep
- Doxepin • Sinequan
- Estazolam • ProSom
- Eszopiclone • Lunesta
- Flurazepam • Dalmane
- Gabapentin • Neurontin
- Methamphetamine • Desoxyn
- Methylphenidate • Concerta, Ritalin, others
- Mirtazapine • Remeron
- Nefazodone • Serzone
- Nortriptyline • Pamelor
- Pregabalin • Lyrica
- Quazepam • Doral
- Quetiapine • Seroquel
- Ramelteon • Rozerem
- Temazepam • Restoril
- Theophylline • Theo-24, others
- Trazodone • Desyrel
- Triazolam • Halcion
- Zaleplon • Sonata
- Zolpidem • Ambien, Ambien CR
Dr. Conroy and Dr. Arnedt report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Brower is a consultant to Pfizer.
Acknowledgment
This work was supported by an NIH grant to Dr. Brower (2K24 AA00304).
