Nicholas Rosenlicht, MD
Clinical Professor of Psychiatry, University of California, San Francisco, School of Medicine. Founder and served for 15 years as the director of the UCSF-VAMC Mood Disorders Clinic.
Dr. Rosenlicht has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
TCPR: Why is sleep so important in addictions? Dr. Rosenlicht: Sleep problems are common in recovery, and they have many causes such as withdrawal states, circadian rhythm disruptions, and a host of psychiatric and medical comorbidities. It’s a two-way street: Insomnia raises the risk of substance misuse, and addiction can cause or worsen sleep problems. For people in recovery, it’s very distressing to be up all night, and their distress tolerance is already pretty low. Worse, the major stress reliever—their substance of choice—is no longer available. Patients don’t want to be upset and staring at the ceiling all night.
TCPR: How do you address this issue? Dr. Rosenlicht: I start with a behavioral approach. Surprisingly, sleep hygiene by itself is not terribly effective for general insomnia. It’s a more complex approach—cognitive behavioral therapy for insomnia (CBT-I)—that has the best data. However, I find sleep hygiene works well in recovery because patients’ sleep hygiene is often so poor to begin with. They may be spending their evenings smoking cigarettes, drinking coffee, and getting emotionally aroused hearing harrowing stories of recovery at 12-step meetings. And sleep hygiene is something you can address at a brief medication visit.
TCPR: What are your high-yield behavioral interventions? Dr. Rosenlicht: The most important is: Don’t fret in bed. I’ll tell them, “Get up if you’re worrying. Yes, you’ll probably feel worse the next day, but if you stay in bed you are perpetuating the problem.” They can write their worries down in a notebook. I’ll say, “If it’s on your mind, it’s probably worth worrying about, but not at 2 a.m.” I also find sleep logs useful. Most people with insomnia vastly underreport their sleep, and with a sleep log they notice the problem isn’t as bad as they think. It gives them a sense of control and mastery.
TCPR: Any other steps? Dr. Rosenlicht: A wind-down period before bed is also useful. Patients need to do something relaxing in this period. It could be a book; it could be thinking, meditating, or planning the upcoming day. People in recovery are working hard, and that doesn’t jive with sleep. The harder you try to sleep, the harder it is. You allow sleep. The effort should be on things that prepare them for sleep.
TCPR: Where do sleep medications fit in? Dr. Rosenlicht: These are second-line after behavioral interventions. Actually, they’re second-line for primary insomnia too, and for the recovery population even more so. On the other hand, addressing sleep is an alliance builder. It lets people know you are hearing their distress and giving them some hope and nursing them along through the recovery process. If I use them, it tends to be in early recovery, like the first 6–12 months. I’ll warn them, though: “This will help you lower your distress and get you sleeping better, but we are going to have to deal with the problem later.”
TCPR: What is it you have to deal with? Dr. Rosenlicht: When we withdraw sleep medication, patients will likely have some rebound insomnia, and that puts them at risk for relapse again. There was a much-quoted study of trazodone for insomnia during alcohol recovery. In the first 3 months the risk of drinking with trazodone and placebo were about the same, but 6 months later—when the trazodone was withdrawn—those who had been on the medication were more likely to relapse into alcohol (Friedmann PD et al, Alcohol Clin Exp Res 2008;32(9):1652–1660). I don’t think that problem is unique to trazodone. We run the risk when starting sleep meds that there may be a provocation to relapse later on when we’re getting them off the sedative.
TCPR: There are a handful of medications that promote sobriety. Do any of them help sleep as well? Dr. Rosenlicht: Almost anything that helps people stay clean will tend to improve their sleep. That’s been found with acamprosate (Campral) and topiramate (Topamax) with alcohol use disorders. These medications improve sleep when used in recovery, even though they can worsen sleep in other populations. Prazosin and gabapentin both have controlled trials where they helped people stay sober, and these can be useful for sleep. In early alcohol recovery, REM sleep with vivid dreams can be increased, which prazosin may help (Mason BJ et al, JAMA Intern Med 2014;174(1):70–77; Simpson TL et al, Am J Psychiatry 2018; Aug 29).
TCPR: How do you choose a hypnotic in someone who is recovering from alcohol? Dr. Rosenlicht: With alcohol—and with marijuana—sleep can be disrupted for up to a year after the patient withdraws from the substance. With alcohol, I generally start with a sedating antidepressant like low-dose doxepin (5–10 mg qhs; the dose can be titrated using the liquid concentrate), amitriptyline (10 mg), trazodone (25 mg), or mirtazapine (7.5–15 mg). I tend to advise against using antihistamines, especially OTC diphenhydramine (Benadryl). Their anticholinergic effects can be problematic, especially in the elderly and particularly when used in the 50–100 mg range that people favor—an anticholinergic load that is an order of magnitude higher than what you get with a low-dose TCA. Some studies show that daytime cognition can worsen with antihistamines even when they increase sleep, but this may be true for most sedatives (Aritake S et al, Hum Psychopharmacol 2012;27(4):428–436).
TCPR: What can work for people in recovery from cocaine? Dr. Rosenlicht: Actually, modafinil (Provigil), taken in the morning, may improve sleep for these patients. In one study, it improved total sleep time and stage 3 sleep in people recovering from chronic cocaine use (Morgan PT et al, Am J Psych 2010;167:331–340). Modafinil also improves sobriety from cocaine. We also tend to see more restless leg syndrome when people withdraw from cocaine or stimulants, and that may need to be addressed with pramipexole or gabapentin.
TCPR: What about benzodiazepines? Dr. Rosenlicht: That’s a difficult one. We actually have some data indicating that people who abuse alcohol don’t tend to abuse benzodiazepines as much as we think. They do it more than the general population, but not more, for example, than other psychiatric populations (Mueller TI et al, Alcohol Clin Exp Res 2005;29(8):1411–1418). For former opioid abusers, we need to be more careful, as the combination of opioids and benzos can be fatal. But outside of that scenario, they can be used cautiously. You want to have a very good relationship and see the person often, which is harder nowadays. But I’d say there’s not an absolute prohibition against using them in recovery—they’re just farther down the list. We usually try other things first.
TCPR: Are the z-hypnotics like zolpidem (Ambien) less addictive than the benzos? Dr. Rosenlicht: Slightly. I think most of what I say about benzos applies to them, but maybe slightly less. I haven’t seen that much z-hypnotic abuse, but there are studies where substance abusers found them just as enjoyable as benzos when they’re given blinded (Evans S et al, J Pharmacol Exp Ther 1990;255(3):1246–1255). There is also one study where baboons liked zolpidem at least as much as barbiturates and benzos, but we don’t really see that much in people (Griffiths RR et al, J Pharmacol Exp Ther 1992;260(3):1199–1208). Part of the reason we don’t see as much abuse with people is that it tends to cause nausea—when the dose is raised to 20–30 mg, they get nauseated.
TCPR: Is the risk in this population that they are going to abuse the hypnotic or go back to their drug of choice? Dr. Rosenlicht: We worry about both. People do abuse anything—quetiapine (Seroquel), antihistamines—but mainly it’s the benzodiazepines we have to be careful about.