Dana, 42, is in early recovery from alcohol use disorder. She reports no alcohol use in the last four weeks, but she also hasn’t slept more than a few hours a night since stopping. She worries insomnia will drive her back to drinking. Prescribing a benzodiazepine (BZD) feels like trading one problem for another.

Patients with substance use disorders (SUDs) experience sleep disruption at rates far higher than the general population, and insomnia can be particularly destabilizing during early recovery. Managing it effectively is important, but so is avoiding medications like BZDs and Z-drugs whenever possible, which carry a risk of misuse and dependence.

Fortunately, several non-addictive alternatives exist. Some are underutilized; others are prescribed with little evidence. Here’s how to choose among them for patients with SUDs.

Dual orexin receptor antagonists (DORAs)
Suvorexant (Belsomra), lemborexant (Dayvigo), and daridorexant (Quviviq) represent a shift in how we have traditionally approached insomnia pharmacologically. Rather than broadly suppressing the central nervous system, DORAs work by blocking orexin (aka hypocretin) signaling, which drives wakefulness. Clinical trials show consistent improvement in both sleep onset and sleep maintenance with little risk of dependence (Morin CM and Buysse DJ, N Engl J Med 2024;391(3):247–258).

Though DORAs are effective, there are some practical downsides. Next-day sedation is a concern, especially at higher doses and for agents with longer half-lives. Daridorexant has the shortest half-life (8 hours), lemborexant has the longest (18), and suvorexant is intermediate (12).

DORAs are Schedule IV, so refills are limited and some systems may require urine drug screening, though misuse potential appears low. Cost is also a barrier, since no generic versions exist and coverage is inconsistent. Avoid combining them with CYP3A4 inhibitors, and use caution in patients with hepatic impairment.

Doxepin (Silenor)
Doxepin is a tricyclic antidepressant approved for insomnia at doses far below what is typically used for depression (3–6 mg vs > 75 mg). At these doses, its mechanism is almost purely histamine H1 antagonism, with minimal anticholinergic activity. It is especially helpful for maintaining sleep (Sateia MJ et al, J Clin Sleep Med 2017; 13(2):307–349).

One potential drawback is that low-dose tablets are not available on many hospital formularies. Higher doses can be prescribed, though you may run into anticholinergic side effects. To avoid this, you can prescribe the oral liquid if available. If not, we recommend the lowest available oral dose, typically 10 mg.

Ramelteon (Rozerem)
Ramelteon is an MT1/MT2 melatonin receptor agonist approved for sleep-onset insomnia. It resets the circadian rhythm and is not a pure sedative. It works best for sleep-onset problems, particularly those arising from circadian disruption (jet lag, shift work, delayed sleep phase). It is very safe and may be a good choice for patients who need something with minimal side effects or drug interactions.

While ramelteon has little to no potential for misuse, its overall effect size is modest. Compared to DORAs and doxepin, ramelteon is the least effective and has a higher discontinuation rate (De Crescenzo F et al, Lancet 2022;400(10347):170–184). When prescribing, counsel patients that the effect tends to build over time, may be subtle, and may not feel overtly sedating.

Trazodone
Though it is perhaps the most prescribed sleep medication in addiction medicine, the evidence for trazodone is surprisingly thin. Its low misuse potential makes it a common go-to, but sleep results are inconsistent (Everitt H et al, Cochrane Database Syst Rev 2018;5(5):CD010753). Side effects (orthostatic hypotension, lingering morning grogginess, rare but serious priapism) have led some expert guidelines to explicitly recommend against trazodone for chronic insomnia (Mysliwiec V et al, Ann Intern Med 2020;172(5):325–336). It may help in the short term with insomnia related to opioid use disorder, though this finding needs replication (Goyal P et al, Drug Alcohol Depend 2023;250:110891). For now, consider trazodone a backup option.

Other commonly used agents
Several other medications are worth knowing for SUD-related insomnia:

Hydroxyzine (Vistaril/Atarax)

• Antihistamine with mild anxiolytic properties; useful for anxiety-driven sleep-onset difficulties, particularly in the context of acute withdrawal
• Non-addictive, inexpensive, and widely available
• Main drawbacks are sedation and anticholinergic effects, particularly in older patients
• Not ideal for long-term use given quick development of tolerance

Mirtazapine (Remeron)

• Atypical antidepressant; can be helpful when insomnia co-occurs with depression, poor appetite, or nausea
• Emerging evidence of efficacy for stimulant use disorder (McKetin R et al, JAMA Psychiatry 2026;83(6):581–589)
• Primary concerns are weight gain and daytime sedation
• Lower doses (ie, 7.5–15 mg) tend to be best for sleep

Clonidine (Catapres)

• Alpha-2 agonist commonly used to control autonomic hyperactivity during opioid and alcohol withdrawal
• Minimal direct evidence for use in insomnia, but elevated autonomic tone can disrupt sleep, and anecdotally it can be helpful
• Consider adjunctive clonidine as a short-term bridge to help patients through withdrawal
• Main side effects are hypotension and rebound hypertension if discontinued

Gabapentin (Neurontin)

• Despite its name, does not bind to GABA receptors but rather presynaptic calcium channels
• Can be helpful for insomnia when chronic pain or alcohol withdrawal is part of the picture (Andrade C, J Clin Psychiatry 2020;81(6):20f13775)
• Has misuse potential, particularly in those with comorbid SUD (Evoy KE et al, Drugs 2026; Epub ahead of print)
• Almost certainly safer than BZDs, but be sure to use it thoughtfully and reassess frequently
• Associated with increased risk of overdose when mixed with opioids or BZDs (Evoy KE et al, Drugs 2026; 86(8):1365–1378)

Quetiapine (Seroquel)

• Sedating, low-potency second-generation antipsychotic commonly used for sleep
• Not recommended as a primary sleep aid (Mysliwiec et al, 2020)
• Outside of an approved psychiatric diagnosis, avoid due to metabolic effects, anticholinergic burden, and increased risk of death in elderly
• Can be considered for sleep difficulty in patients who are otherwise eligible for quetiapine treatment (ie, psychotic disorders, bipolar, MDD)

For a framework to help determine the best option, visit: www.thecarlatreport.com/SleepMedsFramework

From the Clinical Update
“Sleep Medications for Patients With Substance Use Disorders”
by Noah Capurso, MD, MHS
The Carlat Addiction Treatment Report, Volume 14, Number 7 & 8
October/November/December 2026
www.thecarlatreport.com

Clinical pearls

• Pair medication with behavioral intervention. Behavioral interventions, especially cognitive behavioral therapy for insomnia (CBT-i), are the most effective long-term treatment for chronic insomnia and should accompany any pharmacologic approach (Morin and Buysse, 2024).
• Set expectations. Patients who regularly use substances to fall asleep often have poor-quality, non-restorative sleep (Oliva HNP et al, EClinicalMedicine 2026;91:103723). Explain that the goal is better sleep quality, not the “knocked out” feeling they may be used to.
• Avoid reflex prescribing. Not every insomnia complaint needs a new medication. Rule out an underlying cause before adding a hypnotic.
• Continually reassess. Sleep often improves naturally during recovery, though the pace varies widely. Reassess symptoms and the need for medication regularly.

You start Dana with low-dose doxepin (3 mg), sleep hygiene counseling, and a referral for CBT-i. A DORA is not covered by her insurance. You plan a follow-up in a few weeks to ensure she is still not drinking and reassess her sleep symptoms.

CARLAT VERDICT
Sleep issues are common in patients with SUDs, where the use of non-addictive medications is particularly important. There are many medication options for these patients, each with advantages and drawbacks. Choose a medication based on a patient’s specific symptoms and comorbidities, reassess their sleep symptoms often, and pair a prescription with behavioral strategies whenever possible.