Insomnia is a “prevalent and persistent” problem for patients in the early phases of recovery from the disease of addiction—and may lead to an increased risk of relapse, according to a report in the November/December Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

“Treating sleep disturbance in early recovery may have considerable impact on maintenance of sobriety and quality of life,” according to Dr Nicholas Rosenlicht of University of San Francisco and colleagues. They summarize the benefits of treatment, highlighting the role of effective behavioral approaches. The lead author was Katherine A. Kaplan, PhD, of Stanford University School of Medicine.

High Rate and Impact of Insomnia during Early Recovery

Dr Rosenlicht and coauthors cite evidence suggesting that the incidence of insomnia in early recovery may be five times higher than the general population and may persist for months to years.

Insomnia may be linked with a higher risk of alcohol-related problems and relapse. The association may run in the other direction as well—population studies report people with sleep disturbance are more likely to be at risk of developing addiction..

Compounding the problem, some patients addicted to alcohol use the substance in the evening in an effort to address sleep problems. Alcohol is a well-documented cause of sleep disruption with toxic effects on several neurobiological systems, and may contribute to lasting sleep problems even during abstinence.

If insomnia contributes to relapse, can treatment for insomnia reduce that risk? The evidence is mixed, with some studies reporting that using medications for insomnia during recovery (mainly from addiction with alcohol) can lower the relapse rate.

Clinicians should be cautious when prescribing medications to address insomnia in the recovering patient. This population of patients may be at increased risk for misuse, abuse, or addiction to sleep medications, or prone to “rebound insomnia” after medications are discontinued. In short, use of such medications may increase the risk of relapse.

Evidence Supports Behavioral Treatments

More generally, clinicians should be aware prescribing medications to treat insomnia may be “incongruent with or unpalatable to” treatment programs focusing on abstinence. In one survey, many addiction medicine specialists said they’d be reluctant to prescribe any medication to patients with sleep problems.

This belief has made behavioral approaches more widely used to treat patients with insomnia during recovery. In particular, evidence supports the use of cognitive-behavioral therapy (CBT). This multicomponent approach includes daily sleep diaries and questionnaires to gather information on the patient’s insomnia and progress during treatment; and education on sleep and the effects of substances, including “sleep hygiene” practices to promote good sleep.

CBT intervenes by targeting processes that perpetuate insomnia. Behavioral interventions include sleep restriction, limiting time in bed to the actual amount of time slept; and stimulus control, seeking to strengthen the association between being in bed and sleeping. Patients also receive cognitive interventions, challenging negative or catastrophic thoughts about the consequences of insomnia.

“Treatment of insomnia after abstinence represents an important treatment target and an integral part of any recovery plan,” Dr Rosenlicht and coauthors conclude. They note the critical need for more research on treatment of insomnia during early recovery with a focus upon understanding if CBT lowers relapse risk. The review is accompanied by a clinical case discussion about effective use of behavioral treatment in a veteran with alcohol dependence with insomnia.