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How to Treat Insomnia in Early Recovery
Integrating Cognitive-Behavioral Techniques & Pharmacological Approaches for the Treatment of Insomnia in Individuals with Addiction
The worst thing in the world is to try to sleep and not to. -F. Scott Fitzgerald
Insomnia is a major problem in the population with over thirty percent of people reporting some difficulties with falling asleep or staying asleep. One of the main complaints reported by individuals coming into treatment for addiction is insomnia. Clinical research has demonstrated that insomnia is often related to medical conditions but also related to psychological disorders, including substance abuse and dependence.
Insomnia has been defined as the inability to achieve adequate sleep due to difficulty falling asleep, staying asleep, or waking up too early.
This article will discuss some of the most commonly used medications for the treatment of insomnia in a chemical dependency setting, as well as the more commonly used cognitive and behavioral techniques used to treat insomnia. This article is not intended to cover every medication available for insomnia, such as hypnotics (e.g. Lunesta) or benzodiazepines (e.g. Ativan), nor is this article intended to address the more common side effects of the medications discussed. This article is intended to provide an overview of real life practice in a residential treatment program.
The number one complaint that I hear from clients is insomnia, and the number one concern is how I will treat their insomnia. The first thing I tell clients is that there is no pill I can give them to put them to sleep only to wake up eight hours later, nor can I give them a large dose of any one medication to “knock them out.” I often use the example of Michael Jackson and his desperate desire to sleep. Clients with addiction often want a quick fix and most have very limited tolerance for frustration. So when I talk about the various options, both medical and behavioral, I try to give them hope and encouragement. The combination of using medication, natural remedies, and cognitive-behavioral therapy is the most effective approach to treat insomnia.
Medications to Treat Insomnia
- Several psychotropic medications have various secondary properties that make them ideal for treating insomnia. Doxepin, a tricyclic antidepressant, is often prescribed in doses of 100mg or more for depression. But at very low doses this medication acts as a hypnotic due to the drug’s affinity for the H1 receptors. Doxepin has been proven to be effective at doses as low as 1mg with the recommended dose being upwards of 50mg. The benefit of using a low dose reduces the risk of next day hangover effects, which is often one reason why clients stop taking sleep medication.
- Another medication frequently used is Trazodone, which is one of the most popular medications used to treat insomnia. Trazodone in low doses (50mg to 100mg) can provide the side effect of sedation without this effect carrying over to the next day. Anecdotal reports reveal that if individuals do not go to sleep within an hour of taking Trazodone there is a paradoxical effect and insomnia is increased. Trazodone has some serious side effects for men, so this and the need to go to sleep within the hour are reinforced. Remeron is an anti-depressant that is used frequently to treat insomnia. Unfortunately, this medication has the unwanted effects of daytime drowsiness due to a long half-life and weight gain. The recommended dose for Remeron is 15mg at bedtime and with this medication as with others, more is not better.
- Seroquel is probably the most requested sleep medication. Most clients in recovery programs know a lot about medication and many will say that the only sleep medication that works is Seroquel. Seroquel, like Doxepin and Trazodone, blocks the H1 receptors or histamine receptors which when blocked are similar to the effects of “anti-histamines.” The typical starting dose for Seroquel as a treatment for insomnia is 50mg but many clients requires as high a dose as 200mg. Seroquel can also be used to treat depression and bipolar disorder at doses of 300mg or higher, and at very high doses, Seroquel begins to take on anti-psychotic properties.
- The use of Hydroxyzine or Vistaril is often added to other medications to provide clients with additional arsenal against insomnia. Hydroxyzine, as with most antihistamines, has a very sedative property, which makes it useful for treating insomnia. The common dose prescribed is 50mg at bedtime, but it can go up to 100mg without any significant adverse effect. Since many clients know that Vistaril is “…nothing more than Benadryl,” it is often suggested that clients take Vistaril with their other sleep medications.
- Melatonin is an over-the-counter natural remedy that has gained popularity in recent years. Melatonin is a natural hormone produced by the pineal gland that is activated at night, but inactive during the day. The pineal gland secretes melatonin in the evening which leads to feelings of drowsiness that make sleep more likely. The typical dose for Melatonin is 3mg to 9mg at bedtime. Taking more melatonin than prescribed may actually have adverse effects on a client’s biological clock – perpetuating insomnia rather than decreasing it. Given that many individuals with addiction often have disrupted sleep-wake cycles, the use of Melatonin may help reset the cycle.
Anecdotal reports reveal that if individuals do not go to sleep within an hour of taking Trazodone there is a paradoxical effect and insomnia is increased.-Marc J. Romano
When applying “off label” uses of anti-depressant medication, anti-psychotic medication, antihistamine medication, and natural remedies, most clients use a combination to achieve sleep in the early days of treatment, but less as time goes on. It is also important to remember that more is not always better when using these types of drugs.
Cognitive Behavioral Therapy for Insomnia
Education on smoking cessation is also discussed given that nicotine cravings may be responsible for clients waking up four to five hours after falling asleep.-Marc J. Romano
The use of medication to treat insomnia is only one part of the treatment plan. The use of Cognitive Behavioral Therapy for Insomnia (CBTI) is the second part that helps clients to learn good sleep hygiene techniques that often allow them to discontinue their medication. CBTI utilizes both cognitive therapy and behavioral therapy to treat insomnia. One of the most important behavioral changes that are suggested is the avoidance of caffeine, nicotine, and food that contains high contents of sugar. Many of these items often act as stimulants that can inhibit clients from falling asleep and very often work in direct contrast to the medications being prescribed for insomnia. Education on smoking cessation is also discussed given that nicotine cravings may be responsible for clients waking up four to five hours after falling asleep.
Clients are encouraged to use relaxation techniques before bed, such as progressive muscular relaxation, a warm bath, or soft music to set the stage for inviting sleep. Often clients report that they can only sleep if they watch television in bed or read in bed, yet upon further assessment they reluctantly admit that these activities often perpetuate staying awake. Therefore, the use of the bedroom for sleep and only sleep is also taught to the clients.
Many individuals report an increase in anxiety when unable to fall asleep and upon further assessment, it is evident that the content of their thoughts often increases anxiety, thereby further delaying sleep. For example, thoughts such as, “If I don’t fall asleep, I won’t be able to function tomorrow” are common themes in individuals with insomnia. Cognitive therapy at its core is about identifying negative thoughts and replacing them with more rational and realistic ones. Clients are encouraged to remain in bed, relax their body, and most importantly, make a mental shift to more positive thoughts, such as:
- “I don’t have to sleep a full eight hours, four or five hours will be enough,”
- “I’m just new to recovery and it is expected that I may not sleep well, but my sleep will get better as I continue in treatment,”
- “This is not so bad, I can just lie in bed and relax which is something I have wanted to do for so long.”
The combination of medication and CBTI provides the best treatment for insomnia in clients recovering from substance abuse disorders. While most individuals present with insomnia when they first come to treatment, over the course of one or two weeks this issue seems to improve. Medications take effect, a more normal sleep-wake cycle gets established, and underlying issues start to get addressed.
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