In this national sample survey of addiction medicine physicians, although two-thirds of these physicians might offer pharmacological treatment on occasion, fewer than one-quarter offer medication to more than half of sleep-disturbed alcoholic patients in early recovery. Consistent with addiction medicine literature that recommends trazodone for sleep-disturbance in alcohol-dependent patients, low-dose trazodone was the most commonly prescribed sleep agent,13,16
and the mean duration of therapy exceeded one month. It is also one of the most commonly prescribed medications for sleep disturbance nationwide,17
though hypnotic efficacy data in the general population remains inadequate. Trazodone is well tolerated,18,19
is safe in combination with alcohol (except, perhaps, in massive overdose),20–26
has low abuse potential,27,28
is effective at bedtime dosing,29–31
and has analgesic effects similar to amitriptyline.32–34
Trazodone’s analgesic effect may be important because of a recently observed association between alcohol dependence, disturbed sleep and pain.11
The overall reluctance of these physicians to offer pharmacotherapy for sleep disturbance following detoxification is consistent with the traditional view that medications should be avoided in recovery. Seeking a solution for sleep problems through the use of medication might promote the alcohol-dependent patient’s propensity to use substances to regulate discomfort or distress rather than seeking non-drug solutions.35
Thus, the prescription of sleep medication in the context of recovery could delay correction of the alcoholic patient’s disturbance in self-regulation36
and increase the risk of subsequent relapse. In addition, in the absence of empirical evidence, sleep medications themselves might increase relapse. For example, some research has suggested that trazodone’s metabolite m-chlorophenylpiperazine might increase craving.37–39
On the other hand, these physicians’ reluctance to treat sleep disturbance with medication may be counterproductive because poor sleep might trigger relapse in several ways.40
First, the distress of sleep disturbance and fatigue itself might create a high-risk situation, especially among recovering persons who expect relief from insomnia through drinking again.8,41
Relatedly, poor sleep that accompanies both the acute and chronic abstinence syndromes may contribute directly to craving and the compulsion to resume drinking.3
In addition, disturbed sleep may also contribute to the development of negative affective states, such as depression, which are themselves important triggers of relapse.8,42–44
Sleep disturbance and the resultant fatigue might also compromise the recovering person’s resolve and ability to cope with high-risk situations or negative affective states,12
or to cope with a lapse. Finally, disturbed sleep may decrease daytime alertness, concentration and performance,44
and thus render alcohol treatment, aftercare and mutual help groups less effective.
Few studies have examined whether treatment of sleep disturbance in early recovery will lower the likelihood of recurrent drinking.13,14
Trazodone has been used to manage sleep disturbance and anxiety among substance-abusing persons.45
A recent abstract described the open-label use of trazodone to treat insomnia in 4 alcohol-dependent subjects in early recovery; all subjects reported significant improvement in subjective sleep quality.46
Another uncontrolled trial of 25 alcohol dependent subjects from a detoxification program found that 48% of subjects who received trazodone were continually abstinent, and 20% relapsed to heavy drinking at 3-month follow-up.47
The authors noted that these rates were similar to those reported for other anti-craving agents, such as naltrexone and acamprosate.48
Although morning somnolence was a common side-effect, these studies noted no untoward interactions with alcohol. Another small study further suggested that trazodone can alleviate symptoms of alcohol withdrawal.49
Few other agents have been investigated. A recent report that described the use of gabapentin in 15 alcoholic outpatients found that a mean dose of 953 mg/day improved sleep disturbance, and all patients remained abstinent from alcohol at 4–6 weeks of follow-up.50
None of the physicians here prescribed gabapentin. Not surprisingly, benzodiazepine and nonbenzodiazepines were infrequently offered for sleep disturbance in this population, and, when offered, the duration of treatment approximated only one week. Although sleep experts prefer nonbenzodiazepines for most insomnias, the risks and appropriate use of these potentially addictive sleep agents require further investigation in the recovering population.
In this study, psychiatrists were most likely to prescribe medication to sleep-disturbed patients in early recovery from alcoholism and most likely to prescribe trazodone, compared with family physicians and internists. This finding is not surprising given psychiatric research and experience using trazodone as a hypnotic for psychotropic-induced or other insomnias.22,23,51–53
Younger addiction medicine physicians were also more likely to prescribe medication and more likely to prescribe an antihistamine or trazodone than were older addictionists. This study cannot discern whether greater clinical experience leads older physicians to prescribe less often or whether older physicians are more likely to avoid pharmacotherapy for ideological reasons.
Although this survey highlights the need for controlled studies of the treatment of sleep disturbance among alcoholic patients, numerous related areas also require further research. These areas include further studies of the sleep disruption that occurs with alcohol withdrawal and its effects on relapse risk; investigations of the biological and genetic mechanisms of alcohol-related sleep disturbance and its polysomnographic correlates; research into the health consequences of sleep disorders among alcoholic patients, including risk factors for the development of obstructive sleep apnea; and natural history studies of insomnia as a predisposing factor for the development of alcohol abuse and alcoholism, especially among adolescents, women and the elderly.54
This study’s reliance on reported, not actual, practices is a key limitation. Its strengths include national representation of addiction medicine physicians and a response rate comparable to other physician surveys.55
We conclude that many addiction medicine experts are reluctant to prescribe pharmacological treament for sleep disturbance among patients in early recovery from alcoholism. When they do prescribe, trazodone, other sedating antidepressants and antihistamines are favored, despite limited evidence for or against this indication. The mean duration of therapy for trazodone and other sedating antidepressants exceeded one month. Conversely, benzodiazepine and nonbenzodiazepines are rarely prescribed to recovering alcoholic patients, and the mean duration of pharmacotherapy is very brief. Although the treatment of disordered sleep among alcoholic patients in early recovery has theoretical merit to prevent relapse, rigorous clinical trials of both pharmacologic and nonpharmacologic interventions are needed.