Insomnia in the Alcoholic dependent patient

[F0nzie]

40 y/o F with ETOH dependence with no other psychiatric or medical issues c/o insomnia mostly difficulty staying asleep and wants to sleep more than 4-5 hrs. Currently drinking 1 bottle of wine in the evenings and was previously taking Clonazepam 1mg HS from her pcp for sleep. I went over sleep hygiene. She's still has some denial about her drinking habits and claimed she had the same problems with sleep even during periods of extended sobriety. I currently have her on Acamprosate and Trazodone but she failed the Trazodone trial.

I read in an addiction textbook that sleep issues can persist up to 18 months in a sober alcoholic patient.
Aside from cutting back from ETOH and MI, is there any other direction I should consider with this patient to help her with sleep?

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[splik]

you could do the 6 session CBT-I protocol with her? When you say failed trazodone - how much trazodone did she get? just keep going up until she gets an effect, its mostly benign though clitoral priapism has been reported. Have you tried any other drugs to help with sleep. 4-5 hours isn't bad. I usually provide education that my goal it to get them to about 6 hours and address misconceptions that we need 8 hours sleep especially as we get older. Beliefs about how much sleep people need are often quite pernicious in themselves. It is true it can take a long time for sleep to normalize after cessation of alcohol but I wouldn't be dismissive of her saying this isn't alcohol related. Insomnia is very common and these patients are more likely to become alcoholic. You may also have more buy in for approaches such as CBT-I if you couch this as something not alcohol related given her denial/minimization of her prior drinking.

There are obviously lots of drugs we abuse to treat insomnia, and here I would try and avoid using drugs if possible, but if you explain the risks and benefits to her you could try other things too such as gabapentin, amitriptyline, doxepin, diphenhydramine, mirtazapine, melatonin. You do want to avoid neuroleptics but they are of course sometimes used for severe recalcitrant insomnia. I had a patient who had been on multiple different drugs (had been abusing clonazepam and ambien and doctor shopping so tapered) and I started him on thorazine after discussion of risks including EPSE and metabolic syndrome - and it worked! not advocating this normally of course.

 

[hamstergang]

The problem I have with antipsychotics strictly for sleep is that they are sedating due to their antihistaminergic properties, right? So why use them instead of a cleaner antihistaminic agent with generally fewer side effects?

When would a sleep study be indicated?

 

[vistaril]

The problem I have with antipsychotics strictly for sleep is that they are sedating due to their antihistaminergic properties, right? So why use them instead of a cleaner antihistaminic agent with generally fewer side effects?

you would think so, but for whatever reason Vistaril, Doxepin, etc don't put people to sleep in facilities(especially treatment centers when people are detoxing and just through detox) like Seroquel does. At least in my experience. You can explain that to the patients all you want, but seroquel puts them down and the others don't. Maybe it's placebo effect I dunno(they think seroquel is stronger maybe and patients talk to each other and confirm bias), but ive worked at more than one residential recovery center and this same issue came up.

 

[nitemagi]

I would be aggressive about the sleep hygiene, including basics of bright light in the morning and darkness at night. Avoid reading. No TV/computer for several hours before bed. Make sure the phone is out of reach. Make sure environment is optimal.

Clarify is it early/mid/late insomnia.

Alcohol throws off the sleep architecture a lot, and can take a long time to normalize. So maximize all the natural factors. I often tell ppl - sleep isn't something you make happen. Set up the right [internal and external] environment/situation, and sleep happens.

 

[OldPsychDoc]

For alcohol dependence, I really would go with gabapentin, esp in first couple of months of sobriety. There's just something about remodulating those folks' GABAergic neurotransmission that makes everything go better. Also, in my experience they usually tolerate it much better than non-alcoholics--can be safely dosed fairly aggressively, like 300 mg bid and 600-900 mg hs. (And is a decent replacement for the clonazepam, as in the OP.) Insomnia in this time period is a pretty notable risk factor for relapse, and getting them a couple of nights of restful sleep will help the CBT, sleep hygeine measures, and recovery therapies along nicely.

 

[nitemagi]

I'd also have the honest conversation that if she's drinking there may be no way to fully normalize sleep.

Point her even to the wiki page. http://en.wikipedia.org/wiki/Ethanol_use_and_sleep

As far as meds I've had a good response to remeron when trazodone fails, +/- gabapentin and melatonin (which really just pulls the sleep cycle not adding to it).

If it's mid insomnia, discuss that as the body breaks down the alcohol, the body temp goes up several degrees (and the body temp needs to be 2 degrees lower than normal to sleep). This leads to mid-insomnia - "I wake up in the middle of the night, wide awake and can't get back to sleep."

 

[Extralong]

I'd also have the honest conversation that if she's drinking there may be no way to fully normalize sleep.

Point her even to the wiki page. http://en.wikipedia.org/wiki/Ethanol_use_and_sleep

As far as meds I've had a good response to remeron when trazodone fails, +/- gabapentin and melatonin (which really just pulls the sleep cycle not adding to it).

If it's mid insomnia, discuss that as the body breaks down the alcohol, the body temp goes up several degrees (and the body temp needs to be 2 degrees lower than normal to sleep). This leads to mid-insomnia - "I wake up in the middle of the night, wide awake and can't get back to sleep."

If the wiki page said "alcohol use and sleep" instead of "ethanol use and sleep" maybe it would get more hits...

 

[HarryMTieboutMD]

Mirtazepine up to 30mg QHS (15mg-22.5mg for most patients). Honestly, I tell patients whose main issue is alcoholism that their sleeping pill for the first year should be reading "How it Works" repeatedly until they fall asleep. But shhhh... don't tell my attendings

 

[smalltownpsych]

Another factor is that a patient who is ETOH dependent is going to wake up as the BAL falls below the level that the body has become accustomed to. Of course that depends on where they are at in the progression of their illness. The question that I would ask is whether you are merely easing the symptoms of substance dependence. The problem with that being that it ameliorates the negative consequences of continued use so less likelihood of change. Also, be careful about colluding with the defenses, addicts are exceptionally good at getting us to agree with their rationalizations and denial mechanisms. "I would be able to stay sober if I didn't have X problem." "I went to those meetings and they didn't work because X reasons". "I use to use really bad drugs a lot now I just use X a little". These are most effective when they are true and especially if they match some of your own beliefs, but regardless of the veracity they are all warning flags or signs of active addiction. Solid CBT therapy can be effective with these patients to help deal with trauma issues or symptom reduction. I would also suggest that any treatment professional who has frequent contact with addicts should become familiar with local 12 step meetings. That can help with collaborative treatment and also to help sort out the truth.

 

[Shikima]

In a cheeky manner, I ask those who have insomnia (in a greater picture) if they're looking to fall asleep or seeking out 'the michael jackson treatment' which is often responded to with a snicker and nodding of the head. I let them know that medications are meant to be assist with the process and not knock them out cold.

The previous responses are gold. I couldn't add anything more. However, I am shocked at the amount of physicians who'll give BZD freely to people who have a history for ETOH Dependency.

CBT and supportive psychotherapy are going to help through the lengthy period of transition and I am pretty clear it will take a good 9-10 months for their brain to normalize from the global suppression. I do see a good amount of despair after this stated but they are encouraged that this is the necessary process. Similar discussions are had by those on long term Benzo's and often experience similar difficulties with insomnia and regulating anxiety when being tapered off of them.

 

[notdeadyet]

I've had good luck with gabapentin. I've had mixed results with CBT-I (you need pretty motivated patients with very supportive partners) and I wouldn't use it in a patient still drinking 1 bottle of wine per day.

 

[F0nzie]

Awesome. Thanks everyone. I will try a few of the recs here and report back. Never learned CBT-I. After having just woken up from a 3 hour nap I feel a bit guilty.

 

[notdeadyet]

Oh yes. Never have I felt like such a hypocrite as when I conduct CBT-I...


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[Shikima]

Oh yes. Never have I felt like such a hypocrite as when I conduct CBT-I...


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Just remember, you're not the one with insomnia.

 

[member2721]

Just remember, you're not the one with insomnia.

Personal experience as relevant to psych meds:
Ambien amnesia
Lunesta sonata effective
Benadryl drowsy
Melatonin strong placebo effect. Favorite
Klonipin- long term risks
Cbt-I - effective, tedious to learn
Sleep hygiene- intuitive effective
Cpap- intolerable

 

[Shikima]

Personal experience as relevant to psych meds:
Ambien amnesia
Lunesta sonata drowsy morning
Melatonin strong placebo
Benadryl drowsy
Lexapro- insomnia
Alcohol- dizzy
Weed- hypoma nix
Klonipin- depression risk
Cbt-I - tedious behavioral
Sleep hygiene- intuitive
Sleep study- mild osa
Cpap- intolerable

Sorry for the typos in my iPhone

Oookkkayyy....

 

[smalltownpsych]

CBT - I is pretty straightforward and includes sleep hygiene, sleep restrictions, stimulus control, and psychoeducation. Not sure why you found it tedious to learn unless it was a boring psychologist teaching it. That's why I try to use amusing anecdotes.

 

[michaelrack]

http://www.sleepreviewmag.com/2014/...1&spJobID=442432013&spReportId=NDQyNDMyMDEzS0

 

[strangeglove]

I would go with Neurontin. Push the dose, especially at HS. Also helps to cut anxiety in the post-acute withdrawal phase.

 

[nitemagi]

I'd be careful with neurontin, personally. It's worked well for mild-moderate alcohol withdrawal, but as a taper. Not much risk, but I haven't seen it be useful as a stand alone insomnia med in active drinkers on an ongoing basis.

 

[heyjack70]

I'd be careful with neurontin, personally. It's worked well for mild-moderate alcohol withdrawal, but as a taper. Not much risk, but I haven't seen it be useful as a stand alone insomnia med in active drinkers on an ongoing basis.

Agree. Not very sedating in my experience.

 

[Red Beard]

Agree. Not very sedating in my experience.

Perhaps not great to assist sleep onset, but a parsimonious choice for possible reduction of alcohol craving and maybe improvement of that early morning alcohol withdrawal related sleep disruption. Would shoot for around 1800mg total daily dose, (like 300-300-900.)

I would also screen for OSA.

 

[F0nzie]

Gabapentin worked! Score guys. Now having constipation side effect.

 

[Shikima]

Gabapentin worked! Score guys. Now having constipation side effect.

Increase fiber?