Management of insomnia in alcohol use disorder

Introduction: Insomnia has been implicated in the development, maintenance, worsening, and relapse of alcohol use disorder (AUD).Areas covered: The authors review the possible pharmacological and non-pharmacological treatment options of insomnia for patients with alcohol-use disorder and provide their expert opinion.Expert opinion: Abstinence, or at least a decrease in alcohol use, may improve insomnia symptoms. Second, sleep education is a cornerstone intervention that should be completed by more structured behavioral therapies or Cognitive Behavioral Therapy for Insomnia (CBT-I). CBT-I is the recommended first-line treatment of combined insomnia and AUD (high level of evidence). Third, in case of insufficient response or non-availability of CBT-I, pharmacological treatments might be added. In addition, CBT-I may take several weeks to be effective, and these medications could be proposed to patients with severe symptoms or psychiatric comorbidities. Mirtazapine, gabapentin immediate release, and quetiapine exhibit a moderate level of evidence. Melatonin, topimarate, trazodone, and acamprosate, have a low level of evidence. Benzodiazepines and other GABA-A agonists should be avoided. A particular attention should be provided to patients who use alcohol to help fall asleep as a higher risk of relapse exists after stopping treatment.