Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

In Brief

Fall 2014 • Volume 8 • Issue 2

Treating Sleep Problems of People in 

Recovery From Substance Use Disorders

Sleep problems are a common complaint among people 

with substance use disorders (SUDs). They can occur 

during withdrawal, but they can also last months and 

years into recovery1

 and can be associated with relapse to 

substance use.2

 This In Brief alerts healthcare providers 

to the relationship between sleep disturbances and SUDs 

and provides guidance on how to assess for and treat sleep 

problems in patients in recovery.

Sleep Disturbances and Substance 

Use

Many Americans suffer from unhealthy sleep-related 

behaviors. The prevalence of insomnia symptoms 

(difficulty initiating or maintaining sleep) in the general 

population is estimated at 33 percent, with an estimated 

6 percent having a diagnosis of insomnia.3

 According to 

a 12-state survey conducted by the Centers for Disease 

Control and Prevention:4

■ 35.3 percent of survey respondents obtain less than 

7 hours of sleep on average during a 24-hour period.

■ 48.0 percent snore.

■ 37.9 percent unintentionally fall asleep during the day.

Substance/medication-induced sleep disorder is 

recognized in the Diagnostic and Statistical Manual 

of Mental Disorders, Fifth Edition.5

 Substance use can 

exacerbate sleep difficulties, which in turn present a risk 

factor for substance use or relapse to use.6

 The types of 

sleep problems vary by substance used and can include 

insomnia, sleep latency (the time it takes to fall asleep), 

disturbances in sleep cycles and sleep continuity, or 

hypersomnia (excessive daytime sleepiness).5

 Specific 

findings on the relationship between sleep disturbances 

and substance use are presented below.

Alcohol Abuse

Insomnia and other sleep disturbances are common 

symptoms of alcohol dependence.1,7 Many people with 

alcohol use disorder (AUD) have insomnia before entering 

treatment.7

 Reported rates of sleep problems among people 

with AUD in treatment range from 25 to 72 percent.8

Some people in recovery from AUD may continue to have 

sleep problems, including insomnia or sleep-disordered 

breathing (such as sleep apnea), for weeks, months, or 

sometimes years after initiating abstinence.9,10,11

Illicit Drug Use

Sleep disturbances are common among people abstaining 

from chronic substance use. People stopping marijuana 

use can experience sleep problems in the first days of 

withdrawal,12 and these problems can last for weeks.13,14 

People in detoxification from opioids often report 

symptoms of insomnia.15,16 A study that objectively 

measured sleep in people who chronically use cocaine 

found that sleep quality deteriorated during a period of 

abstinence, even though the subjects perceived their sleep 

to be improving.17 Another study of people in withdrawal 

from cocaine found that three-quarters experienced poor 

sleep quality.18 In a study of college students, those who 

reported a history of nonmedical psychostimulant use or 

current use reported worse subjective and overall sleep 

quality and more sleep disturbance compared with those 

who had not used such substances.19

The Effects of Sleep Loss During 

Recovery

Sleep loss can have significant negative effects on the 

physical, mental, and emotional well-being of people in 

recovery. It can also interfere with substance abuse 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

2

In Brief

treatment. Persistent sleep complaints after withdrawal 

are associated with relapse to alcohol use.20,21 Poor sleep 

quality before a quit attempt from cannabis use is a risk 

factor for lapsing back into use within 2 days.22

Medication-Assisted Treatment 

and Sleep Disorders

Disrupted sleep, including central sleep apnea and related 

daytime sleepiness, is prevalent in people on methadone 

maintenance therapy for opioid dependence.23,24 Methadone 

dose and duration of opioid use prior to treatment correlate 

linearly with sleep problems.23 The prevalence of sleep 

problems is attributable to the methadone, which is a 

full μ-opioid agonist, and to concurrent factors that often 

affect patients in recovery from opioid addiction, such 

as mental disorders, benzodiazepine abuse, and chronic 

pain. Buprenorphine, a partial μ-opioid agonist, at routine 

therapeutic doses has also been found to induce significant 

alterations of breathing during sleep.25

Assessing Sleep Disorders

If a patient initiating withdrawal from a substance or 

recovering from an SUD complains of a sleep disturbance, 

the healthcare provider should assess for causes by doing 

the following:26

■ Determine the duration of recovery and medications 

used for SUD treatment.

■ Ask questions about difficulty falling asleep, waking 

during the night, amount of sleep per night, snoring, 

sleep apnea, excessive movements during sleep, 

uncontrollable movements that are relieved by getting 

up and walking, and excessive daytime sleepiness. 

If possible, ask significant others the same questions 

about the patient.

■ Rule out other causes of the sleep problem, such as 

stress, a life crisis, or side effects of medications the 

patient is taking.

■ Ask the patient to write in a sleep diary or log 

immediately on awakening. The patient should record 

total time in bed, time of sleep onset, number of times 

awakened, and total time spent awake.

■ Determine the frequency and duration of symptoms 

of insomnia. If difficulties occur two or three nights 

per week and last for 1 month or more, the patient 

warrants a diagnosis of insomnia.

Note that some patients tend to overestimate the quality 

and duration of their sleep on self-report questionnaires 

and in sleep logs.27,28 If warranted, a referral for an 

objective sleep study in a sleep laboratory can be made.

What Healthcare Providers Can Do

■ Screen for insomnia among people in recovery from SUDs.

■ Include questions about sleep during the routine patient history.

■ Rule out other causes of sleep problems (e.g., stress, medications).

■ Educate patients about sleep hygiene, and make referrals to a specialist if necessary.

■ Conduct a careful evaluation, and consider risk factors, before prescribing sedative–hypnotic medications to treat insomnia.

■ Monitor patients for signs of abuse or diversion of scheduled medications prescribed to treat insomnia and other sleep 

disorders.

Treatments

The association between insomnia and relapse calls for 

treatment that addresses insomnia during recovery. The 

first step in treating insomnia should focus on the status 

of the patient’s recovery. Patients should be receiving 

treatment from an appropriate substance abuse treatment 

program. It is important to address other psychological, 

social, and medical problems that may contribute to 

insomnia, such as co-occurring mental and medical 

disorders, use of medications that disturb sleep, and 

nicotine use.29,30

Nonpharmacological Treatments

Nonpharmacological treatments are preferred because 

many pharmacological treatments for insomnia have the 

potential for abuse and can interfere with SUD recovery. 

Research on cognitive–behavioral therapy (CBT) to treat 

insomnia has shown positive results, generally26,31,32 and 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

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Treating Sleep Problems of People in Recovery From Substance Use Disorders

Fall 2014, Volume 8, Issue 2

also in patients who are alcohol dependent.40 Exhibit 1 lists 

several nonpharmacological interventions that have shown 

some degree of effectiveness. Combining approaches may 

be more effective than using one approach.38

Healthcare providers can educate patients about simple 

nonpharmacological techniques that can improve sleep41

(see Exhibit 2). Sleep education includes teaching about 

sleep, the effects of recovery from substance use on sleep, 

and health practices and environmental factors that affect 

sleep.38 Sleep can be improved by limiting bedroom 

activities to sleeping (e.g., refraining from activities such 

as reading the newspaper, paying bills, or working on 

electronic devices) and going to bed only when sleepy 

and at about the same time each day. These activities help 

reassociate the bed and bedroom with going to sleep.37

Establishing a relaxing presleep routine, which can include 

progressive muscle relaxation,35 imagery,42 or a warm 

bath,41 also promotes sleep. Some patients may benefit 

from referral to a sleep medicine specialist. Exhibit 1. Nonpharmacological Treatments

■ Mindfulness meditation. The patient moves into 

a state of restful, present-moment alertness, which 

reduces stress and improves self-control.33,34

■ Progressive muscle relaxation. The patient 

concentrates on tensing and relaxing groups of 

muscles.8,35

■ Biofeedback. The patient becomes aware of 

physiologic stress responses and how to control them.26

■ CBT for insomnia. The patient’s dysfunctional beliefs 

and behaviors are modified to improve his or her 

emotional state.26,36

■ Stimulus control. The patient reassociates the bedroom 

with the rapid onset of sleep.37

■ Exercise. Regular physical activity relieves stress and 

tires the patient.26

■ Sleep restriction therapy. The patient limits sleep 

to a few hours and progressively increases it until the 

desired amount of sleep time is achieved.26

■ Bright-light therapy. Exposure to a natural bright light 

while awake helps promote normal sleep patterns.38

■ Dental devices and continuous positive airway 

pressure machines. These devices help the patient 

with obstructive sleep apnea breathe more easily 

during sleep.39

Pharmacological Treatments

Over-the-counter medications and dietary 

supplements

Some people who have trouble sleeping have tried overthe-counter sleep medications or dietary supplements to 

help them sleep. Patients may ask about these, and care 

should be taken to explain their safety and efficacy. Many 

over-the-counter sleep medications contain antihistamines 

that cause sedation.38 They are not recommended as a 

long-term treatment for insomnia because they negatively 

affect the natural sleep cycle and have side effects such 

as morning grogginess, daytime sleepiness, and impaired 

alertness and judgment.43,44 Furthermore, evidence 

supporting their long-term effectiveness is insufficient.43

Popular dietary supplements taken with the intent to 

promote sleep include valerian and melatonin. Valerian, 

an herb, is thought to have sedative effects.45,46 However, 

studies of valerian offer mixed results,47,48 and evidence 

supporting the supplement’s efficacy is insufficient to 

warrant its use.49,50 In addition, valerian could damage the 

liver.47 Melatonin is a brain hormone that helps regulate 

sleep patterns.51 Limited evidence shows that it can treat 

chronic insomnia in some people and, to date, there is no 

evidence that it is harmful.52

Prescription medications without known 

abuse potential

Medications without known abuse potential should be the 

first treatment option when pharmacotherapy is necessary 

to treat insomnia during recovery. Ramelteon and doxepin 

are the only unscheduled prescription medications 

approved by the U.S. Food and Drug Administration 

(FDA) for the treatment of insomnia. Ramelteon decreases 

the amount of time it takes to fall asleep.53,54 Doxepin, 

originally FDA approved as an antidepressant, has been 

approved for treating insomnia typified by problems 

staying asleep. These medications may be suitable for 

treating insomnia in patients in recovery, because they do 

not appear to have potential for abuse.55,56,57
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In Brief

Exhibit 2. Promoting Sleep Hygiene: Tips for a Good Night’s Sleep58,59

■ Go to bed and get up at the same times each day.

■ Use natural light (that comes through a window) to remind yourself of when it’s time to be asleep and awake. This can help 

you set a healthy sleep–wake cycle.

■ Exercise regularly. 

■ If you take naps, keep them short and before 5 p.m.

■ Don’t eat or drink too much when it is close to bedtime.

■ Avoid caffeine (in coffee, tea, chocolate, cola, and some pain relievers) and nicotine for several hours before bedtime.

■ Wind down before going to bed (e.g., take a warm bath, do light reading, practice relaxation exercises).

■ Keep the bedroom a relaxing place—avoid working or paying bills in bed. 

■ Sleep in a dark, quiet room that isn’t too hot or too cold.

■ Don’t lie in bed awake. If you can’t fall asleep within 20 minutes, get up and do something relaxing.

Off-label medications

Other medications are often prescribed off label (for 

purposes other than the medication’s FDA-approved use) 

to treat insomnia. According to a survey of addiction 

medicine physicians, the sedating antidepressant 

trazodone is the medication most often prescribed for 

the management of sleep disorders in patients in early 

recovery from AUD.60 One study found that its use among 

people in recovery from AUD improved sleep efficiency.61

Studies of its effects on abstinence and relapse in persons 

with AUD are conflicting. A 2008 study comparing 

trazodone with placebo for people after detoxification from 

alcohol showed that the trazodone group had improved 

sleep quality but had less improvement in the proportion of 

days abstinent while taking the medication. Furthermore, 

when the medication was discontinued, the trazodone 

group experienced less improvement in abstinence days 

and an increase in the number of drinks per drinking 

day.62 In contrast, a study published in 2011 of patients 

discharged from residential treatment did not find an 

association between trazodone use and relapse or return 

to heavy drinking.63 A study of patients on methadone 

maintenance treatment found that trazodone use provided 

no improvement in sleep.64

Other sedating antidepressants that have been used to treat 

insomnia include amitriptyline, mirtazapine, nefazodone, 

and nortriptyline.65 In a study of the use of mirtazapine 

on subjects with cocaine dependence and co-occurring 

depression, the medication decreased sleep latency; 

however, it had no measurable effect on treatment for 

cocaine dependence and depressive symptoms.66

Gabapentin, an anticonvulsant with sedative properties, 

also has evidence of efficacy for treating insomnia.50,67 It 

has been found to be more effective in promoting sleep 

than lorazepam (an anxiolytic commonly prescribed to 

treat insomnia) among people withdrawing from alcohol.67

It has also been found to be more effective than trazodone 

in promoting sleep among those in early recovery.

68

Acamprosate, a medication used to maintain alcohol 

abstinence, may also improve sleep during withdrawal 

from alcohol.21,69

Prescription medications with known 

abuse potential

Sedative–hypnotic medications, such as benzodiazepines 

and nonbenzodiazepines, are commonly prescribed to 

treat sleep problems. However, these medications should 

be avoided by people with histories of SUDs, who are at 

increased risk for abusing them.44,70 Benzodiazepines, such 

as alprazolam, diazepam, and triazolam, are especially 

risky for use with people with SUDs because they are 

potentially addicting. They can also cause residual daytime 

sedation, cognitive impairment, motor incoordination, and 

rebound insomnia.50 Long-term treatment of insomnia with 

benzodiazepines may lead to withdrawal symptoms (e.g., 

anxiety, irritability, seizures) when patients stop taking 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

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Treating Sleep Problems of People in Recovery From Substance Use Disorders

Fall 2014, Volume 8, Issue 2

the medications. A careful clinical evaluation is needed to 

ensure appropriate prescribing. Measures to prevent abuse 

include the following:71

■ Observe closely and perform ongoing evaluations.

■ Prescribe a few tablets at a time.

■ Schedule frequent office visits.

■ Conduct occasional urine screenings.

■ Use one source to dispense the medication.

■ Occasionally taper the medication.

■ Be attentive to risk factors such as antisocial 

personality disorder and dependence on multiple 

substances.

Alternatives to benzodiazepines include sedative–hypnotic 

medications such as zaleplon, eszopiclone, and zolpidem. 

These medications all have the same mechanism of 

action as benzodiazepines but lack some of the negative 

side effects. However, some research indicates that 

at high doses they may have the same side effects as 

benzodiazepines.72 The three medications are Schedule IV 

controlled substances, indicating abuse potential. For

these reasons, these medications should be used only for 

short-term treatment of insomnia in people with a history 

of SUDs.

Web Resources

American Academy of Sleep Medicine 

http://www.aasmnet.org

National Center on Sleep Disorders Research 

http://www.nhlbi.nih.gov/about/org/ncsdr

National Sleep Foundation 

http://www.sleepfoundation.org

Notes

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2 Brower, K. J., & Perron, B. E. (2010). Prevalence and correlates 

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3 Ohayon, M. M. (2002). Epidemiology of insomnia: What we know 

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4 Centers for Disease Control and Prevention. (2011). Unhealthy 

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5 American Psychiatric Association. (2013). Diagnostic and statistical 

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6 Hasler, B. P., Smith, L. J., Cousins, J. C., & Bootzin, R. R. (2012). 

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7 Brower, K. J., Krentzman, A., & Robinson, E. A. R. (2011). 

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8 Stein, M. D., & Friedmann, P. D. (2005). Disturbed sleep and its 

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9 Brower, K. J. (2003). Insomnia, alcoholism and relapse. Sleep 

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10 Colrain, I. M., Turlington, S., & Baker, F. C. (2009). Impact of 

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11 Currie, S. R., Clark, S., Rimac, S., & Malhotra, S. (2003). 

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12 Vandrey, R., Smith, M. T., McCann, U. D., Budney, A. J., & Curran, 

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In Brief

15 Hillhouse, M., Domier, C. P., Chim, D., & Ling, W. (2010). Provision 

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20 Hornyak, M., Haas, P., Veit, J., Gann, H., & Riemann, D. 

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21 Staner, L., Boeijinga, P., Danel, T., Gendre, I., Muzet, M., Landron, 

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23 Peles, E., Schreiber, S., & Adelson, M. (2006). Variables associated 

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24 Wang, D., Teichtahl, H., Drummer, O., Goodman, C., Cherry, G., 

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25 Farney, R. J., McDonald, A. M., Boyle, K. M., Snow, G. L., Nuttall, 

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26 Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. 

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In Brief

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Recommended Citation: Substance Abuse and Mental Health Services Administration. (2014). Treating Sleep Problems of 

People in Recovery From Substance Use Disorders. In Brief, Volume 8, Issue 2.

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