No Clear Evidence on How Best to Manage Insomnia in People with Alcohol Dependence

Insomnia among people in treatment for alcohol dependence is common and may be linked to relapse. Researchers conducted a systematic review of open-label and placebo-controlled trials to synthesize the available evidence on the pharmacological treatment of insomnia among people with alcohol dependence. Case reports and case series were excluded. Twenty studies met inclusion criteria.

• The most evidence for efficacy was found for trazodone, which was superior to placebo in 2 randomized trials (RCTs) that examined subjective and objective sleep measures.

• Evidence of efficacy for gabapentin (1 open-label study, 4 RCTs) was equivocal.

• In 1 RCT, topiramate improved subjective sleep measures and reduced heavy drinking days.

• In 2 RCTs, carbamazepine improved subjective sleep measures.

• One RCT showed superiority of lormetazepam over zopiclone on 1 sleep measure (time to fall asleep).

• The remaining evidence came from small, mostly open-label studies with some evidence of efficacy for quietiapine, triazolam, ritanserin, bright light, and magnesium and no evidence or worsening for clomethiazole, scopolamine, and melperone.

Comments:

The most striking finding of this systematic review is that evidence of harm or efficacy for pharmacological substances often used to treat insomnia in people with alcohol dependence (e.g., benzodiazepines) is almost nonexistent. Although trazodone has the most data suggesting efficacy, caution is necessary since 1 study raised concerns that it may decrease days abstinent. High-quality randomized controlled trials are needed to establish the efficacy of pharmacological agents commonly used to treat insomnia among individuals with alcohol dependence, as well as to determine their impact on relapse.

Nicolas Bertholet, MD, MSc

Reference:

Kolla BP, Mansukhani MP, Schneekolth T. Pharmacological treatment of insomnia in alcohol recovery: a systematic review. Alcohol Alcohol. 2011;46(5):578–585.