Insomnia
Background
- Daytime dysfunction due to difficulty initiating sleep or lack of good sleep.
- A common emergency department complaint among patients in recovery from a substance use disorder or a psychiatric disorder
- Most substances of abuse affect sleep during active use, acute withdrawal, and with sustained abstinence
- Specific medications for insomnia should be avoided in patients with history of substance abuse.
Clinical Features
- Difficulty falling asleep and staying asleep
- Impaired daytime function (must also be reported for a diagnosis of an insomnia disorder)
- Simultaneous psychiatric, medications/substances, are usually present
Differential Diagnosis
- Alcohol Abuse, alcohol, benzo, or opioid withdrawal
- Depression/anxiety
- Bipolar disorder, schizophrenia
- Hepatic encephalopathy
- TBI
- Acute mountain sickness
- Delirium
- Hyperphosphatemia
- Medications (many!)
- Excess caffeine
- Sleep-disruptive environmental circumstances
- Restless legs syndrome
- Sleep apnea
- Short duration sleep circadian rhythm disorders
- Chronic sleep restriction
- Psychosis
Evaluation
- A personal medical history considering any medical conditions, any medications being taken, and any stressful life events/changes that could be causing insomnia
- Screen for mood disorders, PTSD, substance use disorders
- A sleep history and review of sleep and wake diaries can be helpful in determining the cause
Management
- Sleep hygiene education, relaxation, and stimulus control
- Zaleplon for sleep onset insomnia, Zolpidem (Ambien) or Eszopiclone for sleep maintenance insomnia[1]
- Trazodone, gabapentin, and melatonin/melatonin agonists
- Benzodiazepines should be avoided (due to risks of overdose when mixed with alcohol or other substances)
Disposition
- Discharge home unless patient acutely psychotic
- Follow up with primary care doctor
- Consider outpatient polysomnography-sleep study