• 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


  • 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


  • 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)


  • Discharge home unless patient acutely psychotic
  • Follow up with primary care doctor
  • Consider outpatient polysomnography-sleep study

See Also

External Links


  1. Bonnet, MH and DL Arand. Treatment of insomnia in adults. In: UpToDate, Benca, R (Ed), UpToDate, Waltham, MA, 2017. ([1])