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
• Obstructive 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
• 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