Trazodone Improves Sleep, but Decreases Abstinence in Recovering Alcoholics

Here’s bad news for a widely used treatment strategy for sleep disturbance in early recovery:

“We were really surprised that, if anything, trazodone made things worse with respect to drinking,” said Dr. Swift. “The sleep was better. The drinking was not.”

“Wired” Recovering Alcoholics

Sleep disturbances are common among patients in recovery from alcoholism, said Dr. Swift, affecting 25% to 50% of patients who are in the early stages of detoxification. Fatigue might be related to relapse, he added.

Off-label prescribing of trazodone, a weak sedating antidepressant, is the most common pharmaceutical treatment for insomniac alcoholic patients in the early stages of detoxification, according to a survey of addiction medicine physicians done by Dr. Friedman and colleagues (J Addict Dis 2003; 22:91-103).

In 2006, there were 16 million prescriptions for trazodone in the United States, said Dr. Swift, speculating that a lot of these prescriptions were for sleep disorders. In laboratory studies, 1 of trazodone’s metabolites — m-chlorophenylpiperazine — was found to increase alcoholic cravings.

The group wanted to determine whether trazodone reduces drinking and improves sleep quality among alcoholic patients who have recently undergone detoxification.

They hypothesized that among alcoholic patients in early recovery, the administration of trazodone would increase days of abstinence, reduce heavy drinking days, reduce drinks per drinking day, and improve sleep quality.

They screened more than 2400 people who were admitted to the state-run detoxification program in Rhode Island. To be included in the study, individuals had to be 18 years or older and meet DSM criteria for alcohol dependence but not for any other drug except nicotine or cannabis. They also had to have sleep problems during previous abstinence periods or have a self-reported global Pittsburgh Sleep Quality Index score of >5 (indicating disturbed sleep).

Most potential subjects were excluded because they abused other drugs. A total of 173 patients were randomized to trazodone 50 to 150 mg (n=88) or to placebo (n=85) for 12 weeks. All patients received a sleep hygiene booklet. Assessments were made at baseline, 1 month, 3 months (study end), and 6 months (follow-up).

Outcome variables included Pittsburgh Sleep Quality Index scores, percentage of abstinent days, drinks per drinking day, and percent of heavy drinking days (5 for men, 4 for women).

Very Heavy Drinkers

The participants had a mean age of 21 years, and women made up less than 10% of the study sample. The group reported heavy drinking in the previous 3 months (a mean of 22 drinks per drinking day, and a mean of 71 heavy drinking days).

Individuals in the trazodone group had less improvement in percentage of abstinent days, a smaller decrease in heavy drinking days, and an increase in drinks per drinking day after the study medicine was stopped.

Trazodone was associated with a greater improvement in sleep quality, but once the medication was stopped, sleep quality was the same as with placebo.

Study limitations include that it was a relatively small sample in a single site and that subjects were all very heavy drinkers.

The group concluded that despite a short-term benefit in sleep quality with trazodone, the drug might impede improvements in alcohol consumption in the postdetoxification period and might lead to increased drinking when stopped.

“Until further studies have established benefits and safety, trazodone for sleep disturbances cannot be recommended after detoxification from alcoholism,” said Dr. Swift.