A Therapy for Sleep in Alcohol Use Disorder

Personalizing sleep therapy for hazardous drinking

STUDY: Pigeon WR et al, SLEEP Advances 2026;7:zpag002, PMID: 41768371

STUDY TYPE: Open-label pilot trial

FUNDING: National Institutes of Health

Background

Insomnia and hazardous alcohol use are a self-reinforcing pair — poor sleep drives drinking, and drinking worsens sleep. Up to 80% of adults in alcohol treatment report using alcohol as a sleep aid, and insomnia nearly doubles alcohol relapse rates. CBT-insomnia is first-line for chronic insomnia, and this study modified the therapy as CBT-I-HAU for hazardous alcohol use.

A Modified CBT-Insomnia

Here’s the original guide to CBT-insomnia (also available as an app), and here’s how they modified it for hazardous drinking:

1. Patients recorded alcohol intake as part of their sleep diary, and whether they drank to sleep
2. Sleep education included discussion of how alcohol affects sleep (including poor sleep quality and greater risk of sleep apnea)
3. Develop goals of alcohol reduction before bed
4. Develop alternative strategies to alcohol as a pre-bedtime routine
5. Identify and address thoughts (cognitions) related to alcohol and sleep, such as “I can’t fall asleep without a few drinks” or “I need a drink to relax my mind before going to bed”
6. Included three alcohol education materials from the National Institute of Alcohol Abuse and Alcoholism (“Harmful Interactions: Mixing Alcohol with Medicines”; “Rethinking Drinking: Alcohol and Your Health”; and “Treatment for Alcohol Problems: Finding and Getting Help”)
7. Create a list of pros and cons of drinking
8. Identify alternatives to drinking
9. Identify triggers to drinking urges and making a plan for handling drinking urges
10. Develop a preferred way of saying “No thanks” when invited to drink alcohol

My tip: Shift the conversation to sleep quality by asking patients to focus on how they feel the next morning, rather than how quickly they fall asleep.

Source: Sleep Foundation

The Study

Ten adults with hazardous alcohol use and chronic insomnia completed four telehealth sessions of CBT-insomnia modified as above. There was no control group. Insomnia severity (ISI) and alcohol outcomes were assessed before and after treatment.

Insomnia improved sharply: Insomnia (ISI) scores dropped 10.7 points (from 15.1 to 4.4), a large effect size (Hedges g = 3.46). Heavy drinking days fell by half — from 27% to 13% of days (g = 0.80). Alcohol-related problems also declined significantly (g = 0.70), though total drinks per drinking day and days abstinent didn’t change. Depression (PHQ-9) and quality of life improved.

Practice Implications

1. While this uncontrolled study doesn’t prove much, it tells us these common sense modifications are feasible
2. Medications that stabilize sleep after alcohol cessation include gabapentin (up to 1,500 mg qhs, usually 900 mg qhs) and pregabalin (up to 300 mg qhs), and these can be used alongside CBT-insomnia

—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report

What’s Your Take? Share in Comments

1. What strategies do you use for sleep as people recover from alcohol use?