Coping with Alcohol Withdrawal Insomnia: Tips and Strategies

15 million Americans struggle with alcohol-use disorder (AUD) – dependence on alcohol!

Of those diagnosed with AUD, between 36% to 72% report difficulty falling or staying asleep (i.e., insomnia). Even more concerningly, alcohol's effect on sleep can persist for weeks to months after the last drink. As a result, many patients resort to using alcohol again, hoping it will help them sleep. This sets off a vicious cycle of alcohol use, relapse, and insomnia, incurring societal costs exceeding $18 billion in the US.

In this article, the experts at Confidant Health break down the effects of alcohol on sleep and ways to deal with it. 

What Is Alcohol Withdrawal Insomnia?

Alcohol withdrawal insomnia refers to the sleeping difficulties (trouble falling or staying asleep) in patients with AUD who quit alcohol. To understand the reasons for this, let’s discuss alcohol’s effects on sleep. 

The Effects of Alcohol on Sleep

Neuroscientists divide the human adult sleep cycle into two phases: 

• Non-rapid eye movement (NREM) sleep dominates the first half of the night and is characterized by slowed breathing and heart rate and a lower body temperature. 
• Rapid eye movement (REM) sleep usually governs the second half of the night, with heightened brain activity and loss of muscle tone as its main features. 

Next, we’ll discuss how alcohol affects each phase differently:

Effects of Alcohol on NREM Sleep

Studies show that alcohol intake reduces the time it takes to fall asleep (which is why alcohol is often used as a sleeping aid) while increasing NREM duration. This is because alcohol triggers the release of Gamma-aminobutyric acid (GABA), a chemical that suppresses brain activity. 

Effects of Alcohol on REM Sleep

As it is an inhibitory neurotransmitter, releasing GABA suppresses the REM sleep cycle (which is characterized by an excitatory brain state). The brain compensates for this by increasing sensitivity to glutamine (an excitatory neurotransmitter). 

Thus, as the body metabolizes and excretes alcohol (usually by the second half of the night), an exaggerated response to glutamine (without the GABA release to counterbalance it) leads to waking up more often. 

Why Does Alcohol Withdrawal Cause Insomnia?

Long-term alcohol use depletes GABA reserves and increases glutamine sensitivity. This results in difficulty falling asleep and staying asleep due to the predominantly excited brain state experienced by users who quit alcohol. 

How Long Does Alcohol Withdrawal Insomnia Last?

Alcohol withdrawal insomnia, on average, lasts for 7-10 days after the last drink. However, keep in mind that this varies considerably on a case-by-case basis depending on many factors (discussed below). 

Factors Affecting the Severity and Length of Alcohol Withdrawal Insomnia

Several factors affect the intensity and duration on alcohol withdrawal insomnia:

• Drinking habits. Alcohol users who consume more than two servings daily report a 39.2% decrease in sleep quality. For users taking less than two servings a day, this number is still a 24% decrease in duration. Similarly, a longer duration of alcohol misuse leads to prolonged withdrawal insomnia. This is because of the greater structural brain changes that occur with long-term alcohol use.
• Gender.Women experience longer, more severe alcohol withdrawal insomnia than men. This is because alcohol remains in their bodies longer due to
• Greater body fat deposits (alcohol is a fat-soluble compound) 
• Lower levels of alcohol dehydrogenase, an enzyme that breaks down alcohol
• Decreased efficiency of Kupffer cells, which are liver cells that metabolize alcohol 
• Age.As age advances, the intensity and severity of alcohol withdrawal increases. For instance, a study comparing alcohol withdrawal intensity among different age groups found that the oldest age group was most severely affected. This is because the volume of the liver (the organ that metabolizes alcohol) decreases with time. 
• Other medical problems. Medical conditions affecting liver, stomach, and kidney function can lead to prolonged, intense alcohol withdrawal insomnia. Understandably, this is because the liver and stomach metabolize alcohol while the kidney excretes its metabolites. 
• Disulfiram use. Disulfiram, a commonly used medication for AUD, deters alcohol use by triggering the accumulation of alcohol metabolites. However, these metabolites also modify serotonin metabolism (a neurotransmitter essential for sustained sleep) leading to reduction in REM sleep.  
• Activity levels. Studies show that exercise speeds up alcohol’s metabolism in the liver because it raises body temperature, which increases the metabolic rate. Thus, individuals with healthier lifestyles experience shorter alcohol withdrawal.

Alcohol Use and Insomnia FAQs

Is Insomnia Normal After Drinking?

Yes, as discussed, alcohol interferes with the sleep cycle, leading to insomnia. 

Can Alcohol Cause Anxiety and Insomnia?

Yes, because alcohol disrupts the neurochemical balance and causes structural changes in the brain. 

How Many Hours of Sleep is Considered Insomnia?

Doctors define insomnia as difficulty falling or staying asleep. This means that the number of hours spent sleeping has nothing to do with insomnia. 

Alcohol Withdrawal Insomnia Diagnosis: How Do You Know You Have It?

Doctors diagnose alcohol withdrawal insomnia in patients who quit or reduce their alcohol intake and then report:

• Difficulty falling asleep
• Trouble staying asleep (in particular, increased awakenings in the second half of the night)
• Other signs of alcohol withdrawal
• Using alcohol to help them sleep better

Preventing Alcohol Withdrawal Insomnia: The Alcohol Taper

Doctors recommend gradually reducing alcohol intake (rather than quitting abruptly) to prevent alcohol withdrawal insomnia. Here are some examples on how to do this:

• Individuals consuming fewer than 20 drinks a day can reduce their intake by two drinks each day. In this case, it would take 10 days for the patient to quit alcohol. 
• Individuals who routinely take more than 20 drinks per day can adopt the following schedule: 
• Day 1 – One drink every waking hour. This equates to 16 drinks total on the first day. 
• Day 2 – A drink every 90 minutes. This equates to a total of 10 drinks for the second day. 
• Day 3 onwards – Consume two fewer drinks each day compared to the previous day 

Keep in mind, these strategies will not work for everyone because of the various factors influencing alcohol withdrawal severity and duration. 

Thus, patients should not attempt to quit alcohol without consulting their healthcare provider (who must supervise this process).  

Alcohol Withdrawal Insomnia Treatment

Many forms of treatment – both non-pharmacological and pharmaceutical – exist for alcohol withdrawal insomnia. Let’s discuss these in more detail. 

Non-Pharmacological Alcohol Withdrawal Insomnia Treatment

Optimize Sleep Hygiene to Reduce Insomnia During Alcohol Withdrawal

Here are some healthy habits that can minimize insomnia associated with alcohol withdrawal:

• Commit to a fixed bedtime (even on weekends). By sleeping at the same time every day, individuals train their mind to automatically activate brain cells that transition them to sleep at their bedtime. As a result, these people report shorter sleep onset durations and fewer nighttime awakenings than their more dynamic counterparts. 
• To strengthen the association further, use your bed only for sleep. This means avoiding activities such as eating, drinking, or watching TV in bed. 
• Avoid caffeinated products (such as coffee, tea, and carbonated drinks) starting at least six hours before bedtime. Caffeine reduces levels of 6-sulfatoxymelatonin (a by-product of melatonin which is a hormone that induces sleep). As a result, individuals who take 400 mg of caffeine in the six hours before bed report struggling to fall and stay asleep.
• Avoid stimulants (such as tobacco) before bed. 32.7% of individuals who smoke and 56% of those who misuse stimulants report struggling with insomnia. This is because these substances trigger the release of epinephrine (the fight-or-flight hormone).  
• Stick to a healthy diet. Deficiencies of vitamins (A, C, D, E, and K) and minerals (calcium and magnesium) reduce levels of serotonin (a key regulator of sleep) in the brain. Understandably, this can lead to insomnia. 
• Studies show that consuming low-glycemic foods before bed can lead to more restful sleep. This is because they trigger the release of serotonin in the brain. 
• Limit fluid intake starting two hours before bed. Drinking fluids before bed can lead to night awakenings due to the urge to urinate. 
• Avoid naps during the day. Napping during the day reduces the sleep drive needed to transition into sleep at night. 
• Exercise regularly (but avoid exercising within three hours of going to bed). Research shows that exercise increases total sleep time and decreases awakenings among participants. This is because of exercise-induced serotonin release in the brain. 
• Invest in a comfortable mattress and pillow. Forty percent of individuals that struggle with insomnia attribute their difficulties to an uncomfortable mattress and pillow (for understandable reasons). In addition, they report significant improvements in sleep quality when provided with a new mattress. 
• Set the thermostat to 65ºF when sleeping. Lower core body temperature triggers the release of melatonin (an essential hormone for sleep). 
• Ensure your bedroom is dark and quiet (and free from screens). Lights and noise suppress melatonin secretion.
• Spend some time in direct sunlight every day. A hallmark study (including half-a-million participants) found that each hour spent outdoors led to significant improvements in insomnia symptoms. This is because early sunlight exposure resets the body’s natural clock.

Behavioral Therapy for Alcohol Withdrawal Insomnia

Behavioral therapy for alcohol withdrawal insomnia falls into two categories:

Cognitive Behavioral Therapy for Alcohol Withdrawal Insomnia (CBT-I)

The American College of Physicians recommends CBT-I as the first line insomnia treatment. This is because it focuses on ways to deal with the thoughts, behaviors, and emotions associated with insomnia. 

A meta-analysis of 20 studies found that CBT-I reduced sleep latency (the time it takes to fall asleep) by 19 minutes and increased total time slept by 26 minutes. Similarly, another meta-analysis showed that 9.91% of CBT-I induced increase in sleep efficiency persisted 12 months later (even when treatment was discontinued). 

Relaxation Therapy for Alcohol Withdrawal Insomnia 

Relaxation therapy (in any of its forms) is a proven, evidence-based treatment for insomnia. This is because it:

• Calms the nervous system
• Boosts melatonin production
• Suppresses the release of stress hormones such as cortisol

Studies show that mindful breathing exercises can significantly improve sleep quality and duration. In addition, these results are sustained three months post treatment. Research shows similar results in patients practicing progressive muscle relaxation techniques. 

Sleep Medications for Alcohol Withdrawal Insomnia

Many medications can help ease alcohol withdrawal insomnia, including:

• Anticonvulsants, such as:
• Carbamazepine. Studies show that carbamazepine reduces sleep latency and increases total sleep duration. This is because it increases the brain’s levels of GABA, which aids progression from wakefulness to sleep. 
• Gabapentin. Seventeen patients struggling with alcohol withdrawal insomnia reported significant sleep improvements with gabapentin. This is because it boosts the brain’s levels of serotonin. 
• Antidepressants, for example:
• Selective serotonin reuptake inhibitors (SSRIs). Studies show that Trazodone (an SSRI) helps increase sleep duration by suppressing the release of excitatory neurotransmitters such as epinephrine. 
• Benzodiazepines (e.g., diazepam) and benzodiazepine-receptor-agonists (e.g., Zolpidem). These increase total sleep time by increasing GABA levels in the brain. 
• Antipsychotics (such as quetiapine). These decrease sleep latency by inhibiting histamine (a hormone that promotes wakefulness). 
• Melatonin. This is a sleep-inducing hormone (available over the counter) that is research-proven to enhance sleep quality. 

We Help You Quit Alcohol Safely So You Can Sleep Without a Worry!

Alcohol withdrawal is unpleasant and dangerous. Luckily, you can avoid it altogether with an evidence-based approach from Confidant Health. Click here to learn more.