Expert opinion on pharmacotherapy · 2026
Current perspectives on the pharmacotherapeutic management of insomnia in Veterans.
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Saliba Ranime, Cercone Julia, El-Solh Ali A
Аннотация
INTRODUCTION: Insomnia is a highly prevalent sleep disorder among Veterans and frequently co-occurs with post-traumatic stress disorder (PTSD), depression, chronic pain, and substance use disorders.
AREAS COVERED: This review synthesizes the current evidence on pharmacological management of insomnia in Veterans with attention to guideline recommendations, veteran-specific safety considerations, and comorbidity-driven prescribing. We discuss the rationale for reducing long-term reliance on benzodiazepines and benzodiazepine receptor agonists (BZRAs) in favor of agents with more favorable long-term risk profiles. Concurrent prescribing of GABAergic hypnotics with opioids is addressed in the context of existing VA Opioid Safety Initiative policy, FDA labeling, and observational overdose data. Off-label agents such as trazodone and quetiapine continue to be widely used despite limited efficacy evidence for insomnia; their use is best reserved for cases in which better-supported options have failed.
EXPERT OPINION: Contemporary guidance places cognitive behavioral therapy for insomnia as first-line treatment, while pharmacotherapy is reserved for patients who do not respond to, cannot access, or decline behavioral treatment. The 2025 VA/DoD guideline suggests several medications when pharmacotherapy is used, including daridorexant, doxepin, eszopiclone, lemborexant, suvorexant, zaleplon, and zolpidem, and recommends against antipsychotics, benzodiazepines, and trazodone for chronic insomnia disorder.
AREAS COVERED: This review synthesizes the current evidence on pharmacological management of insomnia in Veterans with attention to guideline recommendations, veteran-specific safety considerations, and comorbidity-driven prescribing. We discuss the rationale for reducing long-term reliance on benzodiazepines and benzodiazepine receptor agonists (BZRAs) in favor of agents with more favorable long-term risk profiles. Concurrent prescribing of GABAergic hypnotics with opioids is addressed in the context of existing VA Opioid Safety Initiative policy, FDA labeling, and observational overdose data. Off-label agents such as trazodone and quetiapine continue to be widely used despite limited efficacy evidence for insomnia; their use is best reserved for cases in which better-supported options have failed.
EXPERT OPINION: Contemporary guidance places cognitive behavioral therapy for insomnia as first-line treatment, while pharmacotherapy is reserved for patients who do not respond to, cannot access, or decline behavioral treatment. The 2025 VA/DoD guideline suggests several medications when pharmacotherapy is used, including daridorexant, doxepin, eszopiclone, lemborexant, suvorexant, zaleplon, and zolpidem, and recommends against antipsychotics, benzodiazepines, and trazodone for chronic insomnia disorder.