Current perspectives on the pharmacotherapeutic management of insomnia in Veterans

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.