Prazosin for Vivid Craving or Using Dreams in Substance Use Recovery

The American Academy of Sleep Medicine downgraded their recommendation for prazosin after a large 2018 VA study of 304 veterans showed no benefit over placebo at 10 or 26 weeks, despite previous positive trials 1, 2
The guideline notes that many patients respond very well to prazosin and this agent remains the first choice for pharmacologic therapy for PTSD nightmares, despite the contradictory evidence 1
Patients taking SSRIs show diminished response to prazosin for PTSD symptoms, which may significantly limit effectiveness 2, 5

Clinical Decision Making

First-line treatment for patients with substance use disorder and co-occurring PTSD should be Image Rehearsal Therapy (IRT), which involves rewriting nightmare content and rehearsing positive scenarios for 10-20 minutes daily 4
Prazosin may be considered as adjunctive pharmacotherapy for patients with substance use disorder and co-occurring PTSD, starting at 1 mg at bedtime to minimize first-dose hypotension 3, 4
Titrate prazosin by 1-2 mg every few days until clinical response, with target doses of 3-4 mg/day for civilians or 9.5-15.6 mg/day for military veterans 3, 5

Nightmares frequently return to baseline intensity when prazosin is discontinued, indicating it treats symptoms without modifying the underlying condition 5
Effectiveness of prazosin may plateau or diminish over time, becoming unsatisfactory for continued treatment 5
Monitor blood pressure after the initial dose and with each significant dose increase due to orthostatic hypotension risk 3, 4