A guide to the safe and sensible use of nighttime aids.
There are many possible downsides from regular, long-term use of sleeping pills, a class of drugs that doctors call hypnotics.
A study in the American Journal of Public Health showed that long-term use of sleeping pills can double your risk of any accident that requires medical care. Long-term use can trap you in physical dependence. When you try to withdraw from the drug, your insomnia can get worse, and you can develop anxiety, muscle tension, and spasms.
You can also develop mental and psychological dependence, where you think and feel you must take the drug to sleep well. Long-term use also increases the risk of dementia by 39 percent, according to a study in Alzheimer’s Research & Therapy. In a study of nearly 40,000 people, those who regularly took sleeping pills had a 4.6 times higher risk of death. For people with obesity, the risk was eight times higher. The pills were linked to increased rates of cancer, heart disease, and other deadly ailments. But there is a time when you may really need a sleeping pill: When you need to stop short-term insomnia from developing into chronic insomnia.
Released in June 2023, the most recent edition of the International Classification of Sleep Disorders from the American Academy of Sleep Medicine, specifies two types of insomnia:
The two types of insomnia involve similar types of sleeping difficulties, in any possible combination:
The daytime symptoms of short-term and chronic insomnia are the same. They can include fatigue and sleepiness, feeling irritable, depressed or anxious, difficulty with focus, memory or motivation, and frequent worrying about sleep.
Short-term insomnia is very common and is often caused by stress. You’re getting a divorce. You were fired. You have money problems. It’s the holidays. You’re dealing with a natural disaster. The news is bad, and you’re having trouble sleeping.
But for 20 percent of people with short-term insomnia, the sleeping troubles don’t stop. In fact, sleep researchers now understand that short-term insomnia affects brain cells and nerve transmission in such a way that it can contribute to chronic insomnia.
If you have short-term insomnia, the time to take a sleeping pill to break the cycle of sleeplessness is now. But by the time most people see a doctor for insomnia, they’ve already had the problem for at least three months.
Prescription sleeping pills should be taken only short-term to break the cycle of short-term insomnia. Once sleep has been restored, stop taking the pills. If you’re still taking the medication after a month of poor sleeping, it’s time to see your doctor again and to start cognitive behavioral therapy for insomnia. Otherwise, you risk physical, psychological, and mental dependence on the drug.
If you have trouble falling asleep, the best drugs are the nonbenzodiazepine receptor agonists, like zolpidem (Ambien), zaleplon (Sonata), and eszopliclone (Lunesta).
If you have trouble staying asleep, the best drugs are the extended-release (time release) form of Ambien or the extended-release form of eszopliclone (Lunesta). Start with the lowest dose possible, like 5 milligrams (mg) of Ambien for women and 10 mg for men. If you don’t see an effect, increase the dose.
If you’re age 60 or older and the drug hasn’t worked in two weeks, try another class of drugs. You should also switch if the drug causes uncomfortable side effects, like daytime drowsiness.
If these drugs don’t work for you, or they cause side effects, the next class of drug to try is dual-orexin receptor antagonists, like daridorexant (Quviviq) and lemborexant (Dayvigo). If they fail, your doctor could try either a histamine antagonist like doxepin (Silenor) or a melatonin-receptor agonist like ramelteon (Rozerem).
The benzodiazepine receptor agonists (BZRAs) like estazolam (ProSom), flurazepam (Dalmane), temazepam (Restoril), and triazolam (Halcion) are highly addictive and should be used only as a last resort.
You should also avoid trazadone, an antidepressant that is frequently prescribed for insomnia. It can cause increased wakefulness in some people. This drug is best reserved for people with depression.
There are many over-the-counter (OTC) preparations for insomnia, but they are not FDA-approved and should be avoided.
The one exception is melatonin: If you’re already taking melatonin to help you sleep, and it’s working, continue taking it. But if you’re 60 or older, absolutely avoid OTC preparations that contain diphenhydramine, an antihistamine that can cause drowsiness. In seniors, this compound can cause next-day cognitive problems like difficulty focusing and disorganized speech.
Finally, watch out for drug-drug interactions. Don’t take any prescription sleeping pill if you’re also taking any medication that has sedative effects, like a tranquilizer. You may fall asleep faster, but you’ll have less deep sleep and REM sleep, and you’ll shorten overall sleep time.
Similarly, don’t take a sleeping pill with a stimulant medication you use during the daytime. This combination can create a vicious cycle of taking a medication to fall asleep and a medication to stay awake during the day. Also, avoid drinking alcohol in the evenings, and minimize caffeine and nicotine during the day.
There are also classes of medications that can cause insomnia, like corticosteroids and bronchodilators. If CBT-I and sleeping pills haven’t worked, it’s time to see a physician at a sleep center, who can take a deeper dive into possible medical causes of your insomnia.
Sleeping pills don’t work for chronic insomnia because they’re not a long-term solution. Taken long term, they’re a problem. Fortunately, there is a science-supported, effective treatment for chronic insomnia: cognitive-behavioral therapy for insomnia (CBT-I). In fact, the “gold standard” treatment for chronic insomnia starts with CBT-I, with sleeping pills recommended only if CBT-I is unavailable or ineffective. But it’s likely your primary care physician isn’t aware of CBT-I. Nine out of 10 times, primary care doctors treat chronic insomnia with sleeping pills first.
CBT-I systematically replaces insomnia-inducing thoughts (cognitive) and habits (behavioral) with thoughts and habits that are pro-sleep. You’ll also receive relaxation training and learn how to minimize the time you spend awake in bed (sleep restriction and compression). Research shows that CBT-I has an estimated 70 to 80 percent success rate.
Bottom line: If you have chronic insomnia, use CBT-I before you get a prescription for a sleeping pill. You can find CBT-I programs online, like www.thesleepresent.com, a program that is recommended by Stanford Medicine, Yale University School of Medicine, and Harvard Medical School. This online program, which takes 10 minutes a day over eight weeks, has been completed by more than 13,000 people, who report that, on average, they fall asleep 53 percent faster, have two fewer awakenings per night, and sleep 85 minutes longer.
One important point about chronic insomnia: It can have medical causes that need to be diagnosed and treated for the insomnia to stop. These conditions include obstructive sleep apnea, chronic pain, depression, anxiety, benign prostatic hyperplasia (causing repeated awakenings to urinate), periodic limb movement disorder, and restless legs syndrome.
There are five classes of prescription sleeping pills, listed here in order of best to worst choice:
