Disclaimer: Information provided about medications on this website is intended for general educational purposes and does not constitute treatment advice. I am not licensed to prescribe medications. Please seek further guidance from a provider who is licensed to prescribe medications.
Appropriate use of medication
Sleep medications are most appropriate for short-term and/or intermittent use. Longer-term use is mainly appropriate for people who are unable to participate in CBT-I or those who have not sufficiently benefitted from CBT-I. These statements are based on expert consensus statements (see below). Because many sleep medications can suppress breathing, one should take extra care not to combine them with other substances that suppress breathing, including alcohol, anti-anxiety medications (benzodiazepines), and opioid medications.
Strategies for addressing medication use
If you are currently taking a medication for sleep or an over-the-counter remedy for insomnia, we will need to evaluate whether it will be helpful going forward. If it is a prescription medication, we will do this in consultation with your prescribing physician. Depending on the medication, and how long you have used it, strategies for managing medication use include:
Discontinuing the medication before implementing CBT-I.
Stabilizing you on a single medication during CBT-I.
Developing a plan for discontinuing your medication after CBT-I.
Switching your medication to something more appropriate for longer-term use.
Remaining on the medication.
Expert consensus statements regarding sleep medication
The American College of Physicians has stated "...pharmacologic treatments for insomnia are intended for short-term use, and patients should be discouraged from using these drugs for extended periods.” They have also stated that "pharmacologic therapy can be associated with serious adverse events...."
The American Academy of Sleep Medicine has stated that “Medications for chronic insomnia disorder should be considered mainly in patients who are unable to participate in CBT-I, who still have symptoms despite participation in such treatments, or, in select cases, as a temporary adjunct to CBT-I.”
Information about sleep medications
The American Academy of Sleep Medicine (AASM) has recommended the following medications to treat sleep onset insomnia (i.e., problems with falling asleep):
eszopiclone (Lunesta) [a sedative-hypnotic]
zaleplon (Sonata) [a sedative-hypnotic]
zolpidem (Ambien) [a sedative-hypnotic]
temazepam (Restoril) [a benzodiazepine]
triazolam (Halcion) [a benzodiazepine]
ramelteon (Rozerem) [a melatonin agonist]
They have recommended the following medications for sleep maintenance insomnia (i.e., problems with staying asleep):
eszopiclone (Lunesta) [a sedative-hypnotic]
zolpidem (Ambien) [a sedative-hypnotic]
temazepam (Restoril) [a benzodiazepine]
doxepin (Silenor) [an antidepressant]
suvorexant (Belsomra) [an orexin receptor antagonist]
They do not recommend the following:
most antidepressants (including trazodone; except for doxepin) (however, they note that antidepressants such as trazodone may be appropriate in certain situations, such as patients who are experiencing both depression and insomnia)
most antianxiety medications including benzodiazepines such as alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonapin), and diazepam (Valium)
antihistamines, such as diphenhydramine (the active ingredient in Benadryl, Unisom, and Tylenol PM)
tiagabine [an anticonvulsant]
L-tryptophan [an amino acid supplement]
valerian [an herbal supplement]
Medication side effects
Sedative-hypnotics - Side effects of sedative-hypnotics can include: Residual daytime sedation, cognitive impairment, motor incoordination, headache, dizziness, nausea, abdominal pain, respiratory suppression, they may be habit forming with long-term use, and they can cause rebound insomnia on discontinuance. A less common side effect of zolpidem involves inappropriate behaviors while not fully awake (e.g., sleep walking, driving, making telephone calls, eating, or having sex).
Benzodiazepines - These medications are not intended to be taken on a regular basis for the long-term because they are habit forming and cause withdrawal symptoms and rebound insomnia upon discontinuance. Research has found an increased risk for cognitive impairment (including dementia) with long-term benzodiazepine use, particularly by older adults. Other side effects are similar to the sedative-hypnotics (described above).
Melatonin agonists (ramelteon / Rozerem) - Adverse effects are generally milder than those associated with benzodiazepines and sedative-hypnotics, and it has little abuse potential.
Orexin receptor antagonists (suvorexant / Belsomra) - It has the potential for dependence and abuse. It can cause daytime somnolence, and worsen sleep-disordered breathing in vulnerable patients. Other potential side effects include headaches, sleepwalking, REM sleep behavior disorder, suicidal ideation, and the emergence of sleep paralysis, hypnogogic hallucinations, and mild cataplexy.
Antihistamines (diphenhydramine / Benadryl / Unisom / Tylenol PM) - There is little evidence that diphenhydramine improves insomnia and it may cause sedation the next day (due to its long half-life). Additional side effects include changes in sleep architecture (particularly a reduction in REM sleep), decreased alertness, diminished cognitive function (e.g., concentration, memory), delirium, dry mouth, blurred vision, urinary retention, constipation, and increased intraocular pressure. Recent research has shown an increased risk for dementia, particularly when used long-term and by older adults. The AASM recommends that diphenhydramine not be used to treat insomnia.
Melatonin - Melatonin taken at higher doses (>1mg) may dysregulate the sleep clock, worsen insomnia, and cause daytime grogginess. To use melatonin supplements properly do the following: Obtain low-dose melatonin (300 microgram tablets are recommended). This is available at the Corvallis Clinic Pharmacy and online (see example). Consistently take 300mcg at 5 hours before bedtime and take 600mcg at bedtime every night for at least 90 days, and do not expect immediate results. More information about melatonin.
Herbal products - There is little evidence from randomized controlled trials about the efficacy of many herbals, however, and for those that have been well studied (e.g., valerian), there is little evidence of benefit. Valerian has been associated with a greater number of adverse events per person compared with placebo, and it may also produce liver damage. It is not recommended by AASM.
Cannabis - There insufficient research to inform a recommendation regarding cannabis. That said, I have not been impressed by the effects I have observed in my patients with insomnia and other psychiatric disorders (e.g., depression, anxiety) who report using cannabis for these disorders. Here is a good expert opinion about cannabis and sleep. Dr. Matthew Walker is Professor of Neuroscience at the University of California. Huberman Lab (You Tube video), with Dr. Matt Walker: Does Marijuana Disrupt Your Sleep?
Drug interactions
Concurrent use of any sleeping medication and alcohol (or another central nervous system depressant, including diphenhydramine, benzodiazepines, and opioid pain medication) increases the risk of central nervous system depression which results in suppressed breathing, and, therefore, is contraindicated.
Medication and older adults
According to Bonnett and Arand, "Older adults have a particularly high risk of adverse effects from hypnotic drugs, including excessive sedation, cognitive impairment, delirium, night wandering, agitation, postoperative confusion, balance problems, and impaired performance of daily activities. An increased risk of falls with severe consequences, including traumatic brain injury and hip fracture, has been observed in association with both benzodiazepines and non-benzodiazepines" (sedative-hypnotics). A review of studies showed that improvements in sleep were "relatively small compared with the two- to fivefold increase in adverse cognitive or psychomotor events." They conclude "This suggests that additional caution is necessary when deciding whether pharmacotherapy is indicated for an older patient with insomnia." Also see this Up to Date article.
References
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165, 2, 125-133. [Link]
Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13, 2, 307–349. [Link]
Additional references
Chiu, H. Y., Lee, H. C., Liu, J. W., Hua, S. J., Chen, P. Y., Tsai, P. S., & Tu, Y. K. (2021). Comparative efficacy and safety of hypnotics for insomnia in older adults: a systematic review and network meta-analysis. Sleep, 44(5), zsaa260. https://doi.org/10.1093/sleep/zsaa260 https://pubmed.ncbi.nlm.nih.gov/33249496/
De Crescenzo, F., D'Alò, G. L., Ostinelli, E. G., Ciabattini, M., Di Franco, V., Watanabe, N., Kurtulmus, A., Tomlinson, A., Mitrova, Z., Foti, F., Del Giovane, C., Quested, D. J., Cowen, P. J., Barbui, C., Amato, L., Efthimiou, O., & Cipriani, A. (2022). Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis. Lancet (London, England), 400(10347), 170–184. https://doi.org/10.1016/S0140-6736(22)00878-9 https://pubmed.ncbi.nlm.nih.gov/35843245/
Everitt, H., Baldwin, D. S., Stuart, B., Lipinska, G., Mayers, A., Malizia, A. L., Manson, C. C., & Wilson, S. (2018). Antidepressants for insomnia in adults. The Cochrane database of systematic reviews, 5(5), CD010753. https://doi.org/10.1002/14651858.CD010753.pub2 https://pubmed.ncbi.nlm.nih.gov/29761479/
Hasan, F., Lee, H. C., Chen, P. Y., Wang, Y. H., Yuliana, L. T., Romadlon, D. S., Tu, Y. K., & Chiu, H. Y. (2023). Comparative efficacy of hypnotics in young and middle-aged adults with insomnia: a systematic review and network meta-analysis. Sleep & breathing = Schlaf & Atmung, 27(5), 2021–2030. https://doi.org/10.1007/s11325-023-02812-5 https://pubmed.ncbi.nlm.nih.gov/36928548/
Lie JD, Tu KN, Shen DD, Wong BM. Pharmacological Treatment of Insomnia. P T. 2015 Nov;40(11):759-71. PMID: 26609210; PMCID: PMC4634348.
Matheson, E. M., Brown, B. D., & DeCastro, A. O. (2024). Treatment of Chronic Insomnia in Adults. American family physician, 109(2), 154–160.
Pan, B., Ge, L., Lai, H., Hou, L., Tian, C., Wang, Q., Yang, K., Lu, Y., Zhu, H., Li, M., Wang, D., Li, X., Zhang, Y., Gao, Y., Liu, M., Ding, G., Tian, J., & Yang, K. (2023). The Comparative Effectiveness and Safety of Insomnia Drugs: A Systematic Review and Network Meta-Analysis of 153 Randomized Trials. Drugs, 83(7), 587–619. https://doi.org/10.1007/s40265-023-01859-8
Scharner, V., Hasieber, L., Sönnichsen, A., & Mann, E. (2022). Efficacy and safety of Z-substances in the management of insomnia in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing. BMC geriatrics, 22(1), 87. https://doi.org/10.1186/s12877-022-02757-6 https://pubmed.ncbi.nlm.nih.gov/35100976/
Schroeck, J. L., Ford, J., Conway, E. L., Kurtzhalts, K. E., Gee, M. E., Vollmer, K. A., & Mergenhagen, K. A. (2016). Review of Safety and Efficacy of Sleep Medicines in Older Adults. Clinical therapeutics, 38(11), 2340–2372. https://doi.org/10.1016/j.clinthera.2016.09.010 https://pubmed.ncbi.nlm.nih.gov/27751669/
Sys, J., Van Cleynenbreugel, S., Deschodt, M., Van der Linden, L., & Tournoy, J. (2020). Efficacy and safety of non-benzodiazepine and non-Z-drug hypnotic medication for insomnia in older people: a systematic literature review. European journal of clinical pharmacology, 76(3), 363–381. https://doi.org/10.1007/s00228-019-02812-z https://pubmed.ncbi.nlm.nih.gov/31838549/
Wilt, T. J., MacDonald, R., Brasure, M., Olson, C. M., Carlyle, M., Fuchs, E., Khawaja, I. S., Diem, S., Koffel, E., Ouellette, J., Butler, M., & Kane, R. L. (2016). Pharmacologic Treatment of Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Annals of internal medicine, 165(2), 103–112. https://doi.org/10.7326/M15-1781 https://pubmed.ncbi.nlm.nih.gov/27136278/
Zee, P. C., Bertisch, S. M., Morin, C. M., Pelayo, R., Watson, N. F., Winkelman, J. W., & Krystal, A. D. (2023). Long-Term Use of Insomnia Medications: An Appraisal of the Current Clinical and Scientific Evidence. Journal of clinical medicine, 12(4), 1629. https://doi.org/10.3390/jcm12041629
Continue to Strategy 9: Sleep scheduling (Improve sleep efficiency using systematic sleep scheduling)
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