Insomnia Medications Deep Dive (Part I): Know Your Pills

One of the first things most of my insomnia patients want to know is: Will I ever be able to sleep well without my sleep medications? Many had already worked on discontinuing their sleeping pills without success, or are afraid to even try, despite being unhappy about side effects. Some of my older patients simply don’t have a choice because their doctor is no longer willing to prescribe them Ambien given the risk for falling or cognitive impairment. So how can we safely and effectively navigate decision-making around sleep medications? In this 2-part deep dive series on sleep medications, we will bust the myths about sleep medications, consider factors in their benefit (or lack thereof) to you, and discuss some options for changing your relationship to sleeping pills if that’s what you’d like to do. In Part I, let’s start with introducing you to different types of sleep medications and how they work.

Important: Do not make any changes to your sleep (and other) medications without consulting with your prescribing healthcare provider first, even when it comes to over-the-counter supplements. Consider this blog series to be a resource that can help inform your decision-making and your discussions with your doctor, not a guide to what you should and shouldn’t do.

Types of Insomnia Medications

Sleep medications used for insomnia generally fall into three categories:

1. FDA-approved medications specifically designed for insomnia

2. FDA-approved medications used "off-label" for insomnia symptoms

3. Over-the-counter sleep aids (including supplements and herbs)

Medications Designed Specifically to Treat Insomnia

• Doxepin

• Eszopiclone

• Ramelteon

• Suvorexant

• Temazepam

• Triazolam

• Zaleplon

• Zolpidem

This list represents a remarkably diverse group of chemicals. Some are benzodiazepines (e.g., temazepam), a group of drugs that work by amplifying your brain’s GABA (gamma-aminobutyric acid) system—a system that generally inhibits other brain activity. Some are marketed as “nonbenzodiazepines” (e.g., zolpidem), because benzodiazepines have a bad reputation for potential cognitive impairment side effects, as well as having potential for dependence or abuse. These “nonbenzos” technically have a different chemical structure, but they actually act in the same way as benzodiazepines in the brain, and have similar side effect profiles. Some are orexin antagonists (e.g., suvorexant), which means they inhibit the wake-promoting orexin system in the brain. Some are antidepressants (e.g., doxepin) that happen to have an antihistamine effect at a low dosage, which also blocks wake-promoting systems. And some are melatonin receptor agonists (e.g., ramelteon), which enhance the action of the melatonin system, whose job is to tell the rest of the brain and body when it is nighttime. These drugs received FDA approval for treating insomnia because there is a good evidence base for their effectiveness and safety.

The "Off-Label" Approach to Insomnia

• Clonazepam

• Gabapentin

• Hydroxyzine

• Olanzapine

• Quetiapine

• Tiagabine

• Trazodone

The drugs in this category are interesting because the only thing they have in common is that they have a sedating effect, which is really all that’s required for something to be used off-label. They range from antidepressants (e.g., trazodone), to antipsychotics (e.g., quetiapine), to anticonvulsants (e.g., gabapentin). The AASM does not officially recommend any of the drugs listed above for treating insomnia, because there is either not enough evidence supporting their efficacy or that the evidence shows the harms outweigh the benefits, which might surprise you if you are among the 1 percent of the total adult population who takes trazodone for insomnia.

But there are potentially good reasons to go off-label. For example, doctors may hesitate to prescribe on-label treatments that carry significant side effects (such as benzodiazepines), or because patients may have already undergone several trials of on-label meds that proved ineffective. An off-label drug may also better fit the patient’s overall needs—if you have both depression and insomnia, for example, an antidepressant with a sedating effect might be a better option than separately taking a different antidepressant and an on-label insomnia drug. With these considerations, it’s not so surprising that nearly half of the time, people are prescribed off-label meds for insomnia.

Over-the-Counter Sleep Aids

• Acetaminophen (e.g., Tylenol PM)

• Diphenhydramine (e.g., Benadryl)

• Doxylamine (e.g., Unisom)

• Melatonin

• L-tryptophan

• Valerian

• Lavender

• Ashwagandha

• Other supplements and herbs

Some patients feel more comfortable with taking over-the-counter sleep aids compared to prescription insomnia medications. There is some evidence that some of these can be helpful for improving sleep in some circumstances (e.g., melatonin supplementation may be necessary for older adults, or those who have been taking beta-blockers for a long time). However, none of them have enough evidence to have earned a recommendation from the AASM as a stand-alone treatment for insomnia. The way I like to think about supplements is that they may be helpful as an adjunct if the right one is used for the right reason… but none of them will be sufficient as a cure for insomnia.

The biggest concern I have about people using over-the-counter sleep aids is that they’re less likely to read dosage and warning labels, follow instructions, and discuss their use of these sleep aids with their healthcare providers. This worries me because many of these medicines are also not meant to be taken long term, or sometimes even short term if the insomnia has no clear cause. If you read the Tylenol PM label, for example, you’ll see that it’s meant for “occasional insomnia associated with minor aches and pains . . . not for use in treating sleeplessness without pain, or sleep problems that occur often.” And just because Tylenol PM is over-the-counter doesn’t mean it doesn’t have risks, such as risks for liver damage with long-term use, especially if combined with alcohol.

The Reality Check: Effectiveness vs. Expectations

Here's something surprising: Even the FDA-approved, AASM-recommended insomnia medications are underwhelming when you look at their actual effects. Ambien (zolpidem), for example, is the most commonly prescribed sleep medication. Clinical trials show it typically:

- Reduces time to fall asleep by only 5-12 minutes

- Increases total sleep time by less than 30 minutes

Most of my insomnia patients would not be satisfied to fall asleep just a few minutes faster when they’re often struggling for an hour or more at bedtime, or to reduce their hours-long middle-of-the-night vigil by just half an hour… especially when they learn that some people can gain tolerance and need higher doses over time, or experience side effects like nightmares or sleepwalking. Ambien users who think it works better for them may actually just be experiencing its amnesic properties—they might simply remember less of their nighttime wakefulness.

So what does work for insomnia?

I would say I’m biased because I’m a behavioral sleep medicine specialist… but I’m not biased because the data speak for themselves! Cognitive behavioral therapy for insomnia (CBT-I) is the only treatment that received a “Strong” recommendation from both AASM and the American College of Physicians for treating insomnia. This level of recommendation means: “clinicians should, under most circumstances, follow [it].” None of the medications, even the ones AASM recommends, received more than a “Weak” endorsement. This is because CBT-I is an extensively researched treatment that addresses the real roots of insomnia by:

• Educating you about how sleep processes work and how your unique biology, circumstances, and behaviors caused your symptoms

• Providing you with tools that reset your sleep physiology and long-term relationship with sleep

• Cultivating confidence and self-efficacy in your ability to maintain healthy sleep in the long term, even as you go through changes in life

Given how effective and safe CBT-I is, how come sleep medications are still the first go-to treatments for insomnia? For some people, medications are the best option due to their unique medical needs or circumstances (e.g., having another medical disorder that is being treated by the same medication). Other times, the reliance on sleep medications in our society reflects healthcare system realities:

- Severe shortage of behavioral sleep medicine specialists

- Long waiting lists for cognitive behavioral therapy for insomnia (CBT-I) even in healthcare systems that have specialists

- Limited time during medical appointments with primary care providers

- Urgent patient distress that pressure doctors into providing immediate reassurance

Should I Start (or Keep) Taking Insomnia Drugs?

Although the evidence regarding the effectiveness of insomnia medications is not very encouraging, we don’t need to completely write them off. In fact, there are always newer and safer insomnia medications in development, and for some individuals, these medications may be the best option. In my clinical experience, however, most people prefer to avoid long-term use of sleep medications, or need to do so as their healthcare providers become more hesitant to prescribe those meds as they get older.

If you feel conflicted about your insomnia medication, you’re certainly not alone. You might feel that your choices are between bad and worse—continue to experience side effects or risk worse insomnia symptoms. Many of my patients came to me in the first place after attempting to discontinue their sleep medications but ended up going back to them and feeling even worse.

I’m here to reassure you that, even if it doesn’t feel like it right now, you most likely hold the power to decide how you want to take sleep medications (if at all) in the long term. Many of my patients have been pleasantly surprised that they could sleep at all without a medication they’ve been taking nightly for years.

But don’t go it alone, and don’t go cold turkey. Work with your prescribing doctor or a behavioral sleep medicine specialist on a plan to address the real mechanisms underlying your insomnia, and when you’re ready, gradually taper off of your sleep medication in a sustainable way. In Part 2 of this blog series, we’ll do another deep dive into the nuances of coming off insomnia medications, including the psychological factors we often overlook but can make or break the whole process.

*Note: This article is for informational purposes only and should not be used as medical advice. Always consult with your healthcare provider about your specific situation and treatment options.*