Sleeping Pills, Sleep Aids and Medications

Are sleep aids and medications right for you?

The trouble with sleep medications

The thought of a pill that can solve your sleep problems quickly is very appealing.   Unfortunately, sleep medications don't cure insomnia, and they can often make the problem worse in the long run Concerns about the use of both over-the-counter and prescription sleep medications include:

• Drug tolerance. You may have to take more and more of the sleep aid for it to work, which can lead to more side effects.
• Drug dependence. You may come to rely on the medication to sleep, and will be unable to sleep or have even worse sleep without it.
• Withdrawal symptoms. If you  stop the medication abruptly, you may have withdrawal symptoms, such as nausea, sweating and shaking
• Side effects. There are several side effects to sleep medications, such as drowsiness the next day, confusion, forgetfulness and dry mouth. These side effects can be severe.
• Drug interactions. If you are taking other medications, sleeping medications can interact with them. This can worsen side effects and be dangerous with medications like prescription painkillers and other sedatives.  
• Rebound insomnia. If you need to stop the medication, sometimes the insomnia can become even worse than before.   
• Masking an underlying problem. There may be an underlying medical or mental disorder, or even a sleep disorder, that if treated would provide more relief from insomnia.

Sleep medications can help reduce insomnia in special situations

In general, sleep medications are most effective when used sparingly for short term situations. Examples include travel across many time zones or recovering from a medical procedure. Sometimes sleep medications are used briefly at the beginning of behavioral treatment for insomnia, especially if the sleep deprivation has been severe.  If medications are used over the long term, they are best used “as needed” instead of on a daily basis to avoid dependence and tolerance. Working with your healthcare professional is essential to ensure you get the maximum benefit, especially if long term use is being considered. 

Over-the-counter (OTC) sleep aids

The main ingredient of over-the-counter sleeping pills is an antihistamine. Antihistamines are generally taken for allergies. However, histamine, a chemical messenger in the brain, promotes wakefulness, so antihistamine also has the effect of making you feel very sleepy. Some OTC sleep aids also include a pain reliever.   Common OTC sleep medications, with a link to Medline Plus drug information from NIH, include:

Diphenhydramine (found in brand names like Nytol, Sominex, Sleepinal, Compoz)

Doxylamine (found in brand names like Unisom, Nighttime Sleep Aid)

OTC sleep aids are meant to be used for short term insomnia. Tolerance to the medication, meaning that you need a higher dosage of the medication for it to work, can develop in only a few days.

Side effects of OTC sleep aids

The antihistamines used in OTC sleep aids can produce side effects. Effects can be stronger in older adults. As with any medication, it is advisable to consult with your doctor before taking over-the-counter sleep medication. This is especially important if you have glaucoma, trouble urinating due to an enlarged prostate gland, or a breathing problem such as emphysema or chronic bronchitis.

Prescription sleeping medications

Prescription medication types and uses

There are several different types of prescription medications. These medications are classified as sedative hypnotics. In general, the medications act by working on receptors in the brain to slow down the nervous system, inducing and maintaining sleep. The following provides basic information about types of sleep medications. Some medications are used more for inducing sleep, while others are used for staying asleep. Some last longer than others in your system (a longer half life), and some have a higher risk of becoming habit forming. For more information about a medication, follow the link in the table to a Physician’s Desk Reference review of each medication. Consult your healthcare professional if you have a specific question about a medication.

Benzodiazepine sedative hypnotics

Benzodiazepines are the oldest class of sleep medications still commonly in use. Benzodiazepines as a group are thought to have a higher risk of dependence than other insomnia sedative hypnotics. All are classified as controlled substances, although newer formulations attempt to lessen the effect. These drugs are now less frequently prescribed than non-benzodiazepines. Primarily used to treat anxiety disorders, there are several benzodiazepines which are FDA approved to treat insomnia. These include:

Estazolam (ProSom) Flurazepam (Dalmane) Quazepam (Doral)

Temazepam (Restoril) Triazolam (Halcion)

Non-Benzodiazepine sedative hypnotics

Some newer medications don’t have the same chemical structure as a benzodiazepine, but act more specifically on the same area in the brain. They are thought to have fewer side effects, and less risk of dependency, but are still considered controlled substances. One medication in this class, eszopiclone (Lunesta), has been tested for longer term use, up to six months, in clinical trials.

Eszopiclone (Lunesta) Zalepon (Sonata)

Zolpidem (Ambien)

Melatonin receptor agonist hypnotic

This medication mimics the sleep regulation hormone melatonin.  It has little risk of physical dependency but does have side effects. It is used for sleep onset problems and is not effective for problems in staying asleep.

• Ramelteon (Rozerem)

 All prescription sleeping pills have side effects, which can vary depending on the specific drug, the dosage and how long the drug lasts in your system. Check with your healthcare professional about any concerns you have. Common side effects can include headache, muscle aches, constipation, dry mouth, daytime sleepiness, trouble concentrating, dizziness, unsteadiness and rebound insomnia. 

Does newer mean better for sleep medications?

There are certainly lots of commercials for new sleep medications, especially late at night when you might be awake! But does newer mean better? Not necessarily. An older medication may work just as well depending on what type of insomnia you have and other medical considerations. All medications re required to undergo clinical trials to check for interactions and side effects, but older medications often have many additional years of data from patient usage. Older medication may also be more cost effective if available in generic form, which new medications usually are not.  On the other hand, newer medications may also have differences that minimize side effects and concerns of older medications. Bottom line: work with a healthcare professional that you trust in deciding which medication would best suit your needs.

Guidelines for using sleep medications

If you decide to try sleep medications, the following guidelines and precautions are suggested.

• Follow directions closely, starting with a very small dose and increasing gradually, according to the doctor’s schedule. Find out whether you should take your medication with or without food. For some medications, certain foods must be avoided. Most sleeping pills should be taken on an empty stomach.
• Tell your doctor about other medications you are taking. This includes non-prescription medications such as pain relievers and allergy medicines, and herbal supplements. Combining medications can be very dangerous.
• Make sure that your doctor is aware of other medical conditions that you have. Some drugs can have serious side effects for people with other medical problems. Examples of these problems include high blood pressure, liver problems, glaucoma, depression and breathing problems.
• Carefully read the package insert that comes with your medication. Pay careful attention to the potential side effects that it describes.
• Only take a sleeping pill when you will have enough time to get a full night of sleep (7 to 8 hours). Otherwise you may feel drowsy the next day.
• If appropriate, use the medications intermittently, rather than nightly, in order to decrease the negative effects and to increase the effectiveness when you do use them. Be sure to check with your doctor as some medications cause withdrawal side effects when stopped abruptly. 
• Never drink alcohol near the time when you take a sleeping pill. Never drink alcohol in an attempt to fall asleep faster. Not only will alcohol disrupt your sleep even more, it can dangerously interact with the sleeping pill.
• Never drive a car or operate machinery after taking a sleeping pill. Especially when you first start taking a new sleep aid, you may not know how it will affect you, so proceed with caution the next day.
• Ask your doctor for specific instructions for decreasing and/or terminating use. In some cases, stopping medication abruptly can cause uncomfortable side effects and even rebound insomnia

Herbs and alternative supplements- natural remedies for insomnia?

Many people with insomnia choose herbal remedies for treatment. Some remedies, such as lemon balm or chamomile tea are generally harmless. However, others can have more serious side effects and interactions. It’s hard to know if you are getting a consistent dosage of herbs and supplements since they are not regulated by the Food and Drug Administration (FDA). Additionally, the effectiveness of herbal remedies has not been evaluated by the FDA.  Check with your healthcare professional if you are trying a herbal remedy. They may interfere with some prescribed medications. St. John’s Wort, for example, can limit the effectiveness of many prescribed medications such as blood thinners, birth control pills and some anticancer medications.

Herbs

There are several herbs thought to help sleep. Examples include chamomile, valerian root, kava kava, lemon balm, passionflower, lavender, and St. John’s Wort. Many people drink chamomile tea for its gentle sedative properties. Although it is generally safe, it may cause allergic reactions in people who have plant or pollen allergies. There is some data showing valerian to be useful for insomnia, but the overall evidence is still inconclusive as to its effectiveness. At high doses, valerian can cause vivid dreams, blurred vision, changes in heart rhythm, and excitability.  

Melatonin

Melatonin is a naturally occurring hormone whose levels peak at night. It is triggered by dark and levels remain elevated throughout the night until light decreases it. However, most study results have not found melatonin use to be beneficial when compared to a sugar pill (placebo). Some positive results have been shown in helping jet lag and night shift workers, but simple exposure to light at the right time might be just as effective.  Long term effects of melatonin are unknown.

Tryptophan, L-tryptophan

Tryptophan is a basic amino acid used in the formation of the chemical messenger serotonin, a substance in the brain that helps tell your body to sleep. L-tryptophan is a common byproduct of tryptophan, which the body then can change into serotonin. Some studies have shown that L-tryptophan can help you fall asleep faster in both normal sleepers and those with insomnia. These results, however, have not been consistent.

Alternatives to sleep medications

Most of the time, changing your sleep environment and bedtime behaviors is recommended either to start with a sleep medication or as a first line to try before medication. Why? Behavioral and environmental changes can have as much of an impact if not more than sleep medications, without the risk of side effects or dependence.

Related links for sleep medications

Sleep aids and general guidelines

Sleep Aids: All You Ever Wanted to Know...but Were Too Tired to Ask − An overview of insomnia and the sleep aids and medications commonly used to treat it. (National Sleep Foundation)  

Taking Sleep Medications for Insomnia guidelines to make sure that you use sleep medications safely and properly (American Academy of Sleep Medicine)

OTC sleep aids and herbal supplements

Do Drugstores Have the Cure for Your Insomnia? Taking a Closer Look at Common Treatments – An investigative article that looks at various over-the-counter sleep aids, including antihistamines, melatonin, and herbal remedies, and reports on their effectiveness. (American Academy of Sleep Medicine)

OTC sleep aids and supplements: What's best and safe? -Review of available over the counter sleep aids and herbal supplements (Mayo clinic) 

Treating Insomnia With Over-the-counter Sleep Aids, Herbal Supplements  -A position statement by the American Academy of Sleep Medicine

What Are Drug Treatments for Insomnia? − General guidelines on medications for insomnia, as well as natural remedies. (University of Maryland Medical Center)

Melatonin: The Basic Facts – Discussion of melatonin’s effects on insomnia. (National Sleep Foundation)

Questions and Answers About Valerian for Insomnia and Other Sleep Disorders – A review of the use of valerian for treating insomnia and other sleep disorders. (Office of Dietary Supplements, National Institutes of Health)

Prescription Medications

Sedatives: Summary of affordable alternatives – A review of current insomnia medications on the market, their side effects and a discussion of generic and brand name medications. Best buy drugs for Insomnia (PDF) provides the complete report. More information about specific medications can be found in Consumer Reports Medical Guide. (Consumer Reports)

Medline Plus: Drugs and Supplements Prescription and over-the-counter medication information from the National Institutes of Health (Medline Plus)

Prescription sleeping pills: What's right for you? Common uses of sleeping pills and other effective treatments for insomnia (Mayo clinic)  

Sleep Aids: All You Ever Wanted to Know...but Were Too Tired to Ask − An overview of insomnia and the sleep aids and medications commonly used to treat it. (National Sleep Foundation)

Taking Sleep Medications for Insomnia guidelines to make sure that you use sleep medications safely and properly (American Academy of Sleep Medicine)

What Are Drug Treatments for Insomnia? − General guidelines on medications for insomnia, as well as natural remedies. (University of Maryland Medical Center)

Alternatives to Sleep medications

Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills  -Discusses benefits of CBT versus sleep medications. (Mayo clinic) 

Cognitive Behavior Therapy vs. Pharmacotherapy for Insomnia CBT has a better impact on sleep-onset insomnia in young and middle-aged adults than does pharmacotherapy. (American Academy of Family Physicians )

Joanna Saisan, MSW, Gina Kemp, M.A., Suzanne Barston and Robert Segal, M.A., contributed to this article. Last modified on: 7/8/08.