A recurrent sleep disorder like insomnia can cause serious health concerns and life disruptions. There are many ways to treat insomnia. First, it’s important to understand how insomnia affects you and what methods suit you best. You may want to avoid certain treatments depending on your preferences and health history.
Before starting treatment, it is important to address the underlying problem that may be worsening insomnia.
Prescription sleeping pills have a variety of side effects and may react with other medications.
Insomnia medications can cause central nervous system (CNS) depression.
Schedule IV substances may lead to physical and psychological dependence, tolerance, abuse, and addiction.
Here we will discuss insomnia, define it, and delve into what you should know about prescription sleeping pills. Then, by comparing available options with your doctor, hopefully, you’ll find one that works for you.
Insomnia is the most common sleep disorder characterized by difficulty falling/staying asleep and poor sleep quality. To be diagnosed with insomnia, patients must have symptoms three times a week for at least three months. Insomnia can cause serious detrimental effects such as daytime impairment, poor memory, and decreased concentration. Insomnia can be treated through non-drug treatments, natural products, and drug treatments. However, before starting any treatment, it is important to address the underlying condition contributing to insomnia (medication, disease, alcoholism, pain, lifestyle, etc.).
What worsens insomnia?
Before we delve further into various treatments and take a closer look at prescription sleeping pills, it’s important to understand which medications and products may worsen sleep issues, namely insomnia:
Cognitive behavioral therapy (CBT-I) is the preferred method for treating insomnia. The goal of CBT is to change sleep hygiene — creating the ideal sleep environment. For example, the therapy recommends keeping your bedroom dark and quiet and avoiding stimulants such as television. Instead, experts suggest establishing a nighttime routine (reading, stretching, meditation, calming music) — but avoiding exercise immediately before bed. Also, regular sleep schedules, avoiding caffeine in the afternoon, and skipping heavy meals immediately before bedtime have shown benefits. Additionally, daytime naps may help to improve overall sleep quality.
Several natural products help promote sleep. These include chamomile tea, melatonin, and valerian. Talking to your doctor before using natural products is important, as these products may interact with other drugs.
All insomnia medications should be used at the lowest effective dose for the shortest duration possible. This is because insomnia medications cause CNS depression and may have additive effects. Therefore, speaking to your doctor before taking multiple insomnia drug treatments simultaneously is important.
There are numerous medications to help treat insomnia. Insomnia drug treatment can be divided into two categories: drugs to help you fall asleep and drugs to help you stay asleep.
Prescription medications for falling asleep:
- Eszopiclone (Lunesta).
- Ramelteon (Rozerem).
- Zaleplon (Sonata).
Prescription medications for staying asleep:
- Doxepin (Silenor).
- Eszopiclone (Lunesta).
- Suvorexant (Belsomra).
Drug treatment classes
- Eszopiclone (Lunesta) – 1-3mg nightly.
- Zaleplon (Sonata) – 5-20mg nightly.
- Zolpidem/Ambien/Edluar/Intermezzo – dosage depends on the brand.
Medical professionals recommend that patients requiring long-term insomnia drug treatment use non-benzodiazepines (hypnotics) over benzodiazepines. Hypnotics work by increasing gamma-aminobutyric acid (GABA). GABA is an inhibitory neurotransmitter that causes CNS depression to help patients sleep.
Hypnotics are classified as Schedule IV controlled substances (CIV), which require a prescription. Schedule IV substances may cause physical and psychological dependence, tolerance, abuse, and addiction.
Hypnotics have a black-boxed warning — the FDA’s strictest warning — for complex sleep behaviors such as sleepwalking and sleep-driving, which can lead to fatal injuries. Warnings include an increased risk of CNS depression, behavioral changes, respiratory depression, withdrawal symptoms (cramps, nausea, sweating, and shakiness), and the potential for abuse/dependence. Hypnotics are contraindicated in patients with complex sleep behaviors and should not be taken with alcohol or other CNS depressants.
Side effects include dizziness, drowsiness, pins- and needles-like pain, and complex sleep behaviors.
Orexin receptor antagonists
- Suvorexant (Belsomra) – 10-20mg nightly.
Orexin receptor antagonists work by blocking the orexin signaling system. Orexin is a neuropeptide that promotes wakefulness. By blocking the orexin signaling system, orexin is unable to encourage wakefulness which will help patients sleep.
Suvorexant/Belsomra is a CIV, orexin receptor antagonist. Suvorexant is contraindicated in patients with narcolepsy. Warnings include behavioral changes, worsening of depression, suicidal ideation, sleep paralysis, hallucinations, increased risk for complex sleep behaviors, and sudden loss of muscle tone.
Side effects include drowsiness, dizziness, headache, and abnormal dreams.
Melatonin receptor agonists
- Ramelteon (Rozerem) – 8mg nightly.
- Tasimelteon (Hetlioz) – 20mg nightly.
Melatonin receptor agonists work by activating melatonin receptors to promote sleep and circadian rhythm regulation.
Melatonin receptor agonists are contraindicated with fluvoxamine/Luvox use.
Side effects include drowsiness and dizziness. It is important to note that melatonin receptor agonists are not controlled substances but require a prescription.
Doxepin (Silenor) – 3-6mg nightly
Tricyclic antidepressants (TCAs) work by inhibiting neurotransmitter (norepinephrine and serotonin) reuptake and acetylcholine and histamine receptors.
Doxepin (Silenor) is an FDA-approved TCA for the treatment of insomnia. There is a blocked-boxed warning for increased suicidal behavior in children and young adults within the first few months of use and with a dose change. Doxepin is contraindicated with monoamine oxidase inhibitors (MAOIs). Doxepin requires a 2-week washout period before MAOI use and vice versa.
Side effects include dizziness, drowsiness, and anticholinergic effects (dry mouth/eyes, constipation, urinary retention, and confusion).
Generic doxepin and other tricyclic antidepressants such as trazodone and mirtazapine (tetracyclic antidepressant) may be used off-label for treating insomnia; however, it is not recommended.
Silenor is not a controlled substance; however, it requires a prescription.
- Estazolam – 1-2mg nightly.
- Lorazepam (Ativan) – 0.5-2mg nightly.
- Flurazepam – 15-30mg nightly.
- Temazepam (Restoril) – 7.5-15mg nightly.
- Quazepam (Doral) – 7.5-30mg nightly.
- Triazolam (Halcion) – 0.125-0.5mg nightly.
Benzodiazepines (BZDs) may be used for short-term insomnia treatment. BZDs work by enhancing GABA and causing CNS depression. BZDs are Schedule IV controlled substances that require a prescription.
BZDs are not recommended for patients with a current/history of substance abuse or elderly patients. BZDs have a black-boxed warning for increased abuse, addiction, and withdrawal risk. Some BZDs are known to be teratogenic — they cause birth defects. Therefore, patients should speak to their doctors if they are pregnant or are planning on becoming pregnant while using BZDs.
If BZDs are used for the short-term treatment of insomnia, lorazepam and temazepam are preferred in the elderly.
Side effects include drowsiness, dizziness, increased fall risk, cognitive impairment, and complex sleep behaviors.
- Diphenhydramine (Benadryl) – 50mg nightly
- Doxylamine (Unisom SleepTabs) – 25mg nightly
While prescription sleep medication may be the right solution for some, other patients self-treat insomnia by using over-the-counter (OTC) first-generation antihistamines. Antihistamines may be used for short-term insomnia treatment. However, long-term use is not recommended. Antihistamines work by blocking histamine receptors and disrupting histamine from promoting wakefulness.
Side effects include sedation, confusion, cognitive impairment, urinary retention, dry eyes/mouth, and constipation. Patients with glaucoma or benign prostatic hyperplasia (BPH) should avoid using antihistamines.
Prescription sleeping aids may help treat insomnia. However, there are many factors to consider when choosing the right medication for your needs. Some medications may react with others or lead to unwanted side effects. It is important to discuss your medical history and current medication usage with your physician before taking prescription sleeping pills.
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