To Sleep, Perchance to Dream- part II

In today’s post we’ll discuss medications for sleep- see part I for sleep hygiene tips and discussion. Medications for sleep can be divided into 3 general categories: over-the-counter, prescription non-addicting, and prescription addicting. For prescription meds I’ll put the brand name first and the generic name next- doctors use both names interchangeably, but many who don’t work in health care know just one or the other name.

Over the counter meds include Melatonin, which has grown substantially in popularity in recent years. In the 70’s and 80’s it became known for helping with jet lag, but now is used for general insomnia as well. Typical doses are 3, 5, 6, or 10 mg. Since it’s a natural hormone in the body side effects are rare, and since it’s short-acting, morning hangovers are rare. Because it is short-acting it tends to be of limited help for people with sleep maintenance issues (that is, people who can fall asleep ok but tend to wake up a lot). Certainly worth a try if you’re having some temporary issues with your sleep.

I’ll go ahead and mention Rozerem (ramelteon) here- it’s a prescription med that works through the melatonin receptor. It recently went generic but of course remains a pricey medication. It’s not something I prescribe a lot of, basically because I’m not sure how much of an advantage it offers over the cheaper OTC melatonin.

Benadryl (diphenhydramine) is a commonly used OTC med that I do not recommend. Benadryl is an antihistamine that has significant anticholinergic side effects- these interfere with the actions of acetylcholine, a neurotransmitter than carries messages in the nervous system and is strongly involved in memory. Anticholinergic meds have long been known to be best avoided or minimized in the elderly. There’s been more and more research coming out in recent years that anticholinergic meds when used chronically in younger patients may increase your risk for dementia long-term- not a good side effect! Benadryl is found in Tylenol PM, Advil PM, as well as in Sominex, Unisom, and many other OTC sleep preparations. Just don’t. . .

There are a potpourri of other OTC meds used or touted for sleep, including CBD oil, valerian root, 5-HTP, etc. etc. All are worth a go if you have occasional or minor sleep problems.

My usual first-line prescription nonaddicting med for sleep is Desyrel (trazodone). Trazodone is an antidepressant that rarely gets used as a primary antidepressant any more- usually because people find antidepressant doses to be too sedating! Low doses often work well for sleep. Trazodone doesn’t change the sleep architecture (that is, what phases of sleep your sleep patterns are in) which is a good thing. Trazodone is a cheap generic and works quickly and well for most people. Larger doses can cause orthostatic hypotension (a drop in blood pressure when standing) which can be problematic especially in the elderly. And there’s a rare side effect in men called priapism, which is a sustained erection- sounds funny but it isn’t as it can lead to gangrene in the penis- this is a medical emergency that requires an ER visit. 1 in 6000 chance so it’s not common, fortunately.

Other antidepressants helpful for sleep include Silenor (doxepin), Elavil (amitriptyline), and Remeron (mirtazapine). Doxepin and amitriptyline are fairly widely used but carry the anticholinergic baggage of Benadryl. Mirtazapine is helpful in the elderly- most younger people don’t like the weight gain that commonly goes with it.

Bipolar meds helpful for sleep include most prominently Seroquel (quetiapine). Quetiapine is a pretty heavy hitter that can be quite useful for people with tough sleep problems that milder things don’t touch. Quetiapine is a fairly cheap generic in today’s world.

Prescription addicting meds for sleep including a variety of drugs including of course Ambien (zolpidem). In the 2000’s if you went to the doctor with insomnia you often walked out with a prescription for Ambien. It works quickly and works well and became very widely used. I rarely start people on Ambien any more, however. It’s too reinforcing and too hard to get off of. Most people have temporary and occasional insomnia- when you get on Ambien you want to stay on it and even if you’re motivated to get off it can be a challenge. The other issue with Ambien is the amnestic behavior that can happen with it. People will raid the refrigerator, send texts or emails and talk to people on the phone, and sometimes (rarely) even leave their house at night- and not remember anything about it afterwards- obviously not good.

The “Z-drug” cousins to Ambien include Lunesta (eszopiclone) and Sonata (Zaleplon). Lunesta is a good sleeping pill that has an intermediate half-life of 6 hours which is a good duration- it gets people to sleep, keeps them asleep, and rarely gives a morning hangover. It’s available in generic now but unfortunately remains expensive. Sonata has an ultra-short half-life of an hour so is good for sleep initiation- not so much for sleep maintenance.

The benzodiazepine class of meds have been widely used for decades for sleep as well as anxiety. Medical opinion has turned against this family- see my blog post on the benzos for more details. Benzos for sleep do have the disadvantage of suppressing REM sleep (the phase of sleep we dream in)- so if you stop taking them after being on them for a while you get REM rebound (increased dreaming) which can be unpleasant. Primary care docs rarely prescribe this family any more- I will prescribe some but usually look for better long-term alternatives. Restoril (temazepam) is the most widely used pure sleeping pill- many people will take Xanax (alprazolam) or Klonopin (clonazepam) at night to help them sleep.

Finally, in the prescription addictive class of meds we have Belsomra (suvorexant). This has a unique mechanism of action which is always good- it works through the orexin/hypocretin system (basically, it works the opposite way meds like Provigil and Nuvigil work to stimulate you). I’ve found Belsomra to work sometimes where other sleeping pills have failed. The main disadvantage is the cost and insurance coverage- since it’s brand name it’s pricey stuff.

So that’s our quick-and-dirty overview of meds available to help with sleep! As you can see, there are lots of alternatives- as well as some I haven’t even mentioned. They all have their advantages and disadvantages, their benefits and their side effects. Don’t give up if you have chronic insomnia- you can find something to help you!