Sleeping Pills: What the Evidence Says About Benefits and Risks

It is 3 a.m. and you are awake again. You have tried warm milk, no screens, and counting backward. You start to wonder whether a sleeping pill is the answer, or whether the one you already take is still a good idea.

This guide explains what sleeping pills do, how much they help, what risks they carry, and what guidelines recommend first.

Insomnia and the main drug groups

Insomnia means trouble falling asleep, staying asleep, or waking too early, with daytime effects. It is called chronic when it happens at least 3 nights a week for 3 months or more.

Medicines used for sleep fall into several groups:

• Benzodiazepines, such as temazepam, lorazepam, and triazolam.
• "Z-drugs," such as zolpidem, zopiclone (Canada), eszopiclone (US), and zaleplon.
• Orexin receptor blockers, a newer group that includes suvorexant, lemborexant, and daridorexant.
• Low-dose doxepin, an older antidepressant used at a very small dose.
• Drugs used off-label, such as trazodone and quetiapine.
• Nonprescription products, such as diphenhydramine and doxylamine (antihistamines), and melatonin.

What your doctor looks at

First, treatment without pills

The American College of Physicians recommends CBT-I (cognitive behavioral therapy for insomnia) as the first treatment for chronic insomnia in all adults.[1] CBT-I helps people fall asleep faster and stay asleep, and its benefits tend to last after treatment ends. Canadian guidance on reducing sleeping pills also points to CBT-I and sleep habits as the main long-term approach.[5]

Your clinician will also look for problems that cause poor sleep, such as sleep apnea, depression, anxiety, pain, restless legs, alcohol, caffeine, and other medicines.

When medicines are considered

The American Academy of Sleep Medicine (AASM) reviewed the evidence for specific drugs. Its 2017 guideline made only weak recommendations, because benefits were modest and evidence quality was often low.[2]

• It suggested that clinicians could use some drugs, including zolpidem, eszopiclone, temazepam, suvorexant, and low-dose doxepin, for certain sleep problems.
• It suggested against using trazodone, diphenhydramine, melatonin, valerian, and tryptophan for chronic insomnia.[2]
• The American College of Physicians says the choice to use a drug should be shared between you and your clinician, after weighing benefits, harms, and costs, and usually for a short time.[1]

How much do sleeping pills help?

A review of 24 trials in adults 60 and older compared sedatives with placebo:[3]

• Total sleep time rose by about 25 minutes a night on average.
• People woke up slightly less often during the night.
• Sleep quality improved by a small amount.

What are the risks?

The same review found adverse effects were more common than with placebo:[3]

• Memory and thinking problems were about 4.8 times as common.
• Daytime tiredness was about 3.8 times as common.
• Balance and coordination problems were also more common.

The authors concluded that in people over 60, the benefits may not justify the risks, especially for people at risk of falls.[3] The AGS Beers Criteria advise avoiding benzodiazepines and Z-drugs for insomnia in older adults when possible. They also advise avoiding strong anticholinergic drugs such as diphenhydramine.[4]

Other risks named on labels include:

• Next-morning drowsiness, which can affect driving even when you feel awake.
• Complex sleep behaviors, such as sleepwalking or driving while not fully awake. In 2019 the FDA added a boxed warning about these behaviors to zolpidem, eszopiclone, and zaleplon.[6]
• Dependence and withdrawal, especially with benzodiazepines.
• Dangerous drowsiness and slow breathing when combined with alcohol or opioids.

In 2013, the FDA lowered the recommended starting dose of zolpidem for women, because women clear the drug more slowly.

Canada and the US: similar advice

Both countries put CBT-I first. The Canadian deprescribing guideline recommends offering a slow taper to adults 65 and older who take benzodiazepine-type sleeping pills, and to younger adults who have used them for more than 4 weeks.[5] Drug availability differs. For example, zopiclone is common in Canada, while eszopiclone is sold in the US.

How tapering works

If you have taken a sleeping pill for weeks or longer, stopping all at once can cause rebound insomnia and withdrawal. The Canadian guideline suggests lowering the dose slowly, for example by about 25% every 2 weeks, with smaller steps near the end.[5] Your clinician will set a plan that fits you. Starting CBT-I during the taper can help.

Sleep habits that support any treatment

• Keep the same wake-up time every day, including weekends.
• Use the bed only for sleep and sex.
• Get out of bed if you cannot sleep after about 20 minutes, and return when sleepy.
• Limit caffeine after noon and avoid alcohol close to bedtime.
• Get daylight in the morning and keep the bedroom cool, dark, and quiet.

These habits are part of CBT-I, but CBT-I is more structured and works better than habits alone.[1]

Questions to ask your clinician

• Could something else, such as sleep apnea, pain, or a medicine, be causing my insomnia?
• Can I get CBT-I, and is it covered?
• How much benefit can I expect from this sleeping pill?
• What are the risks for me, given my age and other medicines?
• Is it safe for me to drive the morning after I take it?
• How long should I take it, and how would I taper off?

When to get care quickly

Call 911 or go to the emergency department if someone has slow or shallow breathing or cannot be woken after taking a sleep medicine. Get help right away after a fall with a head injury, or if you have thoughts of harming yourself.

Bottom line

Sleeping pills can add a little sleep, but they carry real risks, especially for older adults. Guidelines in Canada and the US put CBT-I first. If a medicine is used, it should be a shared, usually short-term decision, with a plan for how to stop.

Primary AI can show you the guideline and study sources behind this topic in plain language, so you can bring better questions to your appointment.