Key Takeaways
- In 2019 the FDA added a boxed warning to zolpidem, eszopiclone, and zaleplon after reports of sleepwalking, sleep driving, and other complex sleep behaviors, some fatal.
- Z-drugs are Schedule IV controlled substances, and their labeling notes risks of dependence, next-day impairment, and withdrawal symptoms if stopped abruptly.
- Sleep medicine guidelines suggest not using diphenhydramine or melatonin to treat chronic insomnia, and diphenhydramine carries added risks of confusion and falls in older adults.
- A 2023 JAMA analysis found 22 of 25 melatonin gummy products were inaccurately labeled, with actual melatonin ranging from 74 to 347 percent of the label.
- Tapering a regular sleep medication is a decision for your prescriber, and cognitive behavioral therapy for insomnia is the recommended first-line treatment for chronic insomnia.
It usually starts reasonably. A stressful month, a prescription for Ambien, or a bottle of Benadryl or melatonin gummies on the nightstand. Months or years later, the question is no longer how to fall asleep but whether you can sleep at all without it. Sleep aid dependence is one of the quietest problems we see, because it rarely looks like a problem. People who rely on a nightly pill are often careful, high-functioning adults who simply want to be rested for tomorrow. That is exactly why it is worth looking at honestly. For prescription sedative dependence, including benzodiazepines, see our benzodiazepine addiction treatment in Houston page.
This guide covers the three most common kinds of sleep aids, what the research and FDA labeling say about their risks, and why stopping or tapering is a decision to make with a prescriber rather than alone.
Sleep aid dependence, defined: a pattern in which a person comes to rely on a sleep medication or supplement to fall or stay asleep, often using it longer or in larger amounts than intended, and finding sleep worse when they try to stop. Dependence can be physical, psychological, or both. It is not a character flaw, and it is not always the same thing as addiction.
Ambien and Other Z-Drugs: What to Know
Zolpidem (Ambien and related brands), eszopiclone (Lunesta), and zaleplon (Sonata) are often called z-drugs. They are chemically different from benzodiazepines but act on some of the same brain systems, and they are Schedule IV controlled substances. Their FDA labeling notes that this class can cause physical and psychological dependence, and that the risk rises with higher doses, longer use, other sedating drugs, and a personal history of substance use or psychiatric conditions.
Three safety points matter most:
- Complex sleep behaviors. In April 2019 the FDA added a boxed warning, its most prominent kind, to all three drugs after reports of sleepwalking, sleep driving, and other activities while not fully awake, some resulting in serious injury or death. People who have had one of these episodes should not be prescribed these drugs again.
- Next-day impairment. Labeling for eszopiclone warns that it can impair next-day driving and alertness even when taken as prescribed, and that people may not notice the impairment.
- Stopping suddenly. Rapid dose reduction or abrupt discontinuation can produce withdrawal symptoms like those of other sedatives, and sleep may be worse for a time after stopping.
Combining z-drugs with alcohol, opioids, or benzodiazepines compounds the sedation, a risk we explain in our piece on mixing depressants.
Is Benadryl Safe to Take Every Night for Sleep?
Diphenhydramine, the antihistamine in Benadryl and in many “PM” pain relievers and store-brand sleep aids, feels harmless because it is sold over the counter. The evidence is less reassuring. The American Academy of Sleep Medicine’s 2017 guideline on medications for chronic insomnia suggests clinicians not use diphenhydramine to treat it.
Diphenhydramine is also strongly anticholinergic. For older adults in particular, guidance based on the American Geriatrics Society Beers Criteria advises avoiding it, because it can cause confusion and delirium in the short term and has been linked to falls and other adverse effects.
Melatonin Overuse: Natural Does Not Mean Measured
Melatonin has a reputation as the gentle option. But in the United States melatonin is sold as a dietary supplement, not an FDA-approved drug, and what is in the bottle may not match the label.
A 2023 analysis in JAMA tested 25 melatonin gummy products and found that 22 were inaccurately labeled. Actual melatonin content ranged from 74 percent to 347 percent of the amount stated on the label, and some products contained CBD. The same AASM guideline that advised against diphenhydramine also suggested clinicians not use melatonin as a treatment for chronic insomnia. Needing more and more of it is a sign to look at what is driving the insomnia.
| Sleep aid | How it is sold | Main concerns |
|---|---|---|
| Z-drugs (zolpidem, eszopiclone, zaleplon) | Prescription, Schedule IV controlled substance | Dependence, complex sleep behaviors, next-day impairment, withdrawal if stopped abruptly |
| Diphenhydramine | Over the counter, alone or in “PM” products | Not recommended for chronic insomnia; confusion and falls, especially in older adults |
| Melatonin | Dietary supplement, not FDA approved | Inconsistent dosing between products; not recommended for chronic insomnia |
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Signs of Sleep Aid Dependence
- You cannot imagine sleeping without it, or you feel anxious when you run low
- You have increased the dose on your own, or take extra in the middle of the night
- You get refills early or from more than one prescriber
- You have done things at night you do not remember
- You combine it with alcohol, cannabis, or other sedatives to make it work
- You feel foggy, slowed, or unsafe driving the next morning
Alcohol deserves a special mention. Many people use a drink to fall asleep, then a pill when the drink stops working, and the two together are riskier than either alone. Our article on alcohol and sleep explains why alcohol worsens sleep quality even when it shortens the time to fall asleep.
Why Tapering Off Sleep Medication Is a Prescriber Decision
If you have been taking a prescription sleep medication regularly, do not stop it on your own. Abrupt discontinuation of z-drugs can bring withdrawal symptoms and rebound insomnia, and if the medication is a benzodiazepine, stopping suddenly can be medically dangerous, as we explain in our guide to benzodiazepine dependence. How fast to taper, whether to switch medications, and how to monitor progress are decisions for the physician or nurse practitioner who knows your history.
The treatment that usually makes a taper succeed is not another pill. The American College of Physicians recommends cognitive behavioral therapy for insomnia, known as CBT-I, as the first-line treatment for chronic insomnia in adults, and notes that FDA-approved sleep medications are intended for short-term use. CBT-I works on the habits, thoughts, and schedule patterns that keep insomnia going, so that sleep has something to stand on once the medication is gone.
How Heights Can Help
Heights Behavioral Health is an outpatient practice in the Houston Heights. We do not provide detox, and we do not take over tapering decisions from your prescriber. What we do is assess the whole picture, including sleep, anxiety, depression, trauma, and any alcohol or other substance use, and coordinate with your prescribing clinician so the taper and the therapy move together. When medically supervised withdrawal is needed, we help arrange it and have outpatient care ready afterward.
Treatment may include individual therapy using CBT, DBT, or ACT, group therapy, and intensive outpatient or partial hospitalization programming when more structure helps. When sleep aid use is part of a larger substance use pattern, we treat it through our substance use treatment in Houston.
Crisis notice. If someone has taken too much of a sleep medication, is very hard to wake, or is breathing slowly, call 911 immediately. Heights Behavioral Health provides scheduled outpatient care and is not an emergency or detox service. If you are in crisis or thinking about suicide, call or text 988.
Frequently Asked Questions
Is Ambien addictive?
Zolpidem is a Schedule IV controlled substance, and FDA labeling for this class notes that these drugs can cause physical and psychological dependence. The risk is higher with higher doses, longer use, and a history of substance use or psychiatric conditions.
Can I just stop taking my sleep medication?
Not without talking to your prescriber. Stopping a z-drug suddenly can cause withdrawal symptoms and rebound insomnia, and stopping a benzodiazepine suddenly can be dangerous. A planned taper, ideally alongside CBT-I, is safer and more likely to last.
Is it bad to take melatonin every night?
Melatonin is a supplement, and product contents vary widely. Sleep medicine guidelines do not recommend it as a treatment for chronic insomnia. If you need it every night to sleep, it is worth talking with a clinician about what is driving the insomnia.
What is the best treatment for chronic insomnia?
The American College of Physicians recommends cognitive behavioral therapy for insomnia, or CBT-I, as the first-line treatment for adults. Medication may be considered for short-term use in a shared decision with a clinician.
Sources
- U.S. Food and Drug Administration. Certain Prescription Insomnia Medicines: New Boxed Warning Due to Risk of Serious Injuries Caused by Sleepwalking, Sleep Driving and Engaging in Other Activities While Not Fully Awake. fda.gov
- U.S. Food and Drug Administration. Lunesta (eszopiclone) prescribing information. accessdata.fda.gov
- American College of Physicians. ACP Recommends Cognitive Behavioral Therapy as Initial Treatment for Chronic Insomnia. acponline.org
- American Academy of Sleep Medicine. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults. aasm.org
- Cohen PA, et al. Quantity of Melatonin and CBD in Melatonin Gummies Sold in the US. JAMA, 2023. jamanetwork.com
- American Family Physician. Choosing Wisely recommendation on sedative-hypnotics and first-generation antihistamines in older adults. aafp.org
Written and Reviewed by Licensed Clinicians
Joni Ogle is a Licensed Clinical Social Worker (LCSW) and Certified Sex Addiction Therapist (CSAT) with over 37 years of clinical experience in mental health and addiction recovery, dual diagnosis treatment, behavioral addictions, and family intervention. She is the founder of Heights Behavioral Health and Heights Mentoring in Houston, Texas, where she leads a team of licensed clinicians.
Texas LCSW #37376 · Verify license
Deborah Darnell-Drake, LCSW-S, ACSW, LMFT is the Chief Clinical Officer at Heights Behavioral Health and a clinical reviewer. With more than five decades of experience in mental health and substance use disorder treatment, Deborah specializes in addiction, co-occurring mental health conditions, family dynamics, and behavioral addictions including gambling and technology addiction.
Texas LCSW-S #14508 · LMFT #1125 · Verify license
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