Insomnia Treatment Options
To continue where we left in our discussion of insomnia, we should start reviewing the treatment options. First, we should address the pharmacologic therapies (both prescription and over the counter medicines) and later on will get to the non-pharmacologic (such as behavioral or psychological methods) treatments.
Before I even start talking in detail about the medications that are used for the treatment of insomnia, I want to refer you to a recent National Institute of Health (NIH) consensus statement. The statement suggests that despite the widespread use of many over-the-counter (OTC) medications and herbal supplements, there is little medical evidence to support their long-term effectiveness and safety.
In addition, there are many prescription treatments which are used by doctor “off-label” meaning that the Food an Drug Administration has not studied there usage in insomnia, but these medications have been approved for other disorders. That does not mean that they are not safe or effective, just that they have not gone through the usual process to assure that these medications work for the problem that they are being used.
Let’s start with the approved medications (currently only 9 that I am aware of) and those recommended in the NIH paper. The class of medications most prescribed is called the benzodiazepine receptor agonists (BZDRA), which can be broken down into the benzodiazepines (BZDs) and non-BZDs. These are collectively known as sedative hypnotics. All of these work by increasing the action of a brain chemical called GABA.
The main difference between the medications is their duration of action, which actually makes one preferable depending on the type of insomnia the patient suffers from. For instance, if the patient’s problem is initiating sleep, but they are able to stay asleep once sleep has come, a short-acting medication would be sufficient. If the main problem is maintaining sleep, long-acting medication can be prescribed.
The draw-back of using a long-acting medication is that, in some patients, the effects might carry over to the day and cause them a “hang-over” effect. The approved BZDs are as follows: estazolam (Prosom), flurazepam (Dalmane), quazepam (Doral), temazepam (Restoril), and triazolam (Halcion). The approved non-BZDs are: zaleplon (Sonata), zolpidem (Ambien), and eszoplicone (Lunesta).
Another medication which has recently been approved by the FDA (after the NIH statement was published) is called ramelteon (Rozerem). This medication has a novel mechanism of action in that it functions at the melatonin receptor in the brain, which induces sleep by disrupting the normal alerting mechanisms. This drug is only useful as sleep inducing agent, not if the problem is sleep maintenance.
There has been much media coverage of the recent reports of sleepwalking, sleep eating, and sleep driving (see Some Sleeping Pill Users Range Far Beyond Bed, NY Times, 3/8/06), and in March of this year, the FDA actually recommended a label change on this class of medications to made consumers and healthcare aware of their risks. Despite this, this drugs are helpful and generally considered safe and effective for most patients when used according to manufacturers instruction.
Allen Blaivas, FCCP, DABSM, is a graduate of New York College of Osteopathic Medicine and is a quadruple board-certified physician practicing in pulmonary, critical care, and sleep medicine. He runs the sleep laboratory at the VA New Jersey Health Care System and loves taking care of our nation’s veterans. He’s a clinical assistant professor of medicine at Rutgers New Jersey Medical School and holds clinical privileges at Hackensack University Medical Center and New York Presbyterian-Lower Manhattan. He has clinical research interest in obstructive sleep apnea and COPD.