Best Sleep Aids: Prescription vs. Over-the-Counter

Insomnia is when a person finds it difficult to fall asleep or stay asleep. Insomnia is the most common sleep disorder that affects millions of Americans every night. A study estimates that an employee with insomnia loses about eight days of work performance each year; this adds up to $63 billion in lost work performance due to insomnia. The severity and frequency of insomnia vary from person to person. For some, it is a temporary situational problem. For others, insomnia can be a chronic issue that warrants proper medical attention. Are you one of the millions who have trouble sleeping at night? Have you tried all the tips for sleep hygiene without much improvement? The proper sleep aid might be the answer for you, and here’s what you need to know.

What sleep aid options are available?

Many have asked, which is better: prescription or over-the-counter sleep aids? The good news is there are several options for each type. To decide which sleep medicine may suit you best, you should have a good understanding of your general medical history, in addition to the specific cause of your sleep disorder, if any. Your primary care physician or pharmacist are good sources of guidance if you are unsure or have additional questions.

Please keep in mind that the non-pharmacological (no drug) approach is always the first line of therapy for insomnia. Therefore, before initiating any sleep aid, please ensure that you practice good sleep hygiene, including avoiding caffeine and alcohol several hours before bedtime. Regular moderate exercise may improve sleep quality if you have a sedentary lifestyle.

Prescription sleep aids

Benzodiazepine hypnotic sedatives

This group of sleeping pills is effective for short-term use (less than four weeks) to treat insomnia. Long-term use of these prescription sleeping pills is generally not recommended due to their side effects profile. These medications are FDA schedule IV-controlled substances, meaning they have the potential of causing physical dependence, misuse, withdrawal, and addiction. Besides their potential for dependence, benzodiazepines must be used with extreme caution since they can cause sleepiness and dizziness even during the following day. Please make sure you plan to have a whole night of sleep if you take this medication. Examples of benzodiazepines prescribed as sleep medications are listed below, with their brand names in parentheses:

Lorazepam (Ativan)
Temazepam (Restoril)
Estazolam (ProSom)
Triazolam (Halcion)
Flurazepam (Dalmane)
Quazepam (Doral)

Non-benzodiazepine hypnotic sedatives

You probably have heard of “Ambien” at some point in your life. Ambien is the brand name of zolpidem, an agent of this class. This type of sleep aid does not cause dependence or withdrawal, like benzodiazepines. Therefore, this type of sedative can be used long-term in people who have trouble falling asleep or staying asleep. However, this class is known for its side effects of sleepwalking, sleep-driving, or engaging in other activities while not fully awake, potentially leading to serious injuries. Examples of this type of sleep aid are:

Zolpidem (Ambien) – oral tablet
Zolpidem extended release (Ambien CR)
Zolpidem sublingual tablet (Intermezzo, Edluar)
Zolpidem oral spray (Zolpimist)
Zaleplon (Sonata)
Eszopiclone (Lunesta)

Melatonin receptor agonist

This is not the same as over-the-counter melatonin. The only medication in this class is ramelteon (Rozerem). As far as pharmacologic treatment, ramelteon is considered first-line due to the lack of physical dependence, abuse, and that this medication does not seem to cause morning sedation like other hypnotics.

Over-the-counter (OTC) sleep aids:

Melatonin: Melatonin is a hormone that the brain produces; melatonin coordinates the sleep-wake cycle, meaning melatonin sends signals to the brain to tell the body that it is time to sleep. Long-term use of melatonin lacks evidence of safety. However, melatonin is effective in treating short-term insomnia. Melatonin is also helpful to reset the sleep cycle for night-shift workers and blind people who have problems regulating their sleep cycle. Melatonin is available over-the-counter without a prescription; however, a prolonged-release formulation of melatonin called Circadin is a prescription medication.
Diphenhydramine: Diphenhydramine is the generic of Benadryl. One important thing to keep in mind is that diphenhydramine is an ingredient of many cold/flu and allergy medications. If you see a product label that says “PM,” know that diphenhydramine is included to help with sleep and would most likely cause daytime drowsiness. Diphenhydramine is an antihistamine. Therefore, diphenhydramine and diphenhydramine-containing products can have side effects such as drowsiness, dizziness, constipation, blurred vision, and dry mouth. Examples of diphenhydramine-containing products:

Doxylamine Succinate: Similar to diphenhydramine, doxylamine is an antihistamine. Therefore, they have the same side-effects profile. Doxylamine product examples are:

Tip: You can get discounts on over-the-counter sleep aids with a signed prescription from your doctor.

Herbal or natural sleep aids

Herbal products and dietary supplements do not have to be approved by the Food and Drug Administration. Compared to other types of sleep aids, dietary supplements have less evidence regarding their efficacy and safety. Just like over-the-counter or prescription drugs, herbal products can interact with other medications. Please talk to your doctor or pharmacist before taking any herbal supplements if you are currently taking any over-the-counter or prescription medication. Examples of herbal sleep aids include:

Valerian root

Chamomile
Passionflower
Lemon balm
Lavender
L-tryptophan
Kava

Which sleep aid is the best for you?

Struggling with sleep disorders can be frustrating. However, you need to keep in mind that a one-size-fits-all sleep aid does not exist. Meaning, the best sleep aid is the one that is tailored for your specific needs, including getting at the root cause of your insomnia, your age, sex, overall health, and any underlying medical conditions that you may have. Safety is the most important factor when it comes to taking sleeping pills; you should take them at the recommended dose and at the right time. In addition, it is recommended that you plan to have a whole night of sleep if you take a hypnotic sedative. Also, sleep aids should not be mixed with alcohol or sedatives.

Your doctor will be able to guide both pharmacological (drug) and non-pharmacological (non-drug) approaches for insomnia. A short course of sleep medications is usually safe for a generally healthy adult if being taken as directed. However, considering the variety of products in the market and their potential side effects, it is safest to talk to your doctor about your sleeping problems so you can decide together on the best course of treatment for you.

References:

https://sleepeducation.org/insomnia-awareness-day-facts-stats/
Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008 Oct 15;4(5):487-504 full-text
https://www.sleepfoundation.org/insomnia/treatment/safe-use-sleep-aids