There is a common problem that all of us who prescribe psychotropic medications have faced hundreds of times. Some patients strongly request a sleep medication but are at risk for abuse or dependence. Or the institution where they are does not allow medications like benzodiazepines or the Z-drugs.
So, the question is: “How should we deal with demands for sleep medication from patients who say that non-addictive alternatives don’t work for them?”
1. We must realize that some patients are looking for something that would knock them out. That is, a medication whose effect they would feel clearly and that would put them to sleep without their having to do anything.
In these patients, we have to ACCEPT that we are not going to able to satisfy them, so satisfying them is not the goal. This is the most important thing we need to do and is an issue of our mindset. We must give up the expectation that we must be able to put our patients to sleep, no matter what.
2. Not only should we accept this, but we should also tell the patient that it seems like this is what they are looking for and, regrettably, we can’t offer them anything that would accomplish what they want.
3. We should also tell the patient right away what kinds of medications we will NOT prescribe. This reduces arguing back and forth. For several years, I worked on a busy inpatient mental health unit where patients with substance abuse problems would ask me to prescribe them alprazolam or clonazepam “because that is the only thing that works for me.” My standard response was, “We don’t prescribe medications like that here. We can give you either trazodone or Vistaril (hydroxyzine). Which one do you prefer?”
4. So my next point is, we should offer the patient a choice between non-addictive sleep medications that we are willing to prescribe. Giving the patient a choice reduces any power struggle that may happen.
5. It is surprisingly common in patients who complain loudly and repeatedly about insomnia to find that they sleep during the day for several hours! Ask about that.
6. I have also seen dozens of cases of patients who would complain of insomnia, did not find sleep medications helpful, and turned out to have sleep apnea. So, please, please screen patients for that.
a) Only some of the medications mentioned below are FDA-approved for the treatment of insomnia. These are: ramelteon (Rozerem), low-dose doxepin (Silenor), suvorexant (Belsomra), and doxylamine (Unisom). The other medications are mentioned for general educational purposes and are not being recommended for off-label use as hypnotics.
b) Please review the full Prescribing Information before recommending any of these medications.
c) The options below are not listed in order of their utility or the evidence favoring their use.
d) Even though these medications are generally less “addictive” than others like the benzodiazepines, individual patients may abuse them or become dependent on them.
e) The doses suggested here are for healthy adults.
Doxylamine (Unisom)–over-the-counter; 25 mg at bedtime.
Diphenhydramine (Benadryl)–25 to 50 mg at bedtime; available over-the-counter😭
Hydroxyzine (Vistaril or Atarax)–In contrast to diphenhydramine, this is not over-the-counter in the US. Despite what the FDA-approved dose range is, do not use more than 100 mg/day in adults and 50 mg/day in older adults.
Promethazine (Phenergan)–25 t0 50 mg at bedtime. In contrast to diphenhydramine, this is not over-the-counter in the US.
2. Sedating antidepressants
Doxepin (Silenor)–instead of the expensive, brand name Silenor, the inexpensive, generic doxepin 10 mg capsules can be prescribed, one capsule at bedtime.
Trazodone (Desyrel)–50 to 200 mg at bedtime
Mirtazapine (Remeron)–7.5 to 45 mg at bedtime
3. Melatonergic agents
Ramelteon (Rozerem) 8 mg One at bedtime
Melatonin–especially in older adults; 2 to 3 mg at bedtime. This use is different from its use to affect the circadian rhythm, which will be discussed elsewhere on this website.
4. Orexin receptor antagonist
Suvorexant (Belsomra)–10 to 20 mg at bedtime. Suvorexant is not free of abuse potential but this seems to be lower than that for zolpidem (Schoedel et al., 2016).
Gabapentin (Neurontin)–(Furey et al., 2014; Rosenberg et al., 2014).
Topiramate (Topamax)–found to improve sleep in persons with alcohol dependence (Johnson et al., 2008)
6. Sedating antipsychotic
Quetiapine (Seroquel)–While quetiapine is often used off-label for insomnia, a careful risk-benefit analysis should be done before using an antipsychotic for insomnia.
Acamprosate (Campral)–found to improve sleep in persons with alcohol dependence even when alcohol dependence was not significantly improved (Perney et al., 2012)