Is temazepam (a benzodiazepine) suitable for treating insomnia in older adults or those with a history of substance abuse?

Should Temazepam Be Used for Insomnia?

Temazepam can be used for insomnia, but only as a second-line pharmacologic option after cognitive behavioral therapy for insomnia (CBT-I) has been initiated, and it should be reserved for short-term use (7-10 days, maximum 2 weeks) due to significant risks of dependence, withdrawal, complex sleep behaviors, and lack of long-term safety data. 1, 2, 3, 4

Critical Context for Older Adults and Substance Abuse History

Older Adults

• Temazepam requires dose reduction to 7.5-15 mg (not 30 mg) in elderly patients due to increased sensitivity, fall risk, cognitive impairment, and prolonged drug effects 2, 5, 6
• The American Academy of Sleep Medicine specifically studied temazepam 15 mg in patients ≥70 years old with primary insomnia, demonstrating efficacy with minimal adverse effects at this lower dose 1
• Elderly patients are at substantially higher risk for falls, fractures, cognitive impairment, and complex sleep behaviors (sleep-driving, sleep-walking) with all benzodiazepines 2, 3, 6
• Alternative first-line options for elderly patients include ramelteon 8 mg or low-dose doxepin 3 mg, which carry minimal fall risk and cognitive impairment 3

Patients with Substance Abuse History

• Temazepam is absolutely contraindicated or should be avoided in patients with a history of substance abuse 4
• The FDA explicitly warns that temazepam is a Schedule IV controlled substance with significant potential for abuse, misuse, and addiction, even when taken as prescribed 4
• Patients with prior alcohol or drug dependence are at markedly elevated risk for developing benzodiazepine addiction 4
• For patients with substance abuse history, the American Academy of Sleep Medicine recommends ramelteon or suvorexant instead of any benzodiazepine 2

Evidence-Based Treatment Algorithm

Step 1: First-Line Treatment (All Patients)

• Initiate CBT-I before or alongside any pharmacotherapy, as it demonstrates superior long-term outcomes with sustained benefits after discontinuation and minimal adverse effects 1, 3
• CBT-I includes stimulus control therapy, sleep restriction therapy, relaxation techniques, and cognitive restructuring, deliverable through individual therapy, group sessions, telephone, web-based modules, or self-help books 2, 3

Step 2: Pharmacotherapy Selection (If CBT-I Insufficient)

• For sleep onset AND maintenance insomnia: Temazepam 15 mg is an appropriate option, improving both subjective sleep latency (by 23-29 minutes) and total sleep time (by 99 minutes compared to placebo) 1, 5
• Temazepam 15 mg demonstrates clinically significant improvements in sleep latency, total sleep time, and wake after sleep onset, with minimal adverse effects at this dose 1, 5
• Escalate to 30 mg only if 15 mg proves insufficient after adequate trial, though 30 mg carries higher risk of drowsiness, lethargy, vertigo, and daytime impairment 2, 5

Step 3: Duration and Monitoring

• FDA labeling indicates temazepam is intended for short-term use only (7-10 days), with safety and efficacy beyond 2 weeks unknown 4
• If insomnia persists beyond 7-10 days, reassess for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) rather than continuing medication 2, 3
• The American College of Physicians explicitly states there is insufficient evidence to determine the balance of benefits and harms of long-term pharmacologic treatments for chronic insomnia 3

Critical Safety Warnings

Complex Sleep Behaviors

• Patients may engage in activities while not fully awake (sleep-driving, sleep-walking, eating, having sex) with no memory the next morning 4
• Risk is substantially higher when combined with alcohol or other CNS depressants 4
• Discontinue temazepam immediately if patient discovers they performed activities while not fully awake 4

Dependence and Withdrawal

• Physical dependence develops with continued therapy, and abrupt discontinuation can cause life-threatening withdrawal including seizures, delirium, paranoia, and suicidal ideation 4
• Withdrawal symptoms can persist for several weeks to more than 12 months, including anxiety, insomnia, muscle twitching, and cognitive impairment 4
• Taper gradually when discontinuing rather than stopping abruptly 4

Cognitive and Psychomotor Impairment

• All benzodiazepines carry FDA warnings regarding daytime memory impairment, driving impairment, and motor vehicle accidents 3, 4
• Observational studies suggest associations with dementia, fractures, and major injuries, though primarily from benzodiazepine studies 3, 6

Dosing Specifics

Standard Adult Dosing

• Start with 15 mg at bedtime for most adults, taken only when able to get a full night's sleep (7-8 hours) before needing to be active 2, 5, 4
• Peak plasma levels occur 1.2-1.6 hours after dosing, with half-life of 10-15 hours 4, 7
• Take on empty stomach to maximize effectiveness 2

Elderly/Debilitated Dosing

• Start with 7.5 mg at bedtime, with maximum dose of 15 mg 2, 5, 8
• Studies in elderly patients (≥70 years) demonstrate that 7.5 mg produces significant improvement in total wake time (100 vs 145 minutes baseline) with minimal adverse effects 8

Comparative Positioning

When Temazepam May Be Appropriate

• Patient requires treatment for both sleep onset AND maintenance insomnia 2, 3, 5
• First-line non-benzodiazepine options (ramelteon, suvorexant, low-dose doxepin) have failed or are not tolerated 2, 3
• Patient has no history of substance abuse and is not elderly/debilitated 4
• Short-term use only (≤2 weeks) is planned 4

When Temazepam Should Be Avoided

• History of substance abuse or addiction (use ramelteon or suvorexant instead) 2, 4
• Elderly patients (consider ramelteon 8 mg or doxepin 3 mg as safer alternatives) 2, 3
• Need for long-term treatment (CBT-I provides superior sustained benefits) 1, 3
• Comorbid depression/anxiety (sedating antidepressants like mirtazapine or doxepin are more appropriate) 3

Common Pitfalls to Avoid

• Using temazepam as first-line treatment without initiating CBT-I 1, 3
• Prescribing standard adult doses (30 mg) to elderly patients rather than starting with 7.5-15 mg 2, 5, 8
• Continuing pharmacotherapy beyond 2 weeks without reassessing for underlying sleep disorders 2, 3, 4
• Prescribing to patients with substance abuse history 4
• Failing to warn patients about complex sleep behaviors and driving impairment 4
• Abruptly discontinuing after prolonged use rather than tapering gradually 4
• Combining with alcohol or other CNS depressants 4