Which benzodiazepines are available for occasional insomnia in a middle‑aged adult without sleep apnea, dementia, or increased fall risk?

Benzodiazepines Available for Occasional Insomnia

For a middle-aged adult without sleep apnea, dementia, or increased fall risk, the following benzodiazepines are FDA-approved for insomnia, though they are NOT first-line agents and should only be considered after non-benzodiazepine options have failed.

FDA-Approved Benzodiazepine Hypnotics

Short-Acting Benzodiazepines (for sleep-onset insomnia)

• Triazolam – Ultra-short half-life benzodiazepine specifically indicated for sleep-onset insomnia at 0.25 mg, though it carries risk of rebound anxiety and is not considered first-line even among benzodiazepines 1
• Midazolam – Ultra-short acting with 2-8 minute distribution phase and terminal half-life of ~200 minutes, though primarily used for procedural sedation rather than chronic insomnia 2

Intermediate-Acting Benzodiazepines (for combined sleep-onset and maintenance)

• Temazepam – Intermediate half-life benzodiazepine recommended at 15 mg for both sleep-onset and sleep-maintenance insomnia, metabolized by conjugation with no active metabolites 1, 2
• Lorazepam – Intermediate half-life of 8-15 hours with no active metabolites, making it safer in renal insufficiency, though only considered second- or third-line for insomnia 1, 2

Long-Acting Benzodiazepines (generally avoided for insomnia)

• Flurazepam – Long elimination half-life benzodiazepine available in 15 mg and 30 mg doses, FDA-approved for insomnia but carries significant risk of daytime sedation and accumulation 3, 4
• Quazepam – Long-acting benzodiazepine with FDA approval for insomnia, though associated with drowsiness, fatigue, muscle weakness, and ataxia 5
• Nitrazepam – Half-life of 16-38 hours, primarily used for sleep disorders but causes prolonged sedation 2, 4
• Clonazepam – Half-life of 30-40 hours, dosed 0.25-2.0 mg, though primarily indicated for REM sleep behavior disorder and anxiety rather than primary insomnia 2
• Diazepam – Half-life of 20-120 hours with active metabolites (desmethyldiazepam half-life 50-95 hours), causing prolonged sedation and accumulation, explicitly NOT recommended as first-line for insomnia 1, 2

Critical Clinical Context: Why Benzodiazepines Are NOT First-Line

• The American Academy of Sleep Medicine explicitly recommends SHORT/INTERMEDIATE-ACTING BENZODIAZEPINE RECEPTOR AGONISTS (non-benzodiazepines like zolpidem, eszopiclone, zaleplon) or ramelteon as first-line pharmacotherapy—NOT traditional benzodiazepines 1

• Traditional benzodiazepines carry unacceptable risks compared to non-benzodiazepine alternatives: higher dependency potential, more severe withdrawal syndromes, greater cognitive impairment, increased fall risk, respiratory depression (especially with opioids), associations with dementia, and altered sleep architecture 1, 6

• Benzodiazepines should only be considered when:

  • First-line non-benzodiazepine BzRAs (zolpidem, eszopiclone, zaleplon) have failed 1
  • Alternative BzRAs within the same class have been tried unsuccessfully 1
  • The patient has a comorbid condition that might specifically benefit from benzodiazepine treatment (e.g., comorbid anxiety disorder requiring longer-duration anxiolysis) 1

Preferred Non-Benzodiazepine Alternatives (What You Should Use Instead)

• Zolpidem 10 mg – Reduces sleep latency by ~25 minutes, increases total sleep time by ~29 minutes, with moderate-quality evidence for both sleep-onset and maintenance 1, 7
• Eszopiclone 2-3 mg – Increases total sleep time by 28-57 minutes with moderate-to-large improvement in sleep quality for both onset and maintenance 1
• Zaleplon 10 mg – Very short half-life (~1 hour) for rapid sleep initiation with minimal next-day sedation, ideal for middle-of-night dosing when ≥4 hours remain 1
• Low-dose doxepin 3-6 mg – Reduces wake after sleep onset by 22-23 minutes with minimal anticholinergic effects and NO abuse potential 1
• Ramelteon 8 mg – Melatonin receptor agonist with ZERO abuse potential, no DEA scheduling, appropriate for patients with substance use history 1

Dosing Hierarchy for Benzodiazepines (If You Must Use Them)

If non-benzodiazepine options have definitively failed and you must prescribe a benzodiazepine:

1. For sleep-onset only: Triazolam 0.25 mg (shortest-acting option, though rebound anxiety risk) 1
2. For combined onset/maintenance: Temazepam 15 mg (intermediate duration, no active metabolites) 1, 2
3. Avoid entirely: Long-acting agents (flurazepam, quazepam, nitrazepam, diazepam, clonazepam) due to prolonged sedation, accumulation, and daytime impairment 1, 2, 4

Mandatory Safety Warnings for All Benzodiazepines

• FDA BLACK BOX WARNING: Concomitant use with opioids may result in profound sedation, respiratory depression, coma, and death—reserve combination only when no alternatives exist 3
• Abuse, misuse, and addiction risk: All benzodiazepines are DEA Schedule IV controlled substances with significant dependence potential 3
• Withdrawal risk: Abrupt discontinuation after continued use may precipitate life-threatening withdrawal reactions including seizures—always use gradual taper (reduce by 25% every 1-2 weeks) 1, 3
• Complex sleep behaviors: Sleep-driving, sleep-walking, sleep-eating reported with all benzodiazepines—discontinue immediately if these occur 1
• Use lowest effective dose for shortest duration possible: FDA labeling indicates hypnotics are intended for short-term use (≤4 weeks) only 1