What is the safest and most appropriate sleeping medication for an adult with short‑term insomnia?

Best Sleeping Pill for Short-Term Insomnia in Adults

For an adult with short-term insomnia, eszopiclone 2–3 mg or zolpidem 10 mg (5 mg if ≥65 years) are the safest and most appropriate first-line pharmacologic options, but only after initiating Cognitive Behavioral Therapy for Insomnia (CBT-I), which must be started concurrently because it provides superior long-term outcomes. 1, 2

Foundational Non-Pharmacologic Treatment

CBT-I is the standard of care and must be initiated before or alongside any medication. The American Academy of Sleep Medicine and American College of Physicians issue a strong recommendation that all adults with insomnia receive CBT-I as initial treatment because it demonstrates superior long-term efficacy with sustained benefits after medication discontinuation, whereas drug effects cease when stopped. 1, 2

Core CBT-I components include:

• Stimulus control therapy – use the bed only for sleep; leave bed if unable to sleep within 20 minutes 1
• Sleep restriction therapy – limit time in bed to approximate actual sleep time plus 30 minutes 1
• Relaxation techniques – progressive muscle relaxation, guided imagery, breathing exercises 1, 3
• Cognitive restructuring – modify negative beliefs about sleep 1
• Sleep hygiene education – consistent sleep-wake times, avoid caffeine ≥6 hours before bed, limit screen time 1 hour before bed 1, 2

CBT-I can be delivered via individual therapy, group sessions, telephone, web-based modules, or self-help books—all formats show comparable effectiveness. 1, 2

First-Line Pharmacologic Options (After CBT-I Initiation)

For Combined Sleep-Onset and Sleep-Maintenance Insomnia

Eszopiclone 2 mg at bedtime (1 mg if age ≥65 years or hepatic impairment) is the preferred first-line hypnotic after CBT-I initiation. 1, 2, 4

Efficacy:

• Reduces sleep-onset latency by ~19 minutes 2, 5
• Increases total sleep time by 28–57 minutes 1, 2, 5
• Produces moderate-to-large improvements in subjective sleep quality 2, 5
• At 12 weeks, 50% of patients achieve remission (Insomnia Severity Index <7) compared with 19% on placebo 1

Dosing: Take within 30 minutes of bedtime with at least 7 hours remaining before planned awakening. If 2 mg is tolerated but insufficient after 1–2 weeks, increase to 3 mg (maximum 2 mg for age ≥65 years). 1, 2, 5

Zolpidem 10 mg (5 mg if age ≥65 years) is an equally appropriate first-line option. 1, 2, 6

Efficacy:

• Shortens sleep-onset latency by ~25 minutes 1, 6
• Adds ~29 minutes to total sleep time 1, 6
• Effective for both sleep onset and maintenance 1, 6

Dosing: Take immediately before bedtime with at least 7–8 hours remaining before awakening. 1, 6

For Sleep-Onset Insomnia Only

Zaleplon 10 mg (5 mg if age ≥65 years) has an ultrashort half-life (~1 hour) providing rapid sleep initiation with minimal next-day sedation. 1, 2, 4 It can be taken at bedtime or middle-of-night when ≥4 hours remain before awakening. 1, 4

Ramelteon 8 mg is a melatonin-receptor agonist with no abuse potential, no DEA scheduling, and no withdrawal symptoms, making it appropriate for patients with substance-use history. 1, 2, 4

For Sleep-Maintenance Insomnia Only

Low-dose doxepin 3–6 mg reduces wake after sleep onset by 22–23 minutes via selective H₁-histamine antagonism, with minimal anticholinergic effects and no abuse potential. 1, 2, 4

Suvorexant 10 mg (orexin-receptor antagonist) reduces wake after sleep onset by 16–28 minutes and carries lower risk of cognitive and psychomotor impairment than benzodiazepine-type agents. 1, 2, 4

Critical Safety Considerations

All benzodiazepine-receptor agonists (eszopiclone, zolpidem, zaleplon) carry FDA warnings for complex sleep behaviors including sleep-driving, sleep-walking, and sleep-eating. Discontinue immediately if these occur. 1, 2, 5, 6

Next-day impairment: Eszopiclone 3 mg produces measurable psychomotor and memory deficits up to 11.5 hours after dosing; patients often do not perceive the impairment. 1, 5 Zolpidem shows statistically significant decreases in Digit Symbol Substitution Test performance the next morning. 6

Duration of use: FDA labeling indicates hypnotics are intended for short-term use (≤4 weeks) for acute insomnia; evidence beyond 4 weeks is limited. 1, 2, 5

Age-adjusted dosing is essential:

• Eszopiclone: maximum 2 mg for age ≥65 years 1, 2, 5
• Zolpidem: maximum 5 mg for age ≥65 years 1, 2, 6
• Zaleplon: maximum 5 mg for age ≥65 years 1, 2

Hepatic impairment: Reduce eszopiclone to maximum 2 mg and zaleplon to maximum 5 mg. 1, 2

Avoid alcohol while using these agents because it markedly increases risk of complex sleep behaviors and respiratory depression. 1, 2

Medications Explicitly NOT Recommended

Trazodone yields only ~10 minutes reduction in sleep latency and ~8 minutes reduction in wake after sleep onset, with no improvement in subjective sleep quality; adverse events occur in ~75% of older adults. The American Academy of Sleep Medicine issues a weak recommendation against its use. 1, 2, 4

Over-the-counter antihistamines (diphenhydramine, doxylamine) lack efficacy data, cause strong anticholinergic effects (confusion, urinary retention, falls, daytime sedation), and develop tolerance within 3–4 days. 1, 2, 7, 8

Traditional benzodiazepines (lorazepam, clonazepam, diazepam, temazepam) have long half-lives leading to drug accumulation, prolonged daytime sedation, higher fall and cognitive-impairment risk, and are linked to dementia and fractures. 1, 2, 7

Antipsychotics (quetiapine, olanzapine) have weak evidence for insomnia benefit and significant risks including weight gain, metabolic dysregulation, extrapyramidal symptoms, and increased mortality in elderly with dementia. 1, 2

Melatonin supplements produce only ~9 minutes reduction in sleep latency with insufficient evidence of efficacy. 1, 2

Herbal supplements (valerian, L-tryptophan) lack adequate evidence to support use for primary insomnia. 1, 2, 3

Implementation Algorithm

1. Initiate CBT-I immediately for all patients with insomnia, incorporating stimulus control, sleep restriction, relaxation, cognitive restructuring, and sleep-hygiene education. 1, 2

2. Add first-line pharmacotherapy if CBT-I alone is insufficient:

   • Combined sleep-onset and maintenance → eszopiclone 2 mg or zolpidem 10 mg (age-adjusted) 1, 2
   • Sleep-onset only → zaleplon 10 mg or ramelteon 8 mg (age-adjusted) 1, 2
   • Sleep-maintenance only → low-dose doxepin 3 mg or suvorexant 10 mg 1, 2

3. Reassess after 1–2 weeks to evaluate sleep-onset latency, total sleep time, nocturnal awakenings, daytime functioning, and adverse effects (morning sedation, cognitive impairment, complex sleep behaviors). 1, 2

4. If first-line agent fails, switch to alternative agent within same class (e.g., eszopiclone → zolpidem for combined symptoms; zaleplon → ramelteon for onset; doxepin → suvorexant for maintenance). 1, 2

5. Use lowest effective dose for shortest duration (typically ≤4 weeks), and taper gradually when discontinuing to avoid rebound insomnia, using CBT-I to support cessation. 1, 2, 8

Common Pitfalls to Avoid

Initiating hypnotic medication without first implementing CBT-I leads to less durable benefit and contravenes guideline recommendations. 1, 2

Using adult dosing in older adults without age-adjusted reduction (e.g., zolpidem 10 mg instead of 5 mg for ≥65 years) markedly increases fall risk. 1, 2

Combining multiple sedative agents (e.g., adding benzodiazepine to Z-drug) markedly increases risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors. 1, 2

Prescribing trazodone, OTC antihistamines, or traditional benzodiazepines despite lack of efficacy and significant safety concerns. 1, 2, 7

Continuing pharmacotherapy long-term without periodic reassessment every 2–4 weeks to evaluate efficacy, side effects, and plan tapering. 1, 2

Failing to warn patients about complex sleep behaviors and the need to discontinue medication immediately if they occur. 1, 2, 5