Are sleeping pills safe? The risks of prescription and over-the-counter sleep aids, and how to use t

• Sleeping pills are mostly safe, but they do have potentially harmful risks and side effects.
• Prescription sleep aids must be taken under a doctor's supervision, as they can be unsafe with some underlying medical conditions, and overdosing can be very dangerous. 
• Over-the-counter sleep medication is generally safer, but you still must take as directed. 
• This article was medically reviewed by Jason R. McKnight, MD, MS, a family medicine physician and clinical assistant professor at Texas A&M College of Medicine. 
• This story is part of Insider's guide to Insomnia and How to get better sleep

Sleep problems are common. According to the National Sleep Foundation, 30% to 40% of US adults report experiencing symptoms of insomnia, and 4% of adults over the age of 20 use prescription sleep aids.

But you don't necessarily need a prescription. There are also over-the-counter sleeping aids. Here's what you need to know about both types of sleeping pills and their risks, side effects, and safety.

Prescription sleeping pills

Prescription sleep aids are usually reserved for those with diagnosed insomnia. 

Insomnia is defined as trouble falling asleep, staying asleep, or waking up too early for at least three nights per week over a period of three months, says Alex Dimitriu, MD, founder of Menlo Park Psychiatry & Sleep Medicine. 

Other factors that can affect sleep, such as depression, anxiety, alcohol and substance use, or pain and medical problems, have to be absent to make a clear diagnosis of insomnia, Dimitriu says.

If you have addressed other possible medical conditions that can make it difficult to sleep, but still find that insomnia interferes with your daily life, a prescription or over-the-counter sleep aid could help get you back on track. 

Prescription sleeping pills, known as sedative hypnotics, fall into three categories:

• Melatonin-receptor agonists, such as Rozerem and Hetlioz, target the melatonin receptors in the brain that are responsible for the body's sleep-wake cycle. These drugs work by mimicking melatonin,  a naturally occurring hormone produced during sleep. Studies have shown melatonin-receptor agonists reduce the time it takes to fall asleep in both adult and elderly patients, with little evidence of side effects the next day or withdrawal symptoms upon stopping the medication.
• Benzodiazepines, such as Valium and Xanax, target a brain chemical called gamma-aminobutyric acid (GABA) that reduces nerve activity, relaxes muscles, and promotes sleep. However, they are not commonly prescribed to treat insomnia anymore, as they aren't always effective and can be harmful if taken long-term. These drugs can be habit-forming, says Rajkumar Dasgupta, MD, assistant professor of clinical medicine at Keck School of Medicine at the University of Southern California, and the risks often outweigh the benefits. 
• Nonbenzodiazepines, such as Ambien or Lunesta, target GABA as well, but these drugs have a shorter half life than benzodiazepines, meaning they don't last as long in the body. This results in a safer drug with less side effects than benzodiazepines, but also makes nonbenzodiazepines less effective at maintaining sleep throughout the night. 

Are sleeping pills safe? 

Sleeping pills are mostly safe, but they carry some known side effects, which can pose a risk to your health. 

For example, benzodiazepines and nonbenzodiazepines can cause daytime grogginess, which can increase the risk of falls or other accidents, Dasgupta says. Some nonbenzodiazepines are affiliated with dangerous and complex sleep-related behaviors, such as sleepwalking and sleep-driving.

The Food and Drug Administration (FDA) mandates label warnings on three nonbenzodiazepine drugs — eszopiclone, zaleplon and zolpidem — because of "rare but serious injuries and deaths" from sleep-walking or sleep-driving when taking these medications. According to the FDA, these drugs have been connected to 20 reported deaths and 46 non-fatal but serious injuries.

Overall, the safety and effectiveness of sleeping pills depends greatly on the individual. 

"I think this is where you have to tailor the medication with your physician to your situation," Dasgupta says. "It really just depends on the person, everything else that's going on, the options out there, and their medical history."

How to safely use sleeping pills

Sleeping pills are meant for you to take before a full night of sleep to reduce the risk of excessive grogginess the next day. However, sleeping pills, when used incorrectly or by a high-risk group can be extremely dangerous. 

Before seeking a sleep aid, here's what you should know: 

• If you're over 65, consider the risks. People over age 65 are more sensitive to side effects from benzodiazepines, which can impair cognition, mobility and driving skills as well as increase the risk of falls in people over age 65. If you are an older adult, your doctor may prescribe a lower dose or suggest a drug with a shorter half-life to reduce your risk.
• If you're pregnant or breastfeeding, be extra careful. Some studies have found that women who take benzodiazepines while pregnant put their unborn child at greater risk of physical defects at birth such as congenital heart disease.While some sleeping pills are considered safe while breastfeeding, others may not be, so discuss with your doctor. Some sleeping medications may decrease milk supply or can cause side effects in breastfed infants, like irritability. 
• If you have kidney or liver disease, discuss with your doctor. Because these medications can be metabolized by the liver or kidneys, some sleeping pills may be more dangerous for people with kidney or liver disease. Research has shown that the antihistamine hydroxyzine is an effective sleep aid for people with liver disease, but use of a sleep aid in someone with kidney or liver disease should be monitored by a doctor. 
• Don't combine sleeping pills with other medications. Benzodiazepines can be particularly dangerous when combined with prescription painkillers, such as opioids, because both types of drugs can make it more difficult for you to breathe or cause you to stop breathing. 
• Don't combine sleeping pills with alcohol. This can increase the risk of abnormal sleeping behaviors, like sleepwalking, Dasgupta says. Moreover, alcohol can also make you feel tired, and when combined with a sleeping pill, that sedating effect is enhanced. This is a problem, because both drugs depress the central nervous system, slowing down your heart rate and respiratory system, and making it more difficult to breathe.
• Take as directed. It is possible to overdose on sleep aids, so only use them as directed. According to a 2018 report from the Centers for Disease Control and Prevention's National Center for Health Statistics, opioids and benzodiazepines are two of the most commonly used drugs in overdose deaths. 

Common side effects of sleeping pills include headaches, prolonged drowsiness, problems with memory, and dizziness. 

If you notice these side effects, or more severe risks such as sleepwalking or next-day grogginess that impacts your ability to function, Dasgupta recommends stopping the medication and consulting your doctor.

Over-the-counter sleeping pills are safer, but also come with risks

Just because a sleeping pill is over-the-counter doesn't necessarily mean it is safe, Dasgupta says. As with prescription sleep aids, factors like medical history, other medications you're on, and underlying health conditions all contribute to how your body reacts to over-the-counter sleeping pills.

Most over-the-counter sleep aids, such as Unisom, ZzzQuil, and Sleepinal, contain antihistamines, which are typically used to treat allergy symptoms, but can also cause drowsiness. Histamine is produced in the brain and plays a role in helping you feel awake, so medications that interrupt histamine reception can result in sleepiness.

The antihistamine Benadryl, for example, contains an ingredient called diphenhydramine. Long-term use of diphenhydramine has been found to increase the risk of dementia. Moreover, just as with prescription sleep aids, you could become dependent on over-the-counter sleeping pills as well, like Benadryl or Unisom, Dasgupta says. 

Herbal supplements like Valerian root, chamomile, and melatonin can also help with sleep, though they are not regulated nor are they approved by the FDA.

The safest option for treating insomnia isn't medication, but a type of therapy known as cognitive behavioral therapy (CBT), says David Cutler, MD, a family medicine physician at Providence Saint John's Health Center. 

CBT helps you change thoughts and behaviors that may be contributing to your sleep problems, and it doesn't come with common side effects of sleeping pills, like grogginess or abnormal sleep behaviors. Studies show that CBT reduces symptoms of insomnia and helps patients overcome the underlying causes of their sleep problems.

"The mind is very powerful," Cutler says. "A lot of it really does come back to cognitive behavioral therapy, and using the power of the mind to help you be a better sleeper."

Related stories about sleep:

• Why am I having weird dreams? The science behind your dreams and how to manage them
• How to get better sleep with anxiety or stress, in 5 different ways
• Is too much sleep bad? How oversleeping could signal something is wrong
• How melatonin can make you sleep better: what it is, how much to take, and the health benefits
• Why am I always tired? The main causes of sleepiness and fatigue
• A consistent lack of sleep can potentially cause heart disease
• Why depression makes you tired and how to deal with fatigue

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