Sleeping Pills NZ - What Works Best And What’s Safest? Here’s The Science
Which Sleeping Pill Is Right For You?
Struggling with sleep? You're certainly not alone. Studies estimate that 25-29% of NZ adults experience chronic problems with their sleep.
But when counting sheep just doesn't cut it anymore (and if you’re not aware, sleep hygiene isn’t an effective treatment for chronic insomnia either), many people turn to sleep medication for help. But with a growing number of options available, how do you know which one might be right for you? Which sleeping pill works best? And importantly, which sleeping pill is the safest?
While Cognitive Behavioral Therapy for Insomnia (CBT-I) is recommended as the most effective treatment for insomnia, and the first thing to do to treat insomnia (Qaseem et al., 2016; Ree et al., 2017; Riemann et al., 2017), the reality is that it is often the last thing people do.
Instead, sleep medications, also known as sedative-hypnotics, remain the most common approach to treating insomnia, and other sleep disorders such as circadian rhythm disorders, parasomnias (but are not indicated for Obstructive Sleep Apnoea).
In fact, some estimates suggest up to 90% of primary care doctor’s visits for insomnia result in a sleeping pill prescription (Miller et al., 2017).
While we’d love to go on about how sleep medications only treat symptoms, not the cause, and therefore aren’t ineffective in the long term, the reality is that many people just want the first relief from their sleep problems they can get (and that’s understandable). So it’s important to help people understand the differences between sleep medications.
But we think the public should have solid information comparing not just if they work, but how well they work compared to their potential side effects (and side effects can make some medications intolerable for some people). And that information is hard to find.
So how do the various sleeping pills actually stack up against each other when you look closely at both their benefits and their risks?
A recent study published in the Journal of Sleep Research aimed to tackle exactly this question, providing a useful head-to-head comparison of different classes of sleep medications (Cheung et al., 2024).
Let's take a closer look at what they did and what they found.
Choosing A Sleeping Pill - Not Straightforward
You might think that choosing a sleep medication is straightforward, guided by clear recommendations. In fact, several professional groups have published guidelines (Qaseem et al., 2016; Riemann et al., 2017; Sateia et al., 2017; Wilson et al., 2019).
However, many of these guidelines focus on rating the quality of the evidence behind a medication class, rather than directly comparing the size of the benefit versus the frequency of side effects (Cheung et al., 2024).
Studies often use systems like GRADE, which tells us how strong the research is (e.g., strong, moderate, weak evidence) which is great for a sleep researcher, but this doesn't easily translate into "how much better will I sleep?" or "what are my chances of side effects?" (Guyatt et al., 2011) - which is really what the average insomnia sufferer wants to know.
This leaves a bit of a gap for both doctors and patients trying to make informed decisions.
While some previous studies tried to compare medications using a research technique that looks at all the studies together (known as a meta-analysis, e.g., Chiu et al., 2021; Samara et al., 2020), no study had really put safety and effectiveness data together in a clear, measurable risk-benefit score for different sleep medication classes.
So that’s what Cheung et al (2024) set out to do. As they noted:
None has provided an integrative analysis that concurrently quantifies safety and efficacy (e.g., risk–benefit ratios). This represents an important gap for informing clinician decision-making (Cheung et al., 2024, p. 1).
The goal of the study by Cheung et al., 2024 therefore, was clear:
to quantitatively compare the relative safety and efficacy of hypnotics indicated for the treatment of insomnia, and to provide rank orders with respect to efficacy, safety, and risk–benefit (Cheung et al., 2024, p. 2).
Which roughly translates to everyday English as:
what works
what’s safe; and
what’s best when you combine those two factors
Comparing Sleeping Pills
Which Sleep Medications Were Compared?
The study focused on medications that met specific criteria:
Approved by the US Food and Drug Administration (FDA) specifically for treating insomnia (note: not all of these medications are readily available in NZ).
Had standardized safety information available in their official package insert.
Had good quality data from key clinical trials on how much they improved sleep (specifically, self-reported sleep latency, wake time after sleep onset, and total sleep time).
Were recommended for use by the American Academy of Sleep Medicine (AASM) in their 2017 guidelines (Sateia et al., 2017), with an exception made for two newer drugs approved after these guidelines were published (lemborexant and daridorexant).
This process led them to include 10 different medications, grouped into five main classes (Cheung et al., 2024):
Benzodiazepine Receptor Agonists (BZRAs): These are older medications, often just called "benzos." Examples included: temazepam, diazepam and triazolam. They work by enhancing the effect of GABA, a calming neurotransmitter in the brain.
Non-Benzodiazepine Benzodiazepine Receptor Agonists (nBZRAs): Often called "Z-drugs," these are structurally different from benzos but act on the same brain receptors. Examples included: zopiclone (Imovane), zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata).
Dual Orexin Receptor Antagonists (DORAs): These are newer medications that work differently, by blocking orexin, a chemical messenger in the brain that promotes wakefulness. Examples included: suvorexant (Belsomra), lemborexant (Dayvigo), and daridorexant (Quviviq).
Melatonin Receptor Agonist (MELA): This class targets melatonin receptors, which are involved in regulating the sleep-wake cycle. The example included was ramelteon (Rozerem).
Histamine Antagonist (HA): This medication primarily blocks histamine receptors (specifically H1), similar to some allergy medications but used here at a very low dose for sleep. The example was low-dose doxepin (Silenor - typically 3mg or 6mg for insomnia).
Measuring Safety: Counting Side Effects
To get a standardized look at safety, the researchers turned to the official FDA-approved package inserts for each medication.
Why?
Because these inserts contain tables listing the adverse events (AEs) reported during the clinical trials that led to the drug's approval.
They then extracted the percentage of people experiencing specific AEs for both the medication group and the placebo group (people taking a sugar pill). They then converted these percentages into actual counts of events, summed them up for each medication class, and calculated a rate of AEs per 1000 people. Crucially, they subtracted the placebo rate from the medication rate.
This "placebo-adjusted" rate (AEr) gives a clearer picture of side effects likely caused by the drug itself, rather than just occurring by chance or due to the placebo effect (yes, people on placebos report side-effects of taking a sugar-pill!). It's important to note these AEs were generally minor or moderate; serious adverse events are reported differently (Cheung et al., 2024).
Measuring Sleeping Pill Effectiveness: How Much Did Sleep Improve?
For efficacy, the researchers didn't rely solely on the package inserts, as the original published studies often provide more detail.
They identified 18 key randomized controlled trials (RCTs) from previous high-quality reviews and practice guidelines (including sources like Sateia et al., 2017; Buscemi et al., 2007; Chiu et al., 2021; De Crescenzo et al., 2022).
They focused on subjective sleep improvements – meaning, what the participants reported themselves in daily sleep diaries. The three key measures were:
Sleep Latency (SL): How long it took to fall asleep.
Wake Time After Sleep Onset (WASO): How much time was spent awake during the night after initially falling asleep.
Total Sleep Time (TST): The total amount of sleep obtained.
Why use subjective reports instead of objective measures like brainwave recordings (PSG) or wrist-worn trackers (actigraphy)?
The researchers argued that self-reports are "more routinely obtained in pivotal trials," are collected daily over longer periods (giving more stable estimates), and are "more clinically relevant" because treatment decisions in practice are usually based on how the patient feels their sleep is, not on objective tests (Cheung et al., 2024, p. 3; Dietch & Taylor, 2021).
For each of the 18 studies, they calculated the change in SL, WASO, and TST from the beginning of the study (baseline) to the end of the treatment period (or the first follow-up point). They calculated an "Effect Size" (ES) for each measure – essentially, a standardized way to quantify the amount of change.
Like the safety data, these ES values were placebo-adjusted by subtracting the change seen in the placebo group.
To get an overall efficacy score for each medication class, they did two things:
Weighted the ES: They gave more weight to studies with more participants when averaging the ES for each class.
Created a Composite Score (SWT): The SWT score represented the total improvement across all three key aspects of sleep continuity together - SL, WASO, and TST. The idea was that improvements in falling asleep, staying asleep, and getting enough sleep are all important and add up to the overall benefit for the patient (Cheung et al., 2024).
The Risk-Benefit Score: Putting It All Together
Finally, they calculated the risk-benefit ratio. This was done quite simply: they divided the safety score (AEr per 1000) by the overall efficacy score (SWT ES).
Risk-Benefit Ratio = Adverse Event Rate (AEr) / Total Sleep Improvement (SWT ES)
A lower ratio number indicates a more favourable profile – meaning the therapeutic benefits (efficacy) are relatively high compared to the rate of adverse events (risk). A higher number means more risk relative to the benefit (Cheung et al., 2024).
What Did They Find? Ranking the Sleep Medications
After all this calculation, how did the different classes of sleep medications compare? The results, based on data from over 11,000 participants for safety and nearly 7,000 for efficacy across the 18 trials, revealed some clear differences.
Safety First: Which Sleep Meds Had Fewer Side Effects?
When looking purely at the placebo-adjusted adverse event rate (AEr per 1000 people), there was a wide range
Melatonin Receptor Agonist (MELA - ramelteon): Lowest AEr = 43.1 (Safest)
Histamine Antagonist (HA - low-dose doxepin): AEr = 67.3
Dual Orexin Receptor Antagonists (DORAs): AEr = 85.5
Benzodiazepine Receptor Agonists (BZRAs): AEr = 157.2
Non-Benzodiazepine BZRAs (nBZRAs - Z-drugs): Highest AEr = 255.0 (Least Safe)
So, the melatonin agonist ramelteon came out on top for safety, with the fewest side effects attributed to the drug compared to placebo.
The Z-drugs (like zopiclone - often prescribed in New Zealand) had the highest rate of side effects.
The researchers also noted that side effects involving the central nervous system (like dizziness or drowsiness) and the gastrointestinal system (like nausea) were the most common across the classes (Cheung et al., 2024).
Effectiveness Matters: Which Sleeping Pill Improved Sleep Most?
Now, what about how well they worked?
Looking at the total sleep improvement score (SWT ES), the ranking was quite different (Cheung et al., 2024):
Benzodiazepine Receptor Agonists (BZRAs): Highest SWT ES = 1.94 (Most Effective)
Non-Benzodiazepine BZRAs (nBZRAs - Z-drugs): SWT ES = 1.10
Histamine Antagonist (HA - low-dose doxepin): SWT ES = 0.97
Dual Orexin Receptor Antagonists (DORAs): SWT ES = 0.73
Melatonin Receptor Agonist (MELA - ramelteon): Lowest SWT ES = 0.11 (Least Effective)
Here, the older BZRAs or Benzodiazapines showed the largest overall improvement in subjective sleep.
The Z-drugs also performed well.
Low-dose doxepin (the histamine agonist) and the newer DORAs showed more moderate effects.
Interestingly, ramelteon (the melatonin agonist) showed very little improvement in sleep based on this analysis (and this medication is stronger than melatonin itself ,which highlights just how ineffective melatonin is for insomnia).
Looking at the individual sleep measures that make up the SWT score (Cheung et al., 2024):
Falling Asleep (SL): BZRAs were best (ES=0.73), followed by Z-drugs (ES=0.49). The Histamine Antagonist actually performed slightly worse than placebo (ES=-0.044).
Staying Asleep (WASO): BZRAs were best (ES=0.51), but HA was also quite good (ES=0.43). MELA was worst (ES=-0.08).
Total Sleep Time (TST): BZRAs were best (ES=0.70), followed closely by HA (ES=0.58). MELA again showed the smallest effect (ES=0.07).
This breakdown shows that, while BZRAs seemed effective across the board, HA (low-dose doxepin) was particularly helpful for reducing time awake during the night and increasing total sleep time, but not for helping people fall asleep faster.
The Bottom Line: Sleeping Pill Risk vs. Benefit
Okay, so some drugs are safer, others are more effective.
The million dollar question: Which ones offer the best balance?
That's where the risk-benefit ratio comes in (remember, lower is better).
Histamine Antagonist (HA - low-dose doxepin): Lowest Ratio = 69.5 (Most Favourable Profile)
Benzodiazepine Receptor Agonists (BZRAs): Ratio = 81.1
Dual Orexin Receptor Antagonists (DORAs): Ratio = 130.4
Non-Benzodiazepine BZRAs (nBZRAs - Z-drugs): Ratio = 221.7
Melatonin Receptor Agonist (MELA - ramelteon): Highest Ratio = 395.7 (Least Favourable Profile)
This is perhaps the most interesting finding.
Low-dose doxepin (HA) came out on top. Why?
Because doxepin combined a relatively low rate of side effects (second safest) with reasonably good effectiveness (third most effective overall, particularly for sleep maintenance).
Benzos ranked second – their high effectiveness helped offset their higher side effect rate.
The newer DORAs landed in the middle (Lemborexant is available in NZ).
Concerningly, Z-drugs (nBZRAs), the most widely prescribed in New Zealand and other Western nations, ranked poorly due to having the highest side effect rate, despite being quite effective.
And ramelteon (MELA) ended up last. Even though it was the safest, its very low effectiveness score resulted in the worst risk-benefit ratio. Essentially, the analysis suggests it offered too little benefit to justify even its low risk.
Which Sleeping Pill is "Best"? It's Complicated...
Based purely on this quantitative risk-benefit analysis, the study authors suggest:
treatment with a histamine antagonist [low-dose doxepin] is optimal and potentially represents the best first-line therapy for the medical management of insomnia" (Cheung et al., 2024).
This echoes findings from at least one previous analysis (Chiu et al., 2021).
The authors suggest low-dose doxepin might be particularly suitable for people whose main problem is staying asleep (sleep maintenance insomnia), given its stronger effects on WASO and TST compared to SL.
They also note it might be a good option for older adults, as low doses have minimal anticholinergic effects (side effects like dry mouth, constipation, confusion) which can be problematic in this age group (Cheung et al., 2024; Krystal et al., 2013). As older adults are the group most likely to complain from sleep maintenance problems, this would make doxepin a very useful medication. Ironically, doxepin was withdrawn from the New Zealand market in 2019 due to low usage.
But hold on. Does this mean everyone with insomnia should just ask for low-dose doxepin if it’s available?
Not so fast.
The researchers themselves point out several important limitations and caveats (Cheung et al., 2024):
Falling Asleep: If your main issue is taking a long time to fall asleep (sleep initiation insomnia), low-dose doxepin might not be the best choice, as this analysis found it had virtually no effect on SL. In fact, for SL specifically, BZRAs had the best risk-benefit profile, followed by DORAs.
Short-Term Focus: This analysis looked at relatively short-term use (data extraction points ranged from 2 nights to 6 months, often focusing on early weeks). We don't know how these medications compare for long-term safety and efficacy.
Subjective Data: While clinically relevant, the efficacy data relied on self-reports. It didn't include objective measures like PSG or actigraphy, which sometimes show different results.
Safety Data Limits: The AE data from package inserts just gives counts of events, not how many people had side effects or how severe they were. As the authors state, this leads to "a certain level of ambiguity regarding the magnitude of AEs affecting individuals (i.e., 10 AEs experienced by 1 person versus 1 AE experienced by 10 people)" (Cheung et al., 2024). Also, tolerance over time and withdrawal effects weren't assessed.
Equal Weighting: The risk-benefit ratio assumed that risk (side effects) and benefit (sleep improvement) are equally important. Is that always true? Patients may value improved sleep above and beyond the common occurrence of, for example, headache and gastrointestinal distress
Missing Medications: The study only included FDA-approved prescription hypnotics. It didn't look at commonly used off-label medications (like trazodone, quetiapine) or over-the-counter options (like diphenhydramine) or natural products (like valerian or standard melatonin).
Beyond Sleep Continuity: The study focused on SL, WASO, and TST. It didn't include other important aspects like early morning awakenings, overall sleep quality (e.g., using the Insomnia Severity Index), or daytime functioning (e.g., fatigue, concentration, mood) (Cheung et al., 2024).
Clinical Comment
Navigating medication treatment options for insomnia can be complex for a patient and prescriber. Different people have different sleep problems, sleep onset insomnia, sleep maintenance insomnia, early morning awakening insomnia, a bit of everything…… and then there’s side effects.
This study adds a valuable piece to the puzzle by providing a quantitative comparison of risk and benefit for several common prescription sleep aids. What does it mean for you?
CBT-I First: Remember, non-drug behavioral therapies like CBT-I are still considered the gold standard first-line treatment for chronic insomnia (Qaseem et al., 2016; Riemann et al., 2017). Medication is typically recommended if CBT-I isn't available or doesn't provide sufficient relief. In saying that, an experienced CBT-i provider can also provide sleep medication tapers with CBTi which is an effective option for stopping sleep medications and minimises rebound insomnia.
Medication Choice is Individual: There's no single "best" sleep medication for everyone. This study provides useful comparative data, but the right choice depends on your specific sleep problem (trouble falling asleep, staying asleep, or both?), your medical history, other medications you take, your age, and your personal tolerance for potential side effects versus your desire for sleep improvement. That’s why it’s key to work with your doctor (see below).
Low-Dose Doxepin (HA) Shows Promise: Based on this analysis, low-dose doxepin offers a good balance of safety and efficacy, particularly for improving sleep maintenance (staying asleep) and increasing total sleep time, maybe especially in older adults. But it seems less helpful for falling asleep faster. Unfortunately doxepin (a histamine antagonist) is no longer available in NZ.
Older vs. Newer Meds: Older drugs like BZRAs and nBZRAs (Z-drugs) appear highly effective at improving subjective sleep but come with a higher burden of side effects. Newer DORAs seem to offer moderate efficacy with a better safety profile than the BZRAs/nBZRAs.
Ramelteon (MELA): Safe but Maybe Not So Effective? Ramelteon ranked as the safest option but showed very limited efficacy in this analysis, leading to the least favourable risk-benefit score. This is likely going to be the same for melatonin itself, and why Melatonin it is not recommended for insomnia by the American Academy of Sleep Medicine.
Talk to Your Doctor: This information can help you have a more informed discussion, but always make decisions about medication together with your healthcare provider. They can help you weigh the pros and cons in the context of your unique situation (remember, other medications can interact, and age and gender come with differing risks as well).
Talk To Us About Stopping Sleeping Pills: While finding the right sleeping pill may seem complex, it’s straightforward compared to reducing sleeping pill usage. We are helping people come off sleep medications all the time and it can be quite a painless process when done right.
The study was published in Journal of Sleep Research (Cheung et al., 2024)
Written By The Better Sleep Clinic
Reviewed By Dan Ford, Sleep Psychologist
FAQ: Prescription Sleeping Pills NZ
What are the most common types of sleeping pills available in New Zealand?
In New Zealand, the main types of prescription sleeping medications include:
Z-drugs (like zopiclone/Imovane)
Benzodiazepines (like temazepam)
Dual Orexin Receptor Antagonists (like lemborexant)
Over-the-counter options including antihistamines and melatonin
Which sleeping pill has the best safety profile?
Research shows that melatonin receptor agonists have the lowest rate of side effects, followed by low-dose antihistamines. However, safety isn't the only factor to consider - effectiveness matters too. The best balance between safety and effectiveness varies for each person.
How effective are Z-drugs like zopiclone for treating insomnia?
Z-drugs show strong effectiveness for improving sleep, ranking second in sleep improvement among all sleep medications. However, they also have the highest rate of side effects, with about 255 adverse events per 1,000 people above placebo rates.
What's the safest and most effective sleeping pill according to research?
Recent research suggests that low-dose doxepin (a histamine antagonist) offers the best balance of safety and effectiveness. However, this medication is no longer available in New Zealand. Among currently available options, newer medications like DORAs (Dual Orexin Receptor Antagonists) show a good balance of effectiveness with fewer side effects.
Should I try sleeping pills before CBT-I (Cognitive Behavioral Therapy for Insomnia)?
No. Clinical guidelines recommend CBT-I as the first-line treatment for chronic insomnia. While up to 90% of doctor visits for insomnia result in a sleeping pill prescription, CBT-I treats the underlying causes of insomnia rather than just the symptoms.
How long can I safely take sleeping pills?
Sleeping pills are designed for short-term use and clinical guidelines recommend they only be used as a short-term solution. Research on sleep medications primarily focuses on short-term effectiveness (from 2 nights to 6 months). Long-term use can lead to tolerance and dependency. Always follow your healthcare provider's guidance about duration of use.
Do sleeping pills work differently for different types of sleep problems?
Yes. Some medications work better for:
Trouble falling asleep (benzodiazepines work best)
Difficulty staying asleep (histamine antagonists are particularly effective)
Total sleep time (both benzodiazepines and histamine antagonists show good results)
Is melatonin effective for treating insomnia?
Research indicates that melatonin and melatonin-like medications show very limited effectiveness for treating insomnia. The American Academy of Sleep Medicine doesn't recommend melatonin for treating chronic insomnia due to its low effectiveness.
How do I choose the right sleeping pill for my situation?
The best choice depends on several factors:
Your specific sleep problem (trouble falling asleep vs. staying asleep)
Your age
Other medications you're taking
Your medical history
Personal tolerance for side effects Always consult with a healthcare provider to make this decision.
How can I safely stop taking sleeping pills?
Stopping sleeping pills should be done under medical supervision. Working with a CBT-I provider during the tapering process can help minimize rebound insomnia and make the transition smoother. Many people successfully stop sleeping pill use when following a structured approach.
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