Dear Dr. Roach: I have occasional difficulty when going to sleep and/or getting back to sleep. I have tried Ambien, trazodone, clonazepam and Lunesta. All have their pros and cons.
My question regards sleep quality. I know there are several stages of sleep that we should go through and that the brain cleans out junk during sleep. Do these sleep aids still allow a person to go through the needed sleep stages and also allow the brain to clean itself? Are any of these meds better or worse than the others for occasional use? — S.H.
Dear S.H.: How much time we spend in the different stages of sleep is called sleep architecture. Just being asleep isn't enough; people need to have enough time in the different phases of sleep for optimal health.
For example, you refer to the body's waste removal system from the brain, called the glymphatic system. This system removes waste materials from the brain, including amyloid and tau proteins, and it's predominantly active in the N3 stage of non-rapid-eye-movement sleep (non-REM sleep, also called slow-wave sleep or deep sleep). You're quite right that many sleep medications affect sleep architecture, which is one major reason why many sleep experts recommend against the habitual use of sleep medications.
All the medicines you've used can affect sleep architecture. Ambien (zolpidem) and Lunesta (eszopiclone) are in the Z-drug class, which have small to moderate effects on sleep architecture with modest decreases in both REM and N3 sleep. Many people quickly become accustomed to using these drugs, but the occasional use of them presents a low risk.
Clonazepam is a benzodiazepine, which are among the worst offenders against sleep architecture due to their significant reduction in REM and N3 sleep. A reduction in REM sleep is associated with worsened heart disease and overall mortality, as well as emotional problems and dementia. I strongly recommend against the habitual use of benzodiazepines for sleep.
Trazodone actually increases N3 sleep and has no consistent effect on REM sleep, so it's commonly been recommended for sleep. Unfortunately, more recent studies have shown that some people can get used to the drug after only a few weeks, so it stops working as well. Furthermore, studies have only shown very small improvements (a few minutes' worth) in sleep duration. Many people feel very drowsy the following day, and older people are particularly at risk for falls. There are other uncommon but serious side effects, and I've mostly stopped prescribing trazodone to my patients.
Whenever possible, I avoid drugs for the treatment of insomnia. Cognitive behavioural therapy for insomnia is, at least, as effective as medication and has none of the medication-associated risks. There are free cognitive behaviourial therapy programs for insomnia (CBT-I) for mobile devices.
For people who don't do well with CBT-I or people who can't receive it, the medications that are currently considered the safest are low-dose doxepin and dual orexin receptor antagonists (DORAs), such as suvorexant (Belsomra). Both of these medications have minimal negative effects on sleep architecture, and they increase REM sleep. Unfortunately, DORAs are very expensive (around $500 per month, not often covered by insurance), compared to doxepin (less than $50 per month without insurance).
For millions of people, cannabis has become the unofficial prescription for lost sleep. But what feels like a solution may be quietly making the problem worse.
Consider these two cases:
She is 15 and has been lying in bed for the past hour. It is past midnight, and her brain will not quiet down. Her school bus comes at 6:20 a.m. She is getting anxious, knowing that she needs to wake up in six hours. She did all the right things: turned off her phone at 10 p.m., tried melatonin. So tonight she tries something a friend recommended: a cannabis gummy. Within 20 minutes, she’s asleep.
He is 34, a veteran who did two tours and has struggled with sleep since coming home. It takes him two hours to fall asleep, and when he does, he is jolted awake by relentless nightmares. He hasn’t slept more than three hours a night in months, and it’s catching up with him. His buddy swears that cannabis helped him, and with a six-month waiting list for a sleep consultation at the Veteran’s Affairs medical center and a cannabis dispensary six blocks away that’s open until 10 p.m., the decision doesn’t feel complicated.
Both will tell you cannabis works for their specific needs. They are not entirely wrong. But no one has told them what is actually happening inside the brain when the lights go out. It’s complex, and for them – as for many others – ultimately it’s a trap.
As a neurologist specializing in sleep and brain performance, I write this not as someone opposed to cannabis but as someone who regularly sees patients whose sleep has quietly unravelled after months or years of use, especially teenagers and veterans.
I believe the public deserves a more complete picture than they currently have due to the limited research that’s available.
A 2021 brain imaging study of 799 teenagers found that cannabis use was associated with dose-dependent thinning of the cerebral cortex – meaning the more cannabis a teenager used, the thinner their prefrontal cortex became. The prefrontal cortex is the region of the brain responsible for judgment, decision-making and impulse control. Thinning of the cortex in this region has been associated with increased impulsivity, poorer decision-making and reduced inhibitory control.
THC has a sedative effect at low doses but is stimulating at high doses. Cannabis also contains other cannabinoids – plant-derived compounds such as CBD and CBN that interact with a system in the body that produces its own cannabinoids and contributes to the sedative effects of cannabis.
In addition, falling asleep quicker is not the same as sleeping well. A 2025 review of the research to date found that cannabis does not consistently improve sleep overall, including how long people stay asleep or how restful that sleep is.
At this point many people are using cannabis not because it is working well, but because stopping feels worse.
Even when chronic cannabis users have the willpower to stop, they often face brutal withdrawal symptoms that are more severe than what drove them to cannabis in the first place. Sleep disturbance, including insomnia and disturbing dreams, is described as a common manifestation of cannabis withdrawal. In addition, two-thirds of users report other symptoms such as anxiety, depressed mood, restlessness, irritability, decreased appetite or a combination of these symptoms that often persist for weeks after stopping use.
This is the trap – it’s quiet and insidious, which makes it harder to see.
Cannabis works just enough to feel like a solution. Night after night it dulls the problem without fixing it, until stopping feels unthinkable. When someone finally tries to quit, their sleep falls apart. So they go back. The original reason they could not sleep has not been identified or treated, and it hasn’t gone away.
The developing brain is one kind of vulnerability. The traumatized brain is another.
Post-traumatic stress disorder affects an estimated 12% to 23% of post-9/11 veterans, compared with 6% to 8% of the general population. Sleep disturbances affect 70% to 90% of military personnel with PTSD. People with PTSD commonly have nightmares that are visceral, relentless and exhausting. They might be jolted awake with a pounding heart, multiple times a night, for years.
Because these withdrawal symptoms so closely mirror PTSD itself, many veterans interpret the return of symptoms as their condition worsening, not as withdrawal, so they go back to cannabis. And the cycle continues.
This therapy works by modifying sleep habits, regulating sleep-wake schedules, reducing arousal and reframing unhelpful beliefs about sleep. A form of treatment known as image rehearsal therapy, in which patients rewrite the storyline of a recurring nightmare and mentally rehearse the new version while awake, has been shown to be effective for veterans with trauma-related nightmares. But trained CBT-I providers are scarce, wait times are long, and most primary care settings do not offer it.
In other words, the people most vulnerable to the sleep-related harms of cannabis use are the least likely to have access to treatments that address the underlying problem, and the most likely to get caught in a negative cycle.
For those already caught in that cycle, quitting abruptly rarely works and often makes things worse. Research shows that CBT-I can reduce both insomnia and cannabis use at the same time – treating the root problem so cannabis no longer feels necessary.
Sleep is the foundation on which memory, mood, judgment and recovery are built.
The 15-year-old who cannot fall asleep and the veteran who wakes gasping at 3 a.m. both deserve evidence-based information about what is happening in their brains, and real access to care that treats the root cause.
Patients arrive medicated from primary care when the condition is chronic. Three specialists discuss how they help patients stop taking medication
More than six million people in Spain regularly consume hypnotic sedatives, such as sleeping pills or benzodiazepines. This is especially prevalent among women, increasingly younger, according to data from the Ministry of Health's Survey on Alcohol and Other Drugs. "We live in a country where more sleeping pills are consumed than anywhere else. The problem is that higher doses are needed over time due to tolerance, leading to abuse. In this case, the patient faces two issues: insomnia and abuse," says Carlos Egea, president of the Spanish Federation of Sleep Medicine Societies (Fesmes). "Each year, the proportion of people taking them increases," confirms Ainhoa Álvarez, president of the Spanish Sleep Society. "Most drugs used for insomnia, though not all, are benzodiazepines, which cause dependence and tolerance."
When they reach the specialist, patients with sleep problems are already medicated. "An insomnia patient sleeps poorly or little, struggles to fall asleep, or wakes up and cannot return to sleep, and then feels unwell during the day. A diagnosis must rule out other sleep disorders and confirm insomnia," Álvarez continues. "The issue is that by the time they reach the Sleep Unit, they have often already been through primary care and have been prescribed medication, which is the quickest way to sleep."
The use of these drugs begins before the age of 15 in Spain, with an average age of 46. The groups with the highest consumption have low educational levels and work in unskilled manual jobs, administrative roles, rural areas, social services, or are unemployed, according to the 'Conclusions of the Gender Working Group of the Spanish Council on Drug Addiction and Other Addictions'. "If after an evaluation we diagnose chronic insomnia, the first-line treatment is cognitive-behavioural therapy. If there is no response, it is combined with pharmacological treatment to address the underlying mechanisms and correct the disorder with medication," recommends Adolfo Alcoba, a member of the Sleep Alliance. "The question is what to do if there is already dependence and the patient has been taking medication for a long time and developed tolerance."
"There are two public health issues: general sleep problems and the high consumption of hypnotic sedatives."
The most common drugs for insomnia cause cognitive decline in the elderly, affect memory, create dependence, and require increasingly higher doses until they become ineffective, Alcoba states: "Here are two major public health issues. First, general sleep problems, affecting 40% of the population; and second, the high consumption of benzodiazepines and hypnotic sedatives. We need to reduce this percentage to a minimum. But if someone goes to their GP and says they can't sleep or wake up very tired, they are often given a pill by default. Can they stop taking it later?"
A person sitting on their bed at night. (R. C.)
This week, the Sleep Alliance presented the 'Practical Guide to Cognitive Behavioural Therapy for Chronic Insomnia', on psychological intervention in these cases, as the first level of care and to help stop these drugs. This guide outlines several steps: the patient must learn what induces sleep and how to manage these factors, develop a "sleep hygiene routine", control alert stimuli, and apply various measures during insomnia, restrict time in bed, and feel the "pressure of sleep, because if a person doesn't go to sleep and watches TV or uses their phone, they won't sleep and become more alert," says Alcoba, co-author of the study.
"Thoughts about their insomnia problem, which can be intrusive, are changed."
"It has two parts. In the behavioural part, the patient is taught to adopt more suitable behaviours to overcome insomnia, as sometimes we make it worse. For example, staying in bed for too long, hoping to fall asleep. So, we work to change these patient behaviours. In the cognitive part, thoughts about their insomnia problem, which can be intrusive or myths about sleep, are changed," Álvarez explains about a treatment that "is often not offered in the National Health Service. Ideally, this therapy would be provided in primary care."
Years Go By
Something that is not a myth is that insomnia increases with age. "Yes, because we have more problems as we age. Mr. Prostate, Mrs. Hot Flushes, Mr. Pain. Older people have fragmented sleep and not the continuous sleep we all desire. It's more complicated," Egea states. "The age range for sleeping seven to nine hours starts at twenty and goes up to 65, pressured by our working lives. Then comes retirement, which allows more time for sleep, but there are also doctors, anxiety... Each stage has its general problems."
With age, night-time awakenings become more frequent and especially "longer," says Álvarez. "When you're young or a child, you wake up several times at night; it's normal to wake up three or four times. But we turn over, go back to sleep, and don't remember because it lasted thirty seconds or a minute. But when awakenings are longer, we are more aware and have less deep and shorter sleep. Sleep also changes with age. An elderly person may sleep less than two hours at night but take one or two naps, mid-morning and mid-afternoon."
One or Two Naps
Is it beneficial and advisable to take a nap? The experts' answer is 'yes'. "Napping is good, but always short. Less than 30 minutes," Álvarez maintains. "Our brain is programmed to nap, but if it's too long, it will take away from night-time sleep. We tell insomnia patients not to nap for more than 30 minutes, although it depends on each case. Some people work nights, sleep little, and then take a long nap. So, everyone has to adapt their lifestyle."
Egea agrees: "It's only good for about half an hour. The nap complements a little but doesn't replace night-time sleep. It doesn't take away from night-time sleep afterwards, but if you're an insomniac, we don't recommend it."
