Switching off benzodiazepines and z-hypnotics works best in the first year, not the fifth
STUDY: Ayani N et al, Sleep Medicine 2026
STUDY TYPE: Retrospective cohort study
FUNDING: Independent
Background
Benzodiazepine receptor agonists (BZRAs) include traditional benzodiazepines (temazepam, lorazaepam) and z-hypnotics (zolpidem, zaleplon, and eszopiclone).
They work well for insomnia, but long-term use brings dependence, falls, and cognitive fog, especially in older adults. Newer hypnotics, including the orexin blockers suvorexant and lemborexant and the melatonin agonist ramelteon, carry fewer risks. The question is whether adding one of these actually gets patients off their benzodiazepine or just adds a pill.
The Study
- 190 outpatients across two Japanese hospitals who started a novel hypnotic while already on a BZRA hypnotic.
- No control group. Researchers tracked each patient’s own BZRA use before and after starting the novel hypnotic.
- Followed for a median of 12 months.
- Main outcome: did the patient drop at least one BZRA hypnotic?
Results
Just under half (46%) cut back on their BZRA, and 34% stopped it completely. Patients who’d used a BZRA for less than a year succeeded 69% of the time. Those on it a year or more succeeded only 36% of the time. After adjusting for other factors, the odds of successfully cutting back were about a fifth as high in patients with 1 to 5 years of prior use, and a sixth as high with 5 or more years, compared with new or occasional users.
Limitation
No control group, no blinding, retrospective.
Practice Implications
- When switching to a new hypnotic from a BZRA, cross taper over at least two weeks, and longer if they’ve been on that BZRA for more than a year.
- Advise patients that they may not feel the new medication the same way. It doesn’t hit as strong, but most of them improve sleep quality with a stronger effect. “Look at how you function the next day, not just how quickly you fall asleep on it.”
- Unfortunately, it is in older adults where switching to safer sleep meds is most critical, and this is where chronic use of BZRAs is more common.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
6 comments
DavidTwinvegas.us
July 21, 2026 at 7:52 am
Timing really does seem crucial with sleep meds. How do you find the right balance when switching?
Arnold Chien
July 24, 2026 at 12:16 am
I usually recommended swithcing when the patients complained of cognitive side effects, which might serve as a strong motivation for change.
Chris Aiken, MD
July 24, 2026 at 8:10 am
Good point!
Eric H
July 22, 2026 at 12:16 pm
While BZ’s can definitely help you fall asleep faster, they tend to decrease the overall quality of sleep by affecting the sleep stages. So even if you think that you slept a good 8 hours, you may still feel unrefreshed and for longer acting ones, may have lingering morning grogginess. Trazodone at a low dose is a better option to try. With it’s effect on 5HT-2A receptors, some research suggests it may enhance sleep quality.
Chris Aiken, MD
July 22, 2026 at 2:54 pm
Yes very wise words on difference between subjective and objective sleep
Kate Gates
July 25, 2026 at 12:11 am
As a psych NP and a patient who struggles with insomnia, I wish I had never started Ambien. I’m trying to make the switch from Ambien to Dayvigo. It’s rough. And by rough, I mean it feels impossible. We have better studies now, we know better. I think the key becomes keeping the z hypnotic use very minimal or not at all. CBT- I and working on stimulus control is the answer but it’s the hardest prescription to enforce.