Z-Drugs

Z-drugs — zolpidem, zaleplon and eszopiclone — are prescription sleeping pills that work well at first. Used for longer, they are tied to hip fractures and dependence, and rarely to sleep-driving and other complex sleep behaviours serious enough to earn the US regulator's strongest warning.

Use a Z-drug only short term — the European guideline says four weeks at most where possible — and never restart one after a sleep-driving or sleep-walking episode. If you have been taking one for a long time, a slow, supported taper works more often than people expect; never stop abruptly.

What they are, and how well they work

Z-drugs are prescription sleeping pills. They are effective in the short term, but the American sleep-medicine guideline recommends them only weakly, and only for short periods.^[1] The European insomnia guideline endorses them for short-term use only, and says to limit them to four weeks where possible.^[2]

Eszopiclone holds up better than most sleeping pills over time. The largest comparison, pooling 170 randomised trials of 36 treatments, found sustained benefit beyond placebo for only two drugs, eszopiclone and the orexin blocker lemborexant — though the same analysis warned that eszopiclone might cause substantial side effects. For zolpidem and zaleplon it found no such long-term evidence.^[3]

For chronic insomnia, cognitive behavioural therapy for insomnia (CBT-I) comes first, ahead of any pill; see Treating chronic insomnia.

Hip fractures

Pooled observational studies put the relative risk of hip fracture 90% higher for Z-drug users than non-users — higher than the 52% for benzodiazepine users, not lower. In the first weeks of a new prescription the risk was more than double for either kind of pill.^[4]

These are observational data. People who are prescribed sleeping pills are often already frailer and sleeping worse, which inflates the figure. But the spike in new users is hard to explain away, and in an older adult a hip fracture carries substantial mortality.

Sleep-driving and other complex sleep behaviours

Sleep-driving, sleep-eating and sleep-walking on a Z-drug are rare, but serious enough that the US Food and Drug Administration put a boxed warning, its strongest, on zolpidem, eszopiclone and zaleplon. It also made a previous episode an outright contraindication.^[5] Rare is not the same as minor: if it has happened once, the drug should not be restarted.

Who should be especially careful

Older adults. Avoid Z-drugs, benzodiazepines and antihistamine sleep aids where possible; where a drug is needed, an orexin blocker or very low-dose doxepin is the usual choice — for fewer known harms, not proven safety. A 2025 model projected that if Americans over 50 stopped prescription sleep medication, their lifetime falls would drop 8.5% — but it is a model built on observational risks, and some of the harm it assigns to the drugs may belong to the insomnia.^[6]
Anyone who might have sleep apnea. A sleeping pill risks treating the symptom of a condition that hasn't been diagnosed yet; see Sleep-disordered breathing.

Coming off

Getting off is more achievable than people expect. Across sixteen studies that gave patients themselves the information and a tapering plan, roughly a fifth to two-thirds of long-term users in their late sixties and older came off benzodiazepines or Z-drugs. Most of those studies were at high risk of bias, so treat the range as encouraging rather than precise.^[7]

The route is a slow taper with clinician support, ideally alongside CBT-I.

What to do

Keep it short: four weeks at most where possible, for a crisis or as a bridge while CBT-I starts.
Stop for good after any complex sleep behaviour — sleep-driving, sleep-eating or sleep-walking.
If you are older, avoid it where possible; the fracture risk is highest in the first weeks of a new prescription.
If you have taken one for months or years, plan a slow taper with your doctor, alongside CBT-I.