13 Zopiclone alternative drugs for sleeping

Drug availability towards the end of the year has been challenging. Essential drugs like antibiotics (capsules, tablets, and liquid formulations for children) have been short in supply in the UK. The supply of zopiclone tablets has been affected by the temazepam shortage and other market conditions. Initially, in response to the temazepam shortage, zopiclone 3.75mg tablets became out of stock and now, zopiclone 7.5mg tablets followed. Regardless of the reason, this post is for anyone looking for zopiclone alternative drugs for sleeping.

Zopiclone – drug classification

Zopiclone is a prescription-only medication (POM) which is classified as a non-benzodiazepine hypnotic, commonly called Z-drugs. Zopiclone and other z-drugs are similar to benzodiazepines in their mechanism of action, acting on the same receptors in the brain.

Legally, zopiclone is classified as schedule 4 (part 1 controlled drug). Some restrictions apply to schedule 4 controlled drugs:

• Prescriptions issued for controlled drugs are valid for 28 days from the issue date
• The total quantity of supplied drug should not exceed 30 days unless special circumstances apply.

Zopiclone shortage: what to do?

Patients who had their zopiclone sent to a pharmacy on electronic prescription (EPS) may transfer a prescription to another pharmacy, providing no other drugs were dispensed and collected from the same prescription.

With the current shortage (December ’22) of zopiclone 3.75mg tablets, it is highly unlikely to get any supply in any pharmacy since 3.75mg tablets have been out of stock since the end of November and all main pharmaceutical suppliers are out of stock. Zopiclone 7.5mg tablets went out of stock the week beginning of 05/12. Some pharmacies may have ordered extra stock which may last over the next couple of weeks. Patients who were prescribed zopiclone 3.75mg need to contact their GP and ask to issue a prescription for 7.5mg tablets with an amended dosage.

Zopiclone out of stock – Update 02/23

Zopiclone 3.75mg tablets have been continuously out of stock. One email from the NHS Optimisation Team suggests the possible availability of zopiclone 3.75mg at the end of February 2023. Zopiclone is not discontinued. During February zopiclone 3.75mg and 7.5mg came back in stock.

Zopiclone out of stock – Update 03/23

At the beginning of March zopiclone 7.5mg went out of stock. No further information is provided on the timescale of the shortage.

Zopiclone shortage: when is zopiclone coming back in stock?

When a drug is out of stock, pharmaceutical wholesalers do not provide possible re-supply dates. When a shortage is expected to last a few weeks or longer, NHS may provide information on re-supply dates directly from manufacturers. This has not happened yet.

What is the preferred drug treatment option for insomnia?

The use of any prescription sleeping pills is only recommended if insomnia is severe and causes extreme distress. Additionally, the use of drugs for insomnia is recommended short-term and only when non-drug measures have not been successful.

A non-benzodiazepine hypnotics (Z-drugs) are preferred in the management of insomnia over hypnotics like diazepam (NICE, 2022). Benzodiazepines may be considered as a first-line treatment if insomnia is associated with daytime anxiety (NICE BNF, 2022).

Zopiclone alternative drugs

The first zopiclone alternative which may be prescribed by a GP is zolpidem since it belongs to the same class of Z-drugs. Only three drugs belong to the class of Z-drugs: zopiclone, zolpidem and zaleplon.

1. Zolpidem

Like zopiclone, zolpidem is used for short-term treatment of insomnia in adults in situations where the insomnia is debilitating or is causing severe distress for the patient (emc, 2022). Zolpidem comes in two different strengths, zolpidem 5mg tablets and 10mg tablets. Zolpidem is also available as a branded medication called Stilnoct (Zolpidem 10mg).

2. Zaleplon (discontinued)

Zaleplon is also classified as a Z-drug. In 2015, the European Commission withdrew the marketing authorisation for Sonata in Europe at the request of the company which produced Sonata due to commercial reasons (EMA, 2015).

Use of benzodiazepine for insomnia

As discussed, benzodiazepines are not the preferred drugs in the management of insomnia. Benzodiazepines can cause dependence (addiction), withdrawal symptoms on discontinuation and next-day sedation due to a longer mechanism of action compared to Z-drugs. There are many benzodiazepines available in the UK. Not all of them are licensed for the short-term management of insomnia.

3. Diazepam as zopiclone alternative

Diazepam is most commonly prescribed benzodiazepine. Diazepam is mainly prescribed for anxiety, and insomnia, but also muscle spasms. Most commonly diazepam is prescribed in the form of tablets. Different diazepam tablets are available: 2mg, 5mg and 10mg tablets.

Related post: Temazepam vs Diazepam for sleeping.

4. Nitrazepam

Although licensed for insomnia, the use of nitrazepam in recent years has been on the decrease. Nitrazepam is mainly prescribed in form of tablets, 5mg and 10mg tablets are available.

5. Loprazolam

Classified as benzodiazepine, loprazolam is not commonly prescribed overall. One driving factor for limited loprazolam prescribing is the price of the drug, which is about 15x higher than that of zopiclone.

Loprazolam is available only in form of 1mg tablets.

6. Flurazepam

Flurazepam is another benzodiazepine solely licensed for the management of insomnia. Flurazepam is known under the branded name Dalmane. Dalmane comes in two different strengths, 15mg and 30mg capsules.

Dalmane is cannot be prescribed on NHS prescription. Patients can obtain Dalmane by having it prescribed privately.

7. Melatonin

Melatonin offers a different approach to insomnia treatment. Melatonin is a hormone produced in the brain, which is responsible for the sleep-wake cycle. Melatonin is mainly prescribed as a branded product Circadin. Each prolonged-release tablet of Circadin contains 2mg of melatonin.

Circadin is licensed for the management of insomnia in adults over 55 years of age, however, Circadin is commonly prescribed for children (unlicensed use).

The advantage of melatonin over all other prescribed sleeping tablets is non-dependence (does not cause addiction) and lack of withdrawal symptoms.

8. Temazepam

Occasionally, temazepam is considered in the management of insomnia. Temazepam was out of stock for a few months, however, it came back in stock at the beginning of 2023. Read more about the temazepam shortage.

Read more about temazepam: Temazepam vs Diazepam for sleeping.

Over the counter sleeping tablets alternative to zopiclone

Some patients may be prescribed sedative antihistamines, which are also available without a prescription. Sedative antihistamines are commonly purchased from pharmacies for temporary help with sleeping problems. All sleeping aid medicines which are used for sleeping contain first-generation antihistamines, which are characterised by profound sedation.

9. Over the counter promethazine as an alternative to zopiclone

Promethazine hydrochloride can be purchased over the counter without a prescription. Patients can also be prescribed promethazine. The most common brand of promethazine hydrochloride is Phenergan.

Phenergan is available in form of 10mg and 25mg tablets. In addition to the management of insomnia, Phenergan can be used for allergies including allergic rhinitis, urticaria (skin itchiness and rashes) and anaphylactic reactions to drugs and other allergens.

Phenergan Nigh twhich contains 25mg of promethazine is only licensed for the treatment of insomnia in adults and children over 16 years of age.

In the last few months, Phenergan has been out of stock.

Related post: Promethazine alternative drugs for sleeping.

10. Generic promethazine hydrochloride

Generic forms of promethazine 10mg and 25mg tablets are available. Due to the shortage of promethazine, the price of generic promethazine skyrocketed. A box of promethazine 25mg tablets (56 tablets) costs about £58 (standard markup included). Some pharmacies may not dispense generic promethazine since the reimbursement price paid by the Department of Health and Social Care (DHSC) is much lower than the current price of this drug.

Promethazine is included as an active ingredient if a few cold & flu products which can be purchased in pharmacies, for example, Night Nurse.

11. Over the counter Sominex

Sominex is licensed for short-term management of sleeping. Available as pharmacy-only mediation Sominex tablets contain 20mg of promethazine hydrochloride. Despite the shortage of promethazine hydrochloride, Sominex is still available in pharmacies and at a low cost.

Related post: Sominex vs Nytol for sleeping

12. Promethazine Teoclate

Promethazine teoclate is very similar to promethazine hydrochloride. Promethazine teoclate is available as a branded product called Avomine tablets. Avomine tablets are licensed for the management of travel sickness. Due to the same mechanism of action as promethazine hydrochloride, Avomine tablets cause sedation and recently have been prescribed instead of promethazine hydrochloride.

Avomine tablets are much cheaper than Phenergan and generic promethazine hydrochloride. Even during the shortage of zopiclone and promethazine hydrochloride, Avomine tablets cost less than £3 for a box of 10 tablets.

13. Over the counter diphenhydramine as an alternative to zopiclone

Diphenhydramine is another over the counter option for the short-term management of insomnia. Diphenhydramine is mostly known as a branded product called Nytol. Nytol comes in two different forms, Nytol Original (contains 25mg of diphenhydramine) and Nytol One A Night, which contains 50mg of diphenhydramine.

Some generic sleeping tablets containing diphenhydramine are available in pharmacies for example Sleep Aid. Diphenhydramine has good availability with prices which have not changed since the shortage of promethazine

FAQ

Is there a substitute for zopiclone?

Zopiclone belongs to a group of hypnotic drugs called Z-drugs. The only other Z-drug available in the UK is zolpidem, which may be considered as zopiclone substitute.

Can you take zopiclone for years?

Zopiclone and other hypnotics may cause dependance and withdrawal symptoms. Z-drugs and hypnotics (like diazepam) should only be used as short-term relief of sleeping problems.

Is melatonin safer than zopiclone?

Melatonin can be called safer than zopiclone. Melatonin is a natural hormone which plays role in sleep-awake cycle. Unlike zopiclone, melatonind does not cause dependence or withdrawal symptoms.

References:

EMA (2015). Sonata: Withdrawal of the marketing authorisation in the European Union. Available at: https://www.ema.europa.eu/en/documents/public-statement/public-statement-sonata-withdrawal-marketing-authorisation-european-union_en.pdf Accessed on 06/12/2022

emc (2022). SmPC: Zolpidem Tartrate 10mg Tablets. Available at: https://www.medicines.org.uk/emc/product/3975/smp Accessed on 06/12/2022.

NICE (2022). Insomnia: Scenario: Managing short-term insomnia (less than 3 months duration). Available at: https://cks.nice.org.uk/topics/insomnia/management/managing-short-term-insomnia-less-3-months/ Accessed on 06/12/2022

NICE BNF (2022). Hypnotics and anxiolytics. Available at: https://bnf.nice.org.uk/treatment-summaries/hypnotics-and-anxiolytics/ Accessed on 06/12/2022