Vikas Jain, MD, FAASM, FAAFP, CCSH, CPE

Real-World Clinical Insights Regarding Chronic Insomnia Treatments

In clinical experience, dual orexin receptor antagonists (DORAs) have demonstrated strong efficacy and tolerability for treating insomnia. Patients commonly report improvements in both initiating and maintaining sleep without experiencing significant adverse effects. Unlike some older medications, DORAs are generally not associated with issues like excessive daytime sleepiness, parasomnias, or cognitive impairment. This makes them a favorable option for those seeking both effectiveness and minimal disruption to daytime functioning.

When selecting a treatment for insomnia, several factors guide the choice of medication. Historically, benzodiazepines were widely used, but concerns over their potential for dependence, tolerance, and withdrawal have led to more cautious use. While Z-drugs (nonbenzodiazepine hypnotics) present a lower risk in some respects, emerging research has raised concerns about their long-term effects, including possible links to cognitive decline. Melatonin receptor agonists are another option, but they may be less potent for certain types of insomnia. In contrast, DORAs offer a balance of efficacy and safety, showing positive results in reducing insomnia symptoms without many of the risks associated with older drug classes.

Due to this favorable profile, DORAs are now often considered a first-line treatment option for chronic insomnia. Their ability to promote sleep by targeting the wakefulness system—rather than inducing sedation—may also align more closely with the underlying causes of insomnia for many patients. However, access to these medications can sometimes be affected by insurance coverage or payer approval, which may influence the final prescribing decision. Overall, the combination of clinical benefit and a relatively clean safety profile positions DORAs as a preferred choice in modern insomnia management.

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A panelist discusses the strong efficacy and tolerability of dual orexin receptor antagonists (DORAs) for insomnia, noting their minimal adverse effects compared to older medications like benzodiazepines. DORAs are now seen as a first-line treatment option due to their favorable balance of safety and effectiveness, although insurance coverage can influence their availability.

DORA Class for Treating Insomnia

A newer class of medications, known as dual orexin receptor antagonists (DORAs), has emerged as a treatment option for insomnia. Unlike traditional sleep aids that act on GABA receptors to promote sedation and sleepiness—such as benzodiazepines or similar agents—DORAs work by targeting a different mechanism. They inhibit the action of orexin, a chemical that helps regulate wakefulness. Many people with insomnia don't necessarily lack sleepiness but instead struggle with excessive alertness or a racing mind at night. By reducing the activity of wake-promoting signals, these medications aim to make it easier for natural sleep to occur.

When discussing the onset of action for these newer medications, it’s important to help patients understand how they differ from older sleep aids. Traditional medications might cause a noticeable sedative effect soon after taking them, creating an immediate sense of drowsiness. In contrast, DORAs do not create that same pronounced feeling. Instead, they subtly lower wakefulness without artificially boosting sleep pressure. As a result, patients may mistakenly think the medication isn’t working if they don’t feel an immediate “sleepy” sensation. Education about this distinction, along with information from clinical studies showing that improvements may unfold over several weeks or even months, helps reinforce realistic expectations.

To support adherence in the first weeks of therapy, setting the right expectations from the beginning is crucial. Patients are encouraged not to judge the medication’s effectiveness based on the first night alone, especially since anticipation or stress about the new treatment might interfere with sleep. Additionally, those transitioning from one medication to another may experience temporary worsening of sleep, known as rebound insomnia. For this reason, it is often recommended to allow at least 2 weeks before evaluating whether a new sleep aid is truly beneficial, avoiding premature changes and promoting consistent use.

A panelist discusses how dual orexin receptor antagonists (DORAs) offer a novel approach to treating insomnia by reducing wakefulness rather than inducing sedation, highlighting the importance of patient education on their gradual onset, distinct mechanism, and the need for consistent use to achieve long-term benefits.

Common Challenges in Chronic Insomnia Management

One of the major challenges in addressing chronic insomnia is managing patient expectations regarding the timeline for improvement. By definition, chronic insomnia lasts for at least three months, and many individuals may have been struggling with poor sleep for years. Despite this, there is often a belief that the condition can be resolved within just a few nights of treatment. Helping patients understand that recovery is a gradual process is essential. The goal is not an immediate cure, but a steady return to more restorative sleep over time.

Many patients expect that sleep medications will provide instant relief, with noticeable effects on the very first night. While some medications may begin to offer benefits quickly, the primary objective is to improve sleep patterns consistently over the course of several weeks. To help set realistic expectations, analogies can be useful—for example, comparing the process to preparing for a marathon. Just as someone who has been inactive for months cannot expect to run a marathon without training, a person with chronic sleep difficulties needs time and consistent effort to rebuild healthy sleep habits.

Evaluating the effectiveness of treatment involves both standardized tools and patient feedback. Questionnaires like the Epworth Sleepiness Scale can be used to measure improvements in daytime sleepiness, offering a validated way to assess next-day functioning. In addition to these metrics, simple conversations about how a patient feels on the medication—such as whether they are more alert or able to function better during the day—are equally valuable. These strategies help build a complete picture of treatment progress, reinforcing the idea that improvement is ongoing and may include occasional setbacks as part of a broader trend toward better sleep.

A panelist discusses how managing chronic insomnia requires setting realistic patient expectations around gradual improvement, emphasizing consistent effort over time, and using both clinical tools and patient feedback to assess progress toward more restorative sleep.

Chronic Insomnia Diagnosis and Management

A comprehensive, multifaceted approach is essential in managing chronic insomnia. The initial step involves obtaining a detailed sleep history to understand the patient’s sleep patterns, including bedtime, wake time, sleep latency, and nighttime awakenings. Particular attention is paid to what the patient does during periods of wakefulness—whether they stay in bed, use electronic devices, or watch television—as these behaviors can contribute to ongoing sleep disturbances. Evaluating how long the patient has been experiencing symptoms and the amount of time spent in bed each night helps inform the choice of intervention strategies.

Both pharmacologic and nonpharmacologic treatments are utilized, with an emphasis on identifying and managing any coexisting sleep disorders. A sleep study is often performed early in the assessment to rule out or diagnose comorbid conditions that might be impacting sleep quality. Nonpharmacologic therapy plays a central role, especially cognitive behavioral therapy for insomnia (CBT-I), which is recommended for most patients. This evidence-based treatment targets the thoughts and behaviors that perpetuate insomnia and is considered a first-line intervention.

When medication is indicated, treatment typically involves the use of FDA-approved pharmacologic options. These may include benzodiazepine receptor agonists or newer agents such as dual orexin receptor antagonists, depending on the patient’s needs and medical profile. Pharmacologic treatments are generally used alongside behavioral therapies rather than as standalone solutions. This integrated approach, combining behavioral modification with appropriate pharmacotherapy, aims to address both the symptoms and underlying causes of insomnia, leading to more effective and sustainable outcomes.

A panelist discusses how managing chronic insomnia requires a comprehensive, multifaceted approach that integrates behavioral interventions like CBT-I with pharmacologic treatments, guided by thorough sleep assessments and tailored to each patient’s specific sleep patterns and comorbid conditions.

Vikas Jain, MD, FAASM, FAAFP, CCSH, CPE

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