When to Stop

• Complex sleep behaviors (Boxed Warning 2019): sleep-driving, sleep-eating, sleep-cooking, sleep-walking, making phone calls / texts / emails, sexual activity, gunshot wounds, drowning, hypothermia, fatal MVCs. Can occur after first dose, at lowest doses, with or without alcohol. Absolute contraindication if it has occurred previously on any Z-drug.
• Suicidal ideation / behavior — rare but documented; some cases coupled to sleep-amnestic state.
• Severe allergic reactions — angioedema, anaphylaxis (rare).
• Respiratory depression — substantially elevated when combined with opioids, alcohol, benzos. FDA has issued multiple safety communications.
• Seizures — typically only in heavy abuse cessation, but possible.
• Dependence + withdrawal — develops within 2–4 weeks of regular use; severity proportional to dose × duration; withdrawal can include seizure risk in heavy users.
• Death — most commonly in combination with alcohol, opioids, benzos, or in elderly falls. Standalone overdose deaths are uncommon but documented.
• First dose: complex sleep behavior risk is non-zero from dose 1 — co-bedding partner should be aware.
• First 2 weeks: dependence has not yet formed but tolerance to onset may already begin in some users.
• Beyond 4 weeks: dependence, rebound, and tolerance are likely; cognitive thinning starts to be subjectively noticeable in many users.
• Discontinuation: taper over ≥2 weeks for any user >4 weeks of nightly dosing; abrupt cessation produces worst rebound insomnia and risk of withdrawal seizures in heavy users.
• Elderly (>65): falls + dementia signal warrant strong avoidance per Beers Criteria 2023.