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Hypnotic Discontinuation in Chronic Insomnia. Sleep Med Clin 2022; 17:523-530. [PMID: 36150811 DOI: 10.1016/j.jsmc.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Insomnia disorder is common in adults and children. The estimated prevalence ranges from 9% to 15% in the general population, with higher prevalence in certain subpopulations. Hypnotic medications are those that tend to produce sleep and are frequently used to treat insomnia. Commonly used hypnotics in adults include benzodiazepines (BZDs), BZD receptor agonists, antihistamines, antidepressants, melatonin receptor agonists, orexin receptor antagonists, and antipsychotics. However, hypnotic discontinuation is difficult and often unsuccessful. This article discusses strategies to discontinue hypnotics and evidence supporting their use.
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Narisawa H, Inoue Y, Kobayashi M, Okajima I, Kikuchi T, Kagimura T, Matsui K, Inada K, Mishima K. Development and validation of the Benzodiazepine Hypnotics Withdrawal Symptom Scale (BHWSS) based on item response theory. Psychiatry Res 2021; 300:113900. [PMID: 33812220 DOI: 10.1016/j.psychres.2021.113900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
This study aimed to refine and validate the Benzodiazepine Hypnotics Withdrawal Symptom Scale (BHWSS). The 12-item prototype version of the BHWSS was administered to a sample of 346 patients with chronic insomnia (161 males and 185 females, mean age: 52.8 ± 16.6 years) who had been taking hypnotics (benzodiazepines [BZDs] or BZD receptor agonists) for at least 3 months. The item information curve indicated that two of the 12 BHWSS items should be excluded. As a result of analyzing the 10-item version of the BHWSS (revised-BHWSS), the contribution rate in the case of the factor 1 was 0.49, Cronbach's α was 0.90, and the reliability coefficient ω was 0.91. An analysis of the item information curve for the revised-BHWSS indicated that the information amount per item increased from 3.90 for the original 12-item BHWSS to 4.37 for the 10-item revised-BHWSS. The receiver operating characteristic curve indicated that 6.5 points on the revised-BHWSS was the most appropriate cutoff for estimating moderate or severe withdrawal symptoms using the Benzodiazepine Dependence Self-Report Questionnaire as a reference. These results suggest that the 10-item revised-BHWSS has sufficient reliability and validity for evaluating the severity of withdrawal symptoms after discontinuing BZDs.
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Affiliation(s)
- Hajime Narisawa
- Department of Psychology, Aichi Shukutoku University, 2-9 Katahira, Nagakute-shi, Aichi 480-1197 Japan; Institute of Neuropsychiatry, Japan Somnology Center, Tokyo, Japan, 1-24-6 Yoyogi, Shibuya-ku, Tokyo 151-0053 Japan
| | - Yuichi Inoue
- Institute of Neuropsychiatry, Japan Somnology Center, Tokyo, Japan, 1-24-6 Yoyogi, Shibuya-ku, Tokyo 151-0053 Japan; Department of Somnology, Tokyo Medical University, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo 160-8402 Japan; Foundation of Sleep and Health Science, Tokyo, Japan, 1-24-6 Yoyogi, Shibuya-ku, Tokyo 151-0053 Japan.
| | - Mina Kobayashi
- Institute of Neuropsychiatry, Japan Somnology Center, Tokyo, Japan, 1-24-6 Yoyogi, Shibuya-ku, Tokyo 151-0053 Japan; Foundation of Sleep and Health Science, Tokyo, Japan, 1-24-6 Yoyogi, Shibuya-ku, Tokyo 151-0053 Japan
| | - Isa Okajima
- Institute of Neuropsychiatry, Japan Somnology Center, Tokyo, Japan, 1-24-6 Yoyogi, Shibuya-ku, Tokyo 151-0053 Japan; Department of Psychological Counseling, Faculty of Humanities, Tokyo Kasei University, 1-18-1 Kaga, Itabashi-ku, Tokyo 173-8602, Japan
| | - Takashi Kikuchi
- Translational Research Information Center, 1-5-4 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Tatsuo Kagimura
- Translational Research Information Center, 1-5-4 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Kentaro Matsui
- Institute of Neuropsychiatry, Japan Somnology Center, Tokyo, Japan, 1-24-6 Yoyogi, Shibuya-ku, Tokyo 151-0053 Japan; Department of Psychiatry, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo Japan
| | - Ken Inada
- Department of Psychiatry, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita-shi, Akita 010-8543 Japan; International Institute for Integrative Sleep Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba-shi, Ibaraki 305-8575 Japan
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Abstract
Patients with chronic insomnia are commonly prescribed hypnotic medications. The long-term effects of chronic hypnotics are not known and discontinuation is encouraged but often difficult to achieve. A gradual taper is preferred to abrupt cessation to avoid rebound insomnia and withdrawal symptoms. Written information provided to the patient about medication discontinuation may be helpful. Cognitive behavioral therapy or behavioral therapies alone can improve hypnotic discontinuation outcomes. There is limited evidence for adjunct medications to assist in hypnotic cessation for insomnia.
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Affiliation(s)
- Jonathan P Hintze
- Division of Pediatric Sleep Medicine, University of South Carolina School of Medicine-Greenville, Greenville Health System, 200 Patewood Drive, Suite A330, Greenville, SC 29615, USA.
| | - Jack D Edinger
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
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Pollmann AS, Murphy AL, Bergman JC, Gardner DM. Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review. BMC Pharmacol Toxicol 2015; 16:19. [PMID: 26141716 PMCID: PMC4491204 DOI: 10.1186/s40360-015-0019-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 06/23/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Long-term sedative use is prevalent and associated with significant morbidity, including adverse events such as falls, cognitive impairment, and sedation. The development of dependence can pose significant challenges when discontinuation is attempted as withdrawal symptoms often develop. We conducted a scoping review to map and characterize the literature and determine opportunities for future research regarding deprescribing strategies for long-term benzodiazepine and Z-drug (zopiclone, zolpidem, and zaleplon) use in community-dwelling adults. METHODS We searched PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, CINAHL, TRIP, and JBI Ovid databases and conducted a grey literature search. Articles discussing methods for deprescribing benzodiazepines or Z-drugs in community-dwelling adults were selected. RESULTS Following removal of duplicates, 2797 articles were reviewed for eligibility. Of these, 367 were retrieved for full-text assessment and 139 were subsequently included for review. Seventy-four (53%) articles were original research, predominantly randomized controlled trials (n = 52 [37%]), whereas 58 (42%) were narrative reviews and seven (5%) were guidelines. Amongst original studies, pharmacologic strategies were the most commonly studied intervention (n = 42 [57%]). Additional deprescribing strategies included psychological therapies (n = 10 [14%]), mixed interventions (n = 12 [16%]), and others (n = 10 [14%]). Behaviour change interventions were commonly combined and included enablement (n = 56 [76%]), education (n = 36 [47%]), and training (n = 29 [39%]). Gradual dose reduction was frequently a component of studies, reviews, and guidelines, but methods varied widely. CONCLUSIONS Approaches proposed for deprescribing benzodiazepines and Z-drugs are numerous and heterogeneous. Current research in this area using methods such as randomized trials and meta-analyses may too narrowly encompass potential strategies available to target this phenomenon. Realist synthesis methods would be well suited to understand the mechanisms by which deprescribing interventions work and why they fail.
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Affiliation(s)
- André S Pollmann
- Faculty of Medicine, Dalhousie University, Mail Box #259, 5849 University Avenue, Room C-125, PO Box 15000, Halifax, NS, B3H 4R2, Canada.
| | - Andrea L Murphy
- College of Pharmacy and Department of Psychiatry, Dalhousie University, 5968 College St, PO Box 15000, Halifax, NS, B3H 4R2, Canada.
| | - Joel C Bergman
- College of Pharmacy and Department of Psychiatry, Dalhousie University, 5968 College St, PO Box 15000, Halifax, NS, B3H 4R2, Canada.
| | - David M Gardner
- Department of Psychiatry and College of Pharmacy, Dalhousie University, QEII HSC, AJLB 7517, 5909 Veterans' Memorial Lane, Halifax, NS, B3H 2E2, Canada.
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Staner L, Danjou P, Luthringer R. A new sublingual formulation of zolpidem for the treatment of sleep-onset insomnia. Expert Rev Neurother 2014; 12:141-53. [DOI: 10.1586/ern.11.197] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Victorri-Vigneau C, Dailly E, Veyrac G, Jolliet P. Evidence of zolpidem abuse and dependence: results of the French Centre for Evaluation and Information on Pharmacodependence (CEIP) network survey. Br J Clin Pharmacol 2007; 64:198-209. [PMID: 17324242 PMCID: PMC2000636 DOI: 10.1111/j.1365-2125.2007.02861.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
AIM To show that the nonbenzodiazepine hypnotic zolpidem has a higher abuse potential than previously documented. METHOD An official enquiry was carried out by the Nantes Centre for Evaluation and Information on Pharmacodependence (CEIP). The authors made a review of literature and analysed French data corresponding to the drug's postmarketing period collected by the CEIP network from 1993 to 2002. RESULTS The literature review yielded mixed results concerning the behavioural effects of zolpidem. Data from the CEIP and the 53 literature case reports highlight significant dependence and abuse potential of zolpidem. CONCLUSIONS This study adds to the growing evidence that zolpidem has the potential for abuse and dependence. As a consequence, the French drug monograph has been modified by the French Health Authorities.
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Lemoine P, Kermadi I, Garcia-Acosta S, Garay RP, Dib M. Double-blind, comparative study of cyamemazine vs. bromazepam in the benzodiazepine withdrawal syndrome. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30:131-7. [PMID: 16243418 DOI: 10.1016/j.pnpbp.2005.08.015] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2005] [Indexed: 10/25/2022]
Abstract
Cyamemazine is an anxiolytic antipsychotic, which reduces ethanol withdrawal symptoms. Here, we investigated if cyamemazine can be also effective as substitute drug to facilitate benzodiazepine withdrawal. A total of 168 patients treated with benzodiazepines for at least 3 months and with a <18 score in the Hamilton Anxiety Rating Scale (HARS) were included in the study. Previous benzodiazepine treatment was withdrawn, and patients were randomized to a 4-week treatment with cyamemazine (25-50 mg q.d.) or bromazepam (3-6 mg q.d.), followed by 2 weeks of placebo. The primary efficacy variable was the maximal anxiety rebound as measured with the HARS during the 42 days of treatment. No statistically significant differences between treatment groups were found for the extent or incidence of rebound anxiety. Considering all dropout patients as withdrawal failures, after 6 months of follow-up, 56/84 patients in the cyamemazine group (66.7%) and 55/84 patients in the bromazepam group (65.5%) were successfully withdrawn. 28 patients in the cyamemazine group and 18 in the bromazepam group had an adverse event, including anxiety, insomnia, dry mouth and somnolence. No extra-pyramidal symptoms were reported. In conclusion, cyamemazine was comparable to bromazepam in ensuring successful benzodiazepine withdrawal and in controlling the acute benzodiazepine withdrawal syndrome. Cyamemazine may be useful to facilitate benzodiazepine withdrawal in those patients where bromazepam substitution is not appropriate.
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Tsutsui S. A double-blind comparative study of zolpidem versus zopiclone in the treatment of chronic primary insomnia. J Int Med Res 2001; 29:163-77. [PMID: 11471853 DOI: 10.1177/147323000102900303] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Zolpidem (10 mg/day) and zopiclone (7.5 mg/day), administered at night, were compared in a 14-day, double-blind, equivalence trial on 479 chronic primary insomniacs (zolpidem, 231; zopiclone, 248) throughout Japan, with a 1-week follow-up to assess rebound. The primary endpoint was the investigators' rating of global improvement of sleep disorders. A total of 32 patients in the zolpidem group (13.9%) and 45 patients in the zopiclone group (18.1%) withdrew from the study before the end of the treatment. In the zolpidem group, 67.9% (142/209) of patients were rated at least 'moderately improved' versus 61.6% (135/219) with zopiclone, zolpidem being at least as effective as zopiclone (90% confidence interval: -1.7, 14.3). With zolpidem, sleep onset latency improved in significantly more patients (85.8% versus 77.5%) and significantly fewer patients showed aggravated sleep onset latency relative to baseline at follow-up (4.5% versus 15.4%). Significantly fewer patients receiving zolpidem experienced drug-related adverse events (31.3% versus 45.3%), with bitter taste representing 5.8% (six of 104) of such complaints with zolpidem compared with 39.9% (69/173) with zopiclone. In conclusion, zolpidem was at least as effective as zopiclone, showed significantly less rebound on discontinuation and was better tolerated.
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Affiliation(s)
- S Tsutsui
- Department of Psychosomatic Medicine, Toho University Medical School, Omori Hospital, Japan
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Feige B, Voderholzer U, Riemann D, Hohagen F, Berger M. Independent sleep EEG slow-wave and spindle band dynamics associated with 4 weeks of continuous application of short-half-life hypnotics in healthy subjects. Clin Neurophysiol 1999; 110:1965-74. [PMID: 10576495 DOI: 10.1016/s1388-2457(99)00147-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Habituation and adverse withdrawal reactions after prolonged medication with benzodiazepine (BZ) hypnotics are believed to play a role in dose escalation and the development of dependence. METHODS In the current sleep EEG study in 43 healthy male subjects, the known property of BZ- and similar hypnotics to change the NREM sleep EEG spectrum is utilized for a detailed quantitative analysis across 4 weeks of continuous medication and a subsequent two-week withdrawal period. The BZ hypnotic triazolam and the non-BZ hypnotics zopiclone and zolpidem, differing in pharmacological properties and reported adverse effects, were examined in parallel to a placebo group. RESULTS Reliably occurring spectral effects in the sleep stage 2 EEG were found in the 3 frequency bands 0.8-5 Hz, 5-10 Hz and 10-15 Hz. All 3 hypnotics showed the typical 'benzodiazepine signature', a 10-15 Hz increase and lower-frequency (<10 Hz) suppression relative to the preceding drug-free night. However, these effects developed differently across the first medication night, across the 4 medication weeks and after withdrawal: While the 5-10 Hz effect covaried with the blood presence of the drugs as estimated from the known plasma half-lifes, showed habituation and a rebound after withdrawal, the 10-15 Hz power increased across medication days and showed no rebound. Effects in the 0.8-5 Hz band in the first medication night correlated with the decrease of sleep efficiency at later withdrawal for triazolam and zolpidem.
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Affiliation(s)
- B Feige
- Department of Psychiatry and Psychotherapy, Albert-Ludwigs-University, Freiburg, Germany.
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Abstract
Zolpidem belongs to a new class of hypnotic agents, chemically distinct from the pre-existing ones, and has a unique neuropharmacological profile. It induces sedative/hypnotic effects in rodents at doses much lower than those for anticonvulsant and myorelaxant activities. Clinically, zolpidem is indicated for the short term treatment of insomnia. It has a short half-life (2.4h), with no active metabolite, and does not accumulate during repeated administration. The pharmacokinetic profile associated with the absence of active metabolites is consistent with the short duration of action and absence of residual effects that have been observed. Polysomnographic experience indicates that zolpidem induces a sleep pattern which is similar to that of physiological sleep, and which produces either no or only minimal effects on sleep architecture after abrupt discontinuation. Aspects of the general safety of zolpidem have been studied in data obtained from healthy volunteers and patients, both adult and elderly, during its clinical development and in post-marketing experience. Zolpidem appears to be well-tolerated in adults and in the elderly, when administered in accordance with prescribing instructions. The available data indicate that, in these circumstances, the risk of abuse or dependence is minimal.
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Affiliation(s)
- G Darcourt
- Department of Psychiatry, CHU Pasteur, Nice, France.
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