Managing Dependence and Withdrawal With Newer Hypnotic Medications in the Treatment of Insomnia

Hypnotic drugs are widely prescribed medications, especially for the elderly. The benzodiazepines and newer, nonbenzodiazepine compounds, such as zopiclone, zolpidem, and zaleplon, are the current favorites. Benzodiazepines can be either long acting (flurazepam and nitrazepam), medium acting (temazepam), or short acting (triazolam). However, duration of action is prolonged in the elderly and is also dose dependent. Although insomnia can be due to many causes, physical and psychiatric disorders are the most common. Many people with insomnia, however, are chronically symptomatic without apparent cause (“primary” insomnia). Long-term use of a prescribed hypnotic is, unfortunately, a common consequence. Upon discontinuation of prolonged hypnotic use, withdrawal syndromes can occur that comprise a characteristic set of symptoms and signs temporarily associated with the discontinuation and not reported prior to treatment. These are generally taken as indications of physical dependence. Of major concern is abuse—the use of high doses for recreational purposes, outside the medical context, and possibly with supplies illegally obtained. Withdrawal is usually uneventful with the newer nonbenzodiazepine drugs. They can even be used as transitional therapies in the more difficult task of discontinuing benzodiazepines in long-term dependent users. However, dosage considerations are important with all hypnotics, and treatment, especially in the elderly, should be at the lowest effective dose and for the shortest duration.