Eszopiclone dependence and withdrawal - myth?

[thelastpsych]

We all know the risks of dependence with benzodiazepines and such, and Z-drugs wre marketed as safer and less tolerance/dependence inducing drugs than benzos. Thing is, we've all seen a lot of patients developing tolerance and dependence to Ambien; ofc there is a strong component of psychological dependence, but that is certainly not all.

I've seen eszopiclone being recomended as a hypnotic more often lately, marketed as a drug that doesn't alter the sleep-wake cycle as much, and has a longer half-life, thus reducing it's risk of dependence. What is your guys take on this drug, and it's risk of dependence? I usually try to treat the primary cause of insomnia, look for secondary causes (OSA, RLS), and when needed, prefer trazodone or ramelteon to Z-drugs or benzos, even in the short term.

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[FlowRate]

I'm skeptical of any Z drug or many of the common benzos causing "dependence"/physiologic tolerance and thus withdrawal from once nightly dosing.

CBTI is the treatment of choice but good luck getting most insomnia patients to actually do it.

 

[PsyDr]

I'm skeptical of any Z drug or many of the common benzos causing "dependence"/physiologic tolerance and thus withdrawal from once nightly dosing.

CBTI is the treatment of choice but good luck getting most insomnia patients to actually do it.

What do you make of the FDA insert recommendation to re-evaluate after 7-10 days?

 

[thelastpsych]

I'm skeptical of any Z drug or many of the common benzos causing "dependence"/physiologic tolerance and thus withdrawal from once nightly dosing.

CBTI is the treatment of choice but good luck getting most insomnia patients to actually do it.

Yeah, I always recommend sleep hygiene measures and CBTi, but most patients are resistant to it. I give some patients sleep diaries to fill when they say they sleep 2h a night for the last six months; haven't had much luck with that yet.

 

[PikminOC]

We all know the risks of dependence with benzodiazepines and such, and Z-drugs wre marketed as safer and less tolerance/dependence inducing drugs than benzos. Thing is, we've all seen a lot of patients developing tolerance and dependence to Ambien; ofc there is a strong component of psychological dependence, but that is certainly not all.

I've seen eszopiclone being recomended as a hypnotic more often lately, marketed as a drug that doesn't alter the sleep-wake cycle as much, and has a longer half-life, thus reducing it's risk of dependence. What is your guys take on this drug, and it's risk of dependence? I usually try to treat the primary cause of insomnia, look for secondary causes (OSA, RLS), and when needed, prefer trazodone or ramelteon to Z-drugs or benzos, even in the short term.

Same class as benzos same risk of dependence etc

 

[Candidate2017]

Most patients have trouble naming their long term, life sustaining medications, much less the exact dosage. But everyone knows the name of their preferred anxiolytic/hypnotic and stimulant, and the exact dosage.

It also seems to me PP psychiatrists do a decent job of diagnosis and med management of new intakes who erroneously claim they have "the bipolar" because of "my hourly mood swings". But if a patient mentions "my anxiety/attention/insomnia" enough times, PP psychiatrists seem to mirror NPs, i.e., willing to accept subjective descriptions as objective proof of a psychiatric disease requiring the exact controlled substance the patient requests. As a specialty, that aspect is laughable. And shameful. I can't imagine an ID doctor prescribing me Vanco if I keep coming back, crying, and complaining about how, "It's the ONLY thing that works for my sniffles".

 

[Sushirolls]

No z drugs.

Trazodone, Gabapentin, or even Histamine varient meds.
Of course refer to CBTi source, if receptive.
Or combo up with remeron.

 

[calvnandhobbs68]

Most patients have trouble naming their long term, life sustaining medications, much less the exact dosage. But everyone knows the name of their preferred anxiolytic/hypnotic and stimulant, and the exact dosage.

It also seems to me PP psychiatrists do a decent job of diagnosis and med management of new intakes who erroneously claim they have "the bipolar" because of "my hourly mood swings". But if a patient mentions "my anxiety/attention/insomnia" enough times, PP psychiatrists seem to mirror NPs, i.e., willing to accept subjective descriptions as objective proof of a psychiatric disease requiring the exact controlled substance the patient requests. As a specialty, that aspect is laughable. And shameful. I can't imagine an ID doctor prescribing me Vanco if I keep coming back, crying, and complaining about how, "It's the ONLY thing that works for my sniffles".

I mean I hope they wouldn't cause PO Vancomycin wouldn't actually help your sniffles anyway....

 

[PikminOC]

Most patients have trouble naming their long term, life sustaining medications, much less the exact dosage. But everyone knows the name of their preferred anxiolytic/hypnotic and stimulant, and the exact dosage.

It also seems to me PP psychiatrists do a decent job of diagnosis and med management of new intakes who erroneously claim they have "the bipolar" because of "my hourly mood swings". But if a patient mentions "my anxiety/attention/insomnia" enough times, PP psychiatrists seem to mirror NPs, i.e., willing to accept subjective descriptions as objective proof of a psychiatric disease requiring the exact controlled substance the patient requests. As a specialty, that aspect is laughable. And shameful. I can't imagine an ID doctor prescribing me Vanco if I keep coming back, crying, and complaining about how, "It's the ONLY thing that works for my sniffles".

$$$

 

[whopper]

I always try to avoid use of a Z-med unless the patient only takes about 2x a week or less. Now all this said, out of all them I do see the least amount of problems with Eszopiclone, but I got no idea if it's because it is a better med vs the more commonly prescribed Zolpidem. The problem here is so many people take Zolpidem that when I do see problems with a Z-med it's almost always Zolpidem. That puts too much bias to parse out if Eszopiclone is a safe med vs Zolpidem from my own clinical experience, although I'd heard of journal articles suggesting Eszopiclone over Zolpidem for safety reasons.

The number of patients I have on Z-meds are less than 1% of my patients and of these almost all of that small amount are the ones who wants a sleep med only PRN and take them less than weekly. Only other patients on a Z-med are the ones where a different doctor prescribed it and refused to stop it despite my recommendation.

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[vanfanal]

Any comments on experience with suvorexant or lemborexant?
I've never used bco none of my pts can afford it.

 

[whopper]

Problem with Lemborexant is every single time I prescribed it insurance wouldn't cover it. Never, and cause the company would never give me samples I literally never had 1 patient take it.

Suvorexant-when it works it can work well. A problem is it could take several days before it starts working and several patients, especially if they've used Zolpidem, give up if it doesn't work 1 night even if you tell them dozens of times it can work better with several days use.

 

[FlowRate]

Any comments on experience with suvorexant or lemborexant?
I've never used bco none of my pts can afford it.

Patients have to have tried everything else to get it covered in our system. I've had a couple of patients try it. By virtue of failing other insomnia meds, neither one is the straightforward sort that you'd like when trying to come to conclusions about a new medication. One of them likes it.

 

[clozareal]

From this study: Eszopiclone for insomnia

Finally, the review did not identify withdrawal symptoms and distinct rebound effects after eszopiclone was discontinued, supporting the conclusion that, if taken as recommended, eszopiclone has a low potential to cause dependence and withdrawal. Findings from randomised placebo‐controlled studies with racemic zopiclone, which failed to demonstrate polysomnographic withdrawal effects after a four‐week treatment in a recommended dose range (Vorderholzer 2001) and did not show abuse‐like effects in drug‐naive participants (Licata 2008), are consistent with our conclusion. Nevertheless, withdrawal symptoms, craving, and severe rebound insomnia associated with the high dose use of zopiclone in individuals with preexisting chemical abuse or psychiatric disorders, as documented in case reports (Cimolai 2007), suggests that safety conclusions might only be valid for the use of eszopiclone in the recommended dose range and without contraindicated substances.

I've heard it places where there is no dependence/tolerance and you can use it chronically. I typically use it for 2-3 weeks at a time every night (not PRN) and then come off of it. How do they know they still have insomnia if they keep taking it?

I always try to avoid use of a Z-med unless the patient only takes about 2x a week or less. Now all this said, out of all them I do see the least amount of problems with Eszopiclone, but I got no idea if it's because it is a better med vs the more commonly prescribed Zolpidem. The problem here is so many people take Zolpidem that when I do see problems with a Z-med it's almost always Zolpidem. That puts too much bias to parse out if Eszopiclone is a safe med vs Zolpidem from my own clinical experience, although I'd heard of journal articles suggesting Eszopiclone over Zolpidem for safety reasons.

A number of placebo-controlled studies were carried out with eszopiclone to suggest that adding it to usual therapy improves sleep and associated conditions such as MDD, GAD, PTSD, rheumatoid arthritis, and chronic low back pain. Zolpidem CR added to SSRI therapy improves sleep but not GAD and MDD.

 

[jbomba]

If I recall eszopiclone affects a different sub unit of the gaba receptor vs other z drugs. It does appear to have a positive effect in GAD and MDD, independent of simply improving sleep.

 

[annoyedpsychiatrist]

I rarely start people on z drugs, and would prefer a tiny dose of a benzo if anything (if other measures have failed). However i commonly get elderly/other people on these meds. It depends on what guidelines you follow really. The american academy of sleep suggests the benefits of pharmacological treatment for sleep outweigh the risks generally, and suggest that if patient has failed/unable to do CBTi then pharmacological treatment long term is warranted. Though how do you know people even failed it or did it is challenging. I also cite these guidelines frequently.

I leave people on ambien, even if geri, if they're medically in good shape, demonstrate good insight, understand risks/benefit after discussion which i document, no falls, no opiates, no drugs, etc. So i do a thorough risk/benefit analysis which I document. Its very rare i start z drugs.

I know lunesta is popular, and maybe has slightly more evidence if you look on american academy of sleep, but still not ultra compelling evidence.

 

[mistafab]

Not to be a pencil-neck, but Z drugs would be much favored over a standard benzo for short term sleep induction, or even chronic use in the elderly. Why? Because if you are looking to induce sleep, theoretically, you want the shortest half-life possible. That way, you induce the sleep, but do not disturb the underlying sleep architecture after the effect wears off.

Additionally, in the elderly, the long half-life of benzos tends to double-whammy them. They wake up in the middle of the night confused (inebriated, really), and then fall.

 

[annoyedpsychiatrist]

Not to be a pencil-neck, but Z drugs would be much favored over a standard benzo for short term sleep induction, or even chronic use in the elderly. Why? Because if you are looking to induce sleep, theoretically, you want the shortest half-life possible. That way, you induce the sleep, but do not disturb the underlying sleep architecture after the effect wears off.

Additionally, in the elderly, the long half-life of benzos tends to double-whammy them. They wake up in the middle of the night confused (inebriated, really), and then fall.

So its tricky. I would wager that .25mg of xanax is tolerated better than ambien 10mg for a lot of patients. Moderate-high doses of benzos i agree would be less tolerated. I also look at medical conditions, fall risk, etc before id consider either direction. Also if you look at guidelines, BEERs criteria suggest that low dose benzo may be appropriate in the elderly in certain settings, and american academy of sleep guidelines as noted above recommends treating sleep, so by going that direction you could argue those two guidelines. BEERs criteria did not have exceptions for z drugs if I remember correctly. Also xanax is very lipophillic, will cross the BBB fast to act fast, and leave quickly as well. You could argue things like volume of distribution, but still. Again though, im not using these drugs in people on polypharm who medically arent in best shape and have a lot of risk factors for delirium/falls. Chances are these people arent sleeping anyways secondary to medical issues, medication, etc.

Realistically both arent great options and im not a big fan of them. I usually dont have significant issue with daytime sedation with ambien as it has low daytime sedation but its only really used for sleep onset. I have one patient on ambien cr for SI/SM who is geri, but the struggle is hes been on it >20 years. Though medically he is also in great shape, no falls/gait issues, no opoids, etc.

 

[clozareal]

Problem with Lemborexant is every single time I prescribed it insurance wouldn't cover it. Never, and cause the company would never give me samples I literally never had 1 patient take it.

Suvorexant-when it works it can work well. A problem is it could take several days before it starts working and several patients, especially if they've used Zolpidem, give up if it doesn't work 1 night even if you tell them dozens of times it can work better with several days use.

From my EMR, I can see if it's covered or not so I don't bother if it isn't since it's so expensive. I've had good luck with lemborexant for the most part but didn't have any effect for one patient. The popular insurance in my area seem to cover it and not suvorexant (???) and less so vice versa so I just choose one or the other if I need something for sleep. I prefer it over Z drugs and benzos for sleep initiation and to increase sleep duration.

If they have middle insomnia, I prefer low dose doxepin.

 

[annoyedpsychiatrist]

i also have a tough time getting the orexin antagonists covered, or the OOP cost is higher to patients

 

[thelastpsych]

From my EMR, I can see if it's covered or not so I don't bother if it isn't since it's so expensive. I've had good luck with lemborexant for the most part but didn't have any effect for one patient. The popular insurance in my area seem to cover it and not suvorexant (???) and less so vice versa so I just choose one or the other if I need something for sleep. I prefer it over Z drugs and benzos for sleep initiation and to increase sleep duration.

If they have middle insomnia, I prefer low dose doxepin.

Doxepin is a nice drug, underused imo for middle insomnia; melatonergic drugs tend to be better for older patients, or ones with sleep phase delay - younger patients without sleep phase delay is a hit or miss, mostly miss in my opinion.

 

[clozareal]

Doxepin is a nice drug, underused imo for middle insomnia; melatonergic drugs tend to be better for older patients, or ones with sleep phase delay - younger patients without sleep phase delay is a hit or miss, mostly miss in my opinion.

My CAP patients with ASD or ADHD tend to do well with melatonin, but Z drugs and benzos don't seem to work as well for that patient population.

 

[Dantes]

Some of the orexin antagonist manufacturers have programs/coupons for those with insurance. At least I'm pretty sure daridorexant does.

 

[annoyedpsychiatrist]

One thing I was thinking, is there any significant evidence that orexin antagonist are significantly safer than z drugs in the long term? Part of me assumed this was the case going off mechanism of action, but the data is up to 12 months. Some of the orexin antagonists ive had people tell me caused daytime sedation, my understanding though is the newer one, quviviq does not typically cause this. Im assuming lower fall risk with orexin antagonists. Also my understanding is orexin antagonists>z drugs in geri patients

we need more data on sleep meds

 

[vanfanal]

One thing I was thinking, is there any significant evidence that orexin antagonist are significantly safer than z drugs in the long term? Part of me assumed this was the case going off mechanism of action, but the data is up to 12 months. Some of the orexin antagonists ive had people tell me caused daytime sedation, my understanding though is the newer one, quviviq does not typically cause this. Im assuming lower fall risk with orexin antagonists. Also my understanding is orexin antagonists>z drugs in geri patients

we need more data on sleep meds

Also very curious on risk of abuse. I haven't heard much in that way and I don't think it's caused problems in rehab centers like Z-drugs and gabapentin do....which is often my indication on when something is rewarding and problematic in the SUD population. My other go to is to see if there's a reddit thread on how to misuse a medication, haha.