Z drugs for chronic insomnia?

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Bartelby

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I am interested in surveying the collective wisdom about Z drugs for insomnia. My usual practice has been to approach them like benzodiazepines, basically avoiding their use for sleep aside from very brief prescriptions. Reading through guidelines (such as https://jcsm.aasm.org/doi/10.5664/jcsm.6470#d1e5029) and other literature (such as Pharmacological Treatment of Insomnia), I wonder if I am being too strict with my prescribing practices and denying patients a potentially effective treatment.

So in brief, do you prescribe Z drugs for chronic insomnia? If you do, are you giving nightly doses, or a supply to cover only intermittent use, or only time-limited supplies? And if you have a lot of experience prescribing these medications, how has it gone? As an aside, when I mention "chronic insomnia" this is typically insomnia associated with issues such as persisting depression, PTSD, etc. and of course doing a full assessment and optimizing management of any such issues (including OSA) is part of the plan. When insomnia persists, though, do you view Z drugs as a good chronic option? For the purposes of this discussion, let's presume worries about abuse or diversion are low for a particular patient (though I'm interested in hearing views on SUDs + Z drug use as well).

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I don't think Z drugs and benzos are equivalent. I feel the efficacy for sleep specifically, side effect profile, and preservation of sleep architecture are all better with Z drugs, and abuse potential is lower vs benzos (not absent though).

I am wondering about the 'chronic' qualifier though. I don't ever intentionally plan for a patient to stay on a pharmacological sleeper of any type indefinitely. I find that once the acute psychiatric issue is effectively treated, most people are able to come off the sleeper without issue.

People with truly chronic insomnia in the absence of a psychiatric or medical issue, I'm steering towards CBTi. I wouldn't even open the Z drug can of worms, and most of those people have tried multiple sleepers anyway with limited success.
 
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I don't think Z drugs and benzos are equivalent. I feel the efficacy for sleep specifically, side effect profile, and preservation of sleep architecture are all better with Z drugs, and abuse potential is lower vs benzos (not absent though).

I am wondering about the 'chronic' qualifier though. I don't ever intentionally plan for a patient to stay on a pharmacological sleeper of any type indefinitely. I find that once the acute psychiatric issue is effectively treated, most people are able to come off the sleeper without issue.

People with truly chronic insomnia in the absence of a psychiatric or medical issue, I'm steering towards CBTi. I wouldn't even open the Z drug can of worms, and most of those people have tried multiple sleepers anyway with limited success.

I've yet to meet a patient on chronic sleep meds who describes their sleep as "good."
 
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I've yet to meet a patient on chronic sleep meds who describes their sleep as "good."
By extension ask any patient on chronic pain management what their pain level is or ask someone prescribed chronic benzodiazepines what their anxiety level is. It is almost never 0/10.
 
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I am interested in surveying the collective wisdom about Z drugs for insomnia. My usual practice has been to approach them like benzodiazepines, basically avoiding their use for sleep aside from very brief prescriptions. Reading through guidelines (such as https://jcsm.aasm.org/doi/10.5664/jcsm.6470#d1e5029) and other literature (such as Pharmacological Treatment of Insomnia), I wonder if I am being too strict with my prescribing practices and denying patients a potentially effective treatment.

So in brief, do you prescribe Z drugs for chronic insomnia? If you do, are you giving nightly doses, or a supply to cover only intermittent use, or only time-limited supplies? And if you have a lot of experience prescribing these medications, how has it gone? As an aside, when I mention "chronic insomnia" this is typically insomnia associated with issues such as persisting depression, PTSD, etc. and of course doing a full assessment and optimizing management of any such issues (including OSA) is part of the plan. When insomnia persists, though, do you view Z drugs as a good chronic option? For the purposes of this discussion, let's presume worries about abuse or diversion are low for a particular patient (though I'm interested in hearing views on SUDs + Z drug use as well).

I have lots of SUD + ambien patients. Try to get them off Z drugs as much as possible. Rozerem/Belsomra good to try.

At the end of the day nothing treats "chronic insomnia" better than addressing people's underlying personality disorders. It's amazing how insomnia resolves when people ... get a job. Or... quit their job that they are poorly suited for, and, GET A NEW JOB, etc.
 
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By extension ask any patient on chronic pain management what their pain level is or ask someone prescribed chronic benzodiazepines what their anxiety level is. It is almost never 0/10.

In my experience, in those cases it isn't even as low as 5/10. I've never seen any functionally better on chronic benzos.
 
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Im in an area where probably around 50% (perhaps even higher) of my patients are >60 years old. So many of them are on z drugs, its unreal. So many of them, despite being on these drugs, still have bad quality of sleep, but do not want to go off it. Some claim its the only thing that helps them sleep.

I almost never start anyone on a z drug. If i continue it, it would be to use sparingly and not consistently every night but the issue is that most of these people dont have insomnia sometimes, they claim its every night they cant sleep so that rarely works.

What do you? Thats the million dollar question. I do it on a patient by patient basis but in general its rare i continue people on it. Some people are genuinely worried that if they dont use it, they wont sleep until they die from sleep deprivation, creating an anxiety behind the use of it, reinforcing use. If theyre using nightly alcohol (which is common in my patients) then im not prescribing z drugs with that. Also people very commonly underestimate the quality of sleep they get/how much time they spend sleeping. Or have untreated OSA.

Im very honest with them in the sense that if i recommending they go off, i explain that it may be worse before its better. I think that in the same way benzos dont fix anxiety, z drugs dont fix sleep. The problem becomes you get angry patients who swear otherwise.
 
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The data, and it's solid, show that more use of Z-meds the less they work. This is from memory but it's actually tested on the board exam, and it's in the psychiatry board review course (that one in NYC where they charge mega bucks) that at about 6 months of use there's no benefit with Zolpidem.

Now all this said do I sometimes give it out? Yes but for only temporary use. I got no problem, like with benzos, if the patient uses them once a week or less.

Chronic use? I tell patients they must reduce the dose over time or I will not be their treating psychiatrist. I allow for slow reduction such as 1 mg/day less per month.

I have seen, very very rarely, a patient where nothing else works. Their sleep doctor even provided me records that nothing else seemed to work well. Only then, and it's only been 3 patients my entire career, where this happened. I also see a patient where this works, hardly anything else works in which case I do a rotation between the Z-med and the other med that works every month. That too is very rare. I have less than 10 patients in my entire practice of well over 1000 patients where this happened.

If I have patients who claim nothing else works I have the patient see a sleep doctor that this causes several problems. I mentioned this is another thread. At least in my area, but I've seen this happen in other states, sleep doctors don't seem to make any big money unless it's OSA. So if it's not OSA but a serious sleep problem that I feel is out of my league several sleep doctors abandon the patient telling them it's not OSA so see another doctor, as if non-OSA shouldn't be treated by a sleep doctor. It's BS. I've had other sleep doctors tell me my suspicion they're abandoning patients is correct.

I've had very extreme sleep problem patients. E.g. a person who can't sleep more than 2-3 hours a night tried on several meds and I know he's not abusing any cause he doesn't want Z-med or benzos. Same thing above happened. Saw a sleep doctor, wasn't OSA so the guy told him not to see him anymore. Only meds I could find that worked on this guy was Orexin-based meds but these same meds caused him to have sleep paralysis that caused him to have extreme anxiety during the same episodes (and I told him sleep paralysis itself isn't dangerous, so why he had acute and severe anxiety episodes I don't know). He finally found a sleep doctor willing to work with him and I told him his case was out of my league.

All of the above is in my private practice. Different settings can be very different. E.g. in a Medicaid office I likely would never ever give out Zolpidem at all. The problem with Medicaid offices is the risk of abuse is so much higher.
 
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In my experience, in those cases it isn't even as low as 5/10. I've never seen any functionally better on chronic benzos.
I have many patients that are doing very well on chronic benzos, the benzos are low dose (1mg Ativan daily) but still doing quite well
 
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I have many patients that are doing very well on chronic benzos, the benzos are low dose (1mg Ativan daily) but still doing quite well

I'd argue that they would likely be doing better not on them. At that point, you've just given them a safety cue, reinforcing and strengthening the underlying anxiety.
 
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Im in an area where probably around 50% (perhaps even higher) of my patients are >60 years old. So many of them are on z drugs, its unreal. So many of them, despite being on these drugs, still have bad quality of sleep, but do not want to go off it. Some claim its the only thing that helps them sleep.

I almost never start anyone on a z drug. If i continue it, it would be to use sparingly and not consistently every night but the issue is that most of these people dont have insomnia sometimes, they claim its every night they cant sleep so that rarely works.

What do you? Thats the million dollar question. I do it on a patient by patient basis but in general its rare i continue people on it. Some people are genuinely worried that if they dont use it, they wont sleep until they die from sleep deprivation, creating an anxiety behind the use of it, reinforcing use. If theyre using nightly alcohol (which is common in my patients) then im not prescribing z drugs with that. Also people very commonly underestimate the quality of sleep they get/how much time they spend sleeping. Or have untreated OSA.

Im very honest with them in the sense that if i recommending they go off, i explain that it may be worse before its better. I think that in the same way benzos dont fix anxiety, z drugs dont fix sleep. The problem becomes you get angry patients who swear otherwise.
How dare you take away my Ambien!
 
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its funny because from what ive seen is there isnt many widescale studies in regard to chronic z drug use for insomnia. You think there would be more data out there given how common of an issue it is. The guidelines from american academy of sleep medicine are basically a joke. "Based upon weak evidence, we potentially recommend xyz" to everything. Also we as psychiatrist kind of got labeled as the Z drug doctors, despite the fact that there is a sleep medicine field who SPECIALIZES IN SLEEP. This part ill never understand, lol. Its like an ortho doctor who says "sorry i only specialize in operating on the left hand, not the right one"
 
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Some people are genuinely worried that if they dont use it, they wont sleep until they die from sleep deprivation, creating an anxiety behind the use of it, reinforcing

Reassure them this is physiologically impossible. If they stay awake long enough, they will fall into a prolonged slumber. And tell them a component of CBT-i, the most effective intervention, is sleep restriction.
 
Reassure them this is physiologically impossible. If they stay awake long enough, they will fall into a prolonged slumber. And tell them a component of CBT-i, the most effective intervention, is sleep restriction.

Also just reassure them that, if they do in fact have fatal insomnia, there is no cure, and their death will be inevitable, with or without sleep meds
 
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I'd argue that they would likely be doing better not on them. At that point, you've just given them a safety cue, reinforcing and strengthening the underlying anxiety.
I think this is true in general but there are some patients with biological anxiety that need long term benzos like for example TBI patients, in some cases long term benzos are unavoidable
 
I think this is true in general but there are some patients with biological anxiety that need long term benzos like for example TBI patients, in some cases long term benzos are unavoidable

I would think that moderate to severe brain injury patients with a specific enough pattern of brain injury causing treatment resistant anxiety requiring maintenance benzos to be exceedingly rare. In my years on acute brain injury and rehab units, I can't recall seeing this.
 
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I refer them to sleep medicine if it's chronic insomnia and have them treat it. It's not my wheelhouse although I will often do an evaluation to see what the underlying cause my be (restless leg syndrome, nightmares, lack of exercise during the day so they're not tired at night). However, I often go for mirtazapine and trazodone, low dose doxepin, prazosin if there's trauma and high hyperarousal, and even third party laboratory tested melatonin before using a Z drug. There's probably more on my list I would use before starting a Z drug that I can't think of right now.

If there's a sleep disturbance that's acute, I will sometimes prescribe 2-4 weeks of a Z drug but stick mainly to eszopiclone because of some evidence of helping with comorbid conditions like GAD, depression, chronic pain irrespective of the effect on sleep. I don't have a hard line against it if there are no red flags for addiction, diversion, or cognitive impairment. I have some cases who use it intermittently, like once a month or less, especially those with bipolar disorder who have enough insight and have good enough family support to help them get sleep with early signs of hypo/mania.
 
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Also just reassure them that, if they do in fact have fatal insomnia, there is no cure, and their death will be inevitable, with or without sleep meds
Take the cold blooded exposure therapy approach. "Do you have fatal familial insomnia? I don't know but I guess we'll find out one way or another!"
 
Take the cold blooded exposure therapy approach. "Do you have fatal familial insomnia? I don't know but I guess we'll find out one way or another!"

If they had sporadic fatal insomnia, I'd juts ask if I could write up their case study after they die given the rarity of like 50 cases in the past decade.
 
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Granted, I see mainly insomnia patients in my practice but...

The chronic Z drug users are usually Delayed Sleep Phase Disorder patients who have been misdiagnosed with simple insomnia and also have work / school / life obligations that require they conform to the sleep schedule of someone with intermediate or (worse even) advanced phase.

Because DSPD is so difficult to manage, with even a single night derailing progress made to advance phase, these folks may need the meds chronically. We try everything else in the book, even looking for work that conforms to their endogenous phase, but sometimes this is a plan of last resort.
 
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I refer them to sleep medicine if it's chronic insomnia and have them treat it. It's not my wheelhouse although I will often do an evaluation to see what the underlying cause my be (restless leg syndrome, nightmares, lack of exercise during the day so they're not tired at night). However, I often go for mirtazapine and trazodone, low dose doxepin, prazosin if there's trauma and high hyperarousal, and even third party laboratory tested melatonin before using a Z drug. There's probably more on my list I would use before starting a Z drug that I can't think of right now.

If there's a sleep disturbance that's acute, I will sometimes prescribe 2-4 weeks of a Z drug but stick mainly to eszopiclone because of some evidence of helping with comorbid conditions like GAD, depression, chronic pain irrespective of the effect on sleep. I don't have a hard line against it if there are no red flags for addiction, diversion, or cognitive impairment. I have some cases who use it intermittently, like once a month or less, especially those with bipolar disorder who have enough insight and have good enough family support to help them get sleep with early signs of hypo/mania.
Can you tell me where to refer people for lab tested melatonin? We really need to get like Europe with pharmaceutical grade stuff.
 
Reassure them this is physiologically impossible. If they stay awake long enough, they will fall into a prolonged slumber. And tell them a component of CBT-i, the most effective intervention, is sleep restriction.

oh i do, but its surprising how many people are genuinelly concerned by this. I usually ask them "how many times on the news have you seen 'man dies from not sleeping 6 nights in a row'"?
 
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oh i do, but its surprising how many people are genuinelly concerned by this. I usually ask them "how many times on the news have you seen 'man dies from not sleeping 6 nights in a row'"?

The sleep bigwig I trained with always made patients complete a Dysfunctional Beliefs About Sleep scale as part of his intake. The results were often illluminating.
 
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its funny because from what ive seen is there isnt many widescale studies in regard to chronic z drug use for insomnia. You think there would be more data out there given how common of an issue it is. The guidelines from american academy of sleep medicine are basically a joke. "Based upon weak evidence, we potentially recommend xyz" to everything. Also we as psychiatrist kind of got labeled as the Z drug doctors, despite the fact that there is a sleep medicine field who SPECIALIZES IN SLEEP. This part ill never understand, lol. Its like an ortho doctor who says "sorry i only specialize in operating on the left hand, not the right one"

It's more like a neurosurgeon who only does spines and doesn't do anything intracranial. Sleep docs are absolutely people who are qualified to treat all kinds of sleeping problems; if they don't care about anything but OSA that is an individual doc thing and not the field. I am assuming it has to do with local reimbursements/many of them coming out of pulmonology backgrounds and not wanting to deal with anything else.
 
I am assuming it has to do with local reimbursements/many of them coming out of pulmonology backgrounds and not wanting to deal with anything else.

What some sleep docs told me is that because most sleep docs are originally IM/pulmonologists once they see it's not OSA they immediately drop the case, and that it's also cause the money factor. Not that they're not supposed to treat it, they are, but they, for themselves, only want to treat a mechanical issue and/or are only interested in the reimbursement.
 
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I would think that moderate to severe brain injury patients with a specific enough pattern of brain injury causing treatment resistant anxiety requiring maintenance benzos to be exceedingly rare. In my years on acute brain injury and rehab units, I can't recall seeing this.
I have 3 patients like this, they weren’t anxious, had a TBI, became very anxious, were tried on all kinds of things until they settled on a low dose benzo regimen and have been on it for many years or decades without much issue, they are not interested in decreasing as it’s been tried in the past without success so we keep them on it
 
I have 3 patients like this, they weren’t anxious, had a TBI, became very anxious, were tried on all kinds of things until they settled on a low dose benzo regimen and have been on it for many years or decades without much issue, they are not interested in decreasing as it’s been tried in the past without success so we keep them on it

This makes me curious - what did they mean when they said "anxious?"
 
What some sleep docs told me is that because most sleep docs are originally IM/pulmonologists once they see it's not OSA they immediately drop the case, and that it's also cause the money factor. Not that they're not supposed to treat it, they are, but they, for themselves, only want to treat a mechanical issue and/or are only interested in the reimbursement.
I spend at least an hour with my patients. When I was working with pulm-based sleep docs, they did have to train in CBT-I, but spending anything more than 20 minutes with someone was visibly discomfiting to them!
 
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The sleep bigwig I trained with always made patients complete a Dysfunctional Beliefs About Sleep scale as part of his intake. The results were often illluminating.
Cognitive restructing is a big part of CBT-I. I would urge people to get high quality training in how to do CBT-I because it treats insomnia in so many cases if you do it yourself whereas when I refer people to get CBT-I, only like 10-20% of my patients will go get it despite my patient population being well resourced and motivated.
 
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It's more like a neurosurgeon who only does spines and doesn't do anything intracranial. Sleep docs are absolutely people who are qualified to treat all kinds of sleeping problems; if they don't care about anything but OSA that is an individual doc thing and not the field. I am assuming it has to do with local reimbursements/many of them coming out of pulmonology backgrounds and not wanting to deal with anything else.
Agreed. Early in training, the sleep docs would need to give me a good talking to every time I referred a patient for a "sleep study." They said to send the patient for a sleep consultation and then they'll determine if the patient needs a sleep study or not and which kind (polysomnography is only one type of sleep study).
 
Can chance you could share a few of your top choices? I don't have access to their results.
Trader Joe's Melatonin 3 mg — Peppermint Flavor / chewable tablet
NOW / Liquid
Natrol / liquid
Nature’s Bounty / softgel or tablet
Jarrow / capsule
Twin Lab / orally disintegrating tablet
Natural Factors / chewable tablet

For timed release melatonin (for middle or terminal insomnia): REMfresh.
 
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And what severity TBI? Anything less than moderate, or complicated mild with imaging findings and you are likely causing them harm with benzo scripts.
TBI requiring neurosurgery, do you think chronic benzos are ever indicated in any circumstances?
 
TBI requiring neurosurgery, do you think chronic benzos are ever indicated in any circumstances?

Requiring neuroposurgery is not very specific. A mild TBI with slight bleed can technically require neurosurgery, but usually have little to no lasting effects.

Perhaps in about .001% of diagnosed individuals woudl I say chronic benzos are indicated. In general they do exceedingly more harm than good.
 
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Requiring neuroposurgery is not very specific. A mild TBI with slight bleed can technically require neurosurgery, but usually have little to no lasting effects.

Perhaps in about .001% of diagnosed individuals woudl I say chronic benzos are indicated. In general they do exceedingly more harm than good.
I respect your opinion but it does not align with the realities of clinical practice
 
TBI requiring neurosurgery, do you think chronic benzos are ever indicated in any circumstances?
I think they are not a prescriber but they are entitled to their opinions. Benzodiazepines for long-term use in anxiety disorders is in fact indicated for a particular set of patients that have no other comorbidities (SUD namely). The comfort levels of chronic prescription tends to vary depending on the era the psychiatrist was trained. Currently we are in the era of antipsychotics so generally newer psychiatrists are very comfortable with these, older psychiatrists might no be as comfortable.

Here is an article by one of my mentors which discusses this particular topic. You can DM to send you the full article if you do not have access.

Sorry for going off-topic as this is related to benzodiazepines and not Z-drugs.
 
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I think they are not a prescriber but they are entitled to their opinions. Benzodiazepines for long-term use in anxiety disorders is in fact indicated for a particular set of patients that have no other comorbidities (SUD namely). The comfort levels of chronic prescription tends to vary depending on the era the psychiatrist was trained. Currently we are in the era of antipsychotics so generally newer psychiatrists are very comfortable with these, older psychiatrists might no be as comfortable.

Here is an article by one of my mentors which discusses this particular topic. You can DM to send you the full article if you do not have access.

Sorry for going off-topic as this is related to benzodiazepines and not Z-drugs.

Unfortunately a lot of the research is very short-term. But, some of the longer term work suggests poorer functional outcomes and diasbiality, as well as cognitive deficits, while improved after discontinuatioj of long-term use, do not go back to a baseline compared to non chronic use (e.g., Crowe & Stranks, 2018). If you have log-term studies otherwise, I'd be interested to read if you could DM them.
 
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Unfortunately a lot of the research is very short-term.
Isn't that the case for most of the research in psychiatry? Longitudinal studies are a luxury that our current research/medical model doesn't really support. I whole-heartedly understand your bias towards chronic benzodiazepine use, you are not alone!
 
Isn't that the case for most of the research in psychiatry? Longitudinal studies are a luxury that our current research/medical model doesn't really support. I whole-heartedly understand your bias towards chronic benzodiazepine use, you are not alone!

It is, but we do have some long term studies, and they do suggest poor outcomes, both functionally and cognitively, in non-demented individuals. I was asking if there were compelling data otherwise, supporting their chronic use. You can call it bias, I simply call it following the best clinical evidence available.
 
It is, but we do have some long term studies, and they do suggest poor outcomes, both functionally and cognitively, in non-demented individuals. I was asking if there were compelling data otherwise, supporting their chronic use. You can call it bias, I simply call it following the best clinical evidence available.
I think the longest one was 22 years for benzos and dementia risk. To make it more complicated, the data shows that this is not a causal association but rather a risk factor.

 
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the recommendation for long term chronic benzo use is also recommended at very low doses. I have used benzos before in things like ID with severe behavioral disturbances and it was the only thing that gave the person any quality of life, but i think chronic benzo use would be indicated in very few people (in very particular circumstances). The reality is, if you give someone a benzo for 30 years, what are you going to do when they're 70? Going off will not be fun at all, and patients tend to tolerate them less as they get older.
 
I think the longest one was 22 years for benzos and dementia risk. To make it more complicated, the data shows that this is not a causal association but rather a risk factor.


The dementia risk lit is somewhat mixed, there are a few long term studies that do and a few that do not show an association. Somewhat messy samples with missing data, particularly the large Canadian and Korean studies. I was referring more to long term outcomes in the non-dementia populations.
 
The dementia risk lit is somewhat mixed, there are a few long term studies that do and a few that do not show an association. Somewhat messy samples with missing data, particularly the large Canadian and Korean studies. I was referring more to long term outcomes in the non-dementia populations.
What do you think the biggest risks are of chronic benzo use in someone who feels it has been helping them for many years without increasing the dose without any substance use issues
 
What do you think the biggest risks are of chronic benzo use in someone who feels it has been helping them for many years without increasing the dose without any substance use issues

Decline in cognition from baseline that does not revert to normal upon discontinuation. Poorer functional outcomes. Worsening of anxiety and making it harder to treat with behavioral methods. As they get older, fall risk, all cause mortality increase. Jury is still deliberating on dementia risk given messy and contradictory findings currently.
 
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If someone is on .25 for alprazolam for sleep I’d rather leave it as is than have them on a Z drug
 
Decline in cognition from baseline that does not revert to normal upon discontinuation. Poorer functional outcomes. Worsening of anxiety and making it harder to treat with behavioral methods. As they get older, fall risk, all cause mortality increase. Jury is still deliberating on dementia risk given messy and contradictory findings currently.
Gotcha, do you believe that all patients with anxiety can be treated to remission without benzos? Also, if you have a patient in front of you and he tells you that his cognition is good, his anxiety is under control, and he is happy with the way things are going and is not interested in changing but understands the theoretical risks you mentioned, you feel you have to change his regimen?
 
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