1
|
Watson NF, Benca RM, Krystal AD, McCall WV, Neubauer DN. Alliance for Sleep Clinical Practice Guideline on Switching or Deprescribing Hypnotic Medications for Insomnia. J Clin Med 2023; 12:jcm12072493. [PMID: 37048577 PMCID: PMC10095217 DOI: 10.3390/jcm12072493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023] Open
Abstract
Determining the most effective insomnia medication for patients may require therapeutic trials of different medications. In addition, medication side effects, interactions with co-administered medications, and declining therapeutic efficacy can necessitate switching between different insomnia medications or deprescribing altogether. Currently, little guidance exists regarding the safest and most effective way to transition from one medication to another. Thus, we developed evidence-based guidelines to inform clinicians regarding best practices when deprescribing or transitioning between insomnia medications. Five U.S.-based sleep experts reviewed the literature involving insomnia medication deprescribing, tapering, and switching and rated the quality of evidence. They used this evidence to generate recommendations through discussion and consensus. When switching or discontinuing insomnia medications, we recommend benzodiazepine hypnotic drugs be tapered while additional CBT-I is provided. For Z-drugs zolpidem and eszopiclone (and not zaleplon), especially when prescribed at supratherapeutic doses, tapering is recommended with a 1–2-day delay in administration of the next insomnia therapy when applicable. There is no need to taper DORAs, doxepin, and ramelteon. Lastly, off-label antidepressants and antipsychotics used to treat insomnia should be gradually reduced when discontinuing. In general, offering individuals a rationale for deprescribing or switching and involving them in the decision-making process can facilitate the change and enhance treatment success.
Collapse
|
2
|
Moniri NH. Reintroduction of quazepam: an update on comparative hypnotic and adverse effects. Int Clin Psychopharmacol 2019; 34:275-285. [PMID: 31274695 DOI: 10.1097/yic.0000000000000277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Insomnia is a prevalent disorder that affects over one-third of the U.S. population to varying degrees and is highly disruptive towards quality of life. Pharmacological treatments for insomnia include benzodiazepines (BZs) and the non-BZ 'Z-drugs' (zolpidem, zaleplon, eszopiclone, zopiclone), which are amongst the most widely prescribed medications. Yet, these agents can produce adverse effects such as tolerance to the hypnotic effect, rebound insomnia, next-day residual drowsiness, as well as amnesia and complex behaviours such as sleep-walking, sleep-eating and sleep-driving. Quazepam, one of the five BZ approved for treatment of insomnia, was recently relaunched to the U.S. market in 2016 and is distinguished amongst hypnotic BZ by unique pharmacological characteristics including selectivity for sleep-promoting α1-subunit containing γ-aminobutyric acid (GABA-A) receptors and a significantly lower relative receptor binding affinity. These features likely drive the decreased rate of adverse events seen clinically with quazepam, such as tolerance, rebound insomnia and amnesic behaviours, compared with other BZ. Given the recent reintroduction of quazepam as a pharmacotherapeutic option, and the lack of head-to-head comparative trials against newer agents, the purpose of this review is to provide an update on distinguishing features of quazepam with regard to its pharmacology, pharmacokinetics, sleep efficacy and potential adverse effects compared to other agents used for insomnia.
Collapse
Affiliation(s)
- Nader H Moniri
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University Health Sciences Center, Mercer University, Atlanta, Georgia, USA
| |
Collapse
|
3
|
|
4
|
Abstract
Ceiling and floor effects dictate that the efficacy of sleep-promoting stimuli should be proportional to the degree of pre-stimulus sleep impairment. This review addressed CF effects in polysomnographic research involving hypnotic drugs and exercise. Correlations of placebo/baseline levels of sleep with changes in sleep following hypnotic or exercise treatment were assessed across both literatures. CF effects were further addressed by comparing sleep-promoting effects of hypnotics vs exercise, after ANCOVA control for substantial baseline differences reported in studies of these stimuli. Significant correlations between placebo-baseline levels and sleep changes were observed following both hypnotic and exercise stimuli. Indeed, approximately 60% of the variance in improvement in sleep latency (SOL), wakefulness after sleep onset (WASO) and total sleep time (TST) following hypnotic treatment was associated with differences in baseline levels. ANCOVAs revealed significantly greater decreases in SOL and WASO following hypnotics compared with exercise. However, no significant difference between stimuli was found for TST, and exercise elicited a significantly greater increase in slow wave sleep. Similar results were found when a comparison between hypnotics and exercise was limited to good sleepers. The results show powerful CF influences on sleep responses to hypnotics and exercise and suggest a need for comparing these treatments in poor sleepers.
Collapse
Affiliation(s)
- Shawn D Youngstedt
- Department of Psychiatry and Sam and Rose, Stein Institute for Research on Aging, University of California, San Diego, California 92093-0667, USA.
| |
Collapse
|
5
|
|
6
|
Monane M, Glynn RJ, Avorn J. The impact of sedative-hypnotic use on sleep symptoms in elderly nursing home residents. Clin Pharmacol Ther 1996; 59:83-92. [PMID: 8549038 DOI: 10.1016/s0009-9236(96)90027-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine the frequency of sleep-related complaints among institutionalized elderly subjects and to assess the relationship between perceived sleep quality and the use of sedative-hypnotic agents and other psychoactive medications. METHODS In 12 nursing homes in Massachusetts, we conducted observational, cross-sectional, and longitudinal studies of 145 institutionalized elderly subjects (average age, 83.0 years; age range, 65 to 105 years). We recorded the patients' demographic characteristics and all medication use (both scheduled and as needed) during a 1-month baseline period. A research assistant who was blinded to diagnoses and medication use performed detailed neuropsychologic testing and administered a series of standardized questions concerning difficulty sleeping, early morning awakening, and time spent awake in bed. Medication use and patient assessments were repeated after a 6-month interval. RESULTS One or more sleep-related complaints were present at baseline in 94 (65%) of the residents studied. Using logistic regression to adjust for potential confounding, we found no relationship in the baseline month between use of sedative-hypnotic agents and the presence or absence of sleep complaints. After 6 months of follow-up, 27 (19%) of the residents had decreased their use of sedative-hypnotic agents and 23 (16%) had increased their use. However, there was no relationship between decreased use of sedative-hypnotic agents and worsened sleep (p > 0.20) or between their increased use and improved sleep reports (p > 0.10). Improvement in functional status was significantly associated with improved sleep at follow-up (p < 0.005). CONCLUSIONS Sleep complaints occur in the majority of institutionalized elderly persons. Neither cross-sectional nor longitudinal analyses showed a relationship between patterns of sedative-hypnotic use and the presence, absence, or change in sleep complaints.
Collapse
Affiliation(s)
- M Monane
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | | |
Collapse
|
7
|
Abstract
This article deals with some of the recent evidence bearing on the issues of the liability of benzodiazepines to lead to abuse, dependence, and adverse behavioral effects. Reviews of epidemiological, clinical and experimental literature indicated that the previous conclusion about abuse of these drugs still holds: the vast majority of the use of benzodiazepines is appropriate. Problems of nonmedical use arise nearly exclusively among people who abuse other drugs. Nevertheless, there are reasons for concern about patients who take benzodiazepines regularly for long periods of time. These drugs can produce physiological dependence when taken chronically, and although this does not appear to result in dose escalation or other evidence of "psychological dependence," physiological dependence can result in patient discomfort if drug use is abruptly discontinued. Also, physicians are currently prescribing shorter-acting benzodiazepines in preference to longer-acting benzodiazepines. The shorter-acting drugs can produce a more intense withdrawal syndrome following chronic administration. Furthermore, rates of use of benzodiazepines increase with age, and elderly patients are more likely than younger ones to take the drug chronically. The clearest adverse effect of benzodiazepines is impairment of memory. This, too, may be particular concern in older patients whose recall in the absence of drug is typically impaired relative to younger individuals, and who are more compromised following drug administration.
Collapse
Affiliation(s)
- J H Woods
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor 48109, USA
| | | |
Collapse
|
8
|
Hallfors DD, Saxe L. The dependence potential of short half-life benzodiazepines: a meta-analysis. Am J Public Health 1993; 83:1300-4. [PMID: 8103297 PMCID: PMC1694983 DOI: 10.2105/ajph.83.9.1300] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The dependence potential of benzodiazepine medications is now widely recognized, but uncertainty exists as to whether use of short half-life vs long half-life drugs results in greater dependence. The present study reports a meta-analysis of the extant research to evaluate the dependence potential of different types of benzodiazepines. METHOD Seven studies were found that specifically compared long half-life and short half-life benzodiazepines and allowed statistical comparison by their homogeneous dependent variables. Drugs in these studies were used as daytime sedatives. RESULTS Substantial evidence was found for differential effects of short vs long half-life drugs at withdrawal. In all studies, dropouts were higher among short half-life subjects. In the random-assignment short-term use studies, Hamilton Anxiety Scale scores showed higher incidence of rebound among subjects who used the short half-life drugs. CONCLUSIONS The present meta-analysis confirms clinical impressions of the greater dependence potential of short vs long half-life benzodiazepines. Doctors, patients, and policymakers need to be informed so as to avoid harm to the public health through unintended drug dependence.
Collapse
Affiliation(s)
- D D Hallfors
- Health Policy Institute, Brandeis University, Waltham, MA 02254-9110
| | | |
Collapse
|
9
|
Staufenberg EF. Sleep disorders. Epilepsy a differential diagnosis in children. BMJ (CLINICAL RESEARCH ED.) 1993; 306:1476. [PMID: 8518654 PMCID: PMC1677885 DOI: 10.1136/bmj.306.6890.1476-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
10
|
|
11
|
Adam K, Oswald I. Triazolam. Unpublished manufacturers research unfavourable. BMJ (CLINICAL RESEARCH ED.) 1993; 306:1475-6. [PMID: 8292128 PMCID: PMC1677863 DOI: 10.1136/bmj.306.6890.1475-b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
12
|
Borrow S, Tattersall ML, Hartman D, Oakey M, Sedgwick P, Crisp AH. Sleep disorders. Consider nocturnal paroxysmal dystonia. BMJ (CLINICAL RESEARCH ED.) 1993; 306:1476-7. [PMID: 8518657 PMCID: PMC1677890 DOI: 10.1136/bmj.306.6890.1476-c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
13
|
Burton G, Carter C. Triazolam. ...and selective referencing. BMJ (CLINICAL RESEARCH ED.) 1993; 306:1476. [PMID: 8518655 PMCID: PMC1677879 DOI: 10.1136/bmj.306.6890.1476-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
14
|
|
15
|
Teboul E, Chouinard G. A guide to benzodiazepine selection. Part II: Clinical aspects. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1991; 36:62-73. [PMID: 1674225 DOI: 10.1177/070674379103600117] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To suit the specific needs of various clinical situations, selection of an appropriate benzodiazepine derivative should be based on consideration of their different pharmacokinetic and pharmacodynamic properties. Benzodiazepine derivatives that are rapidly eliminated produce the most pronounced rebound and withdrawal syndromes. Benzodiazepines that are slowly absorbed and slowly eliminated are most appropriate for the anxious patient, since these derivatives produce a gradual and sustained anxiolytic effect. Rapidly absorbed and slowly eliminated benzodiazepines are usually more appropriate for patients with sleep disturbances, since the rapid absorption induces sleep and the slower elimination rate may induce less tolerance to the sedative effect. Rational selection of a benzodiazepine for the elderly and for the suspected drug abuser is more problematic. The relevant pharmacokinetic and clinical considerations for these users are discussed. Certain derivatives may possess pharmacodynamic properties not shared by the entire benzodiazepine class; empirical studies have suggested the existence of anti-panic properties for alprazolam and clonazepam, antidepressant properties for alprazolam, and anti-manic properties for clonazepam and possibly lorazepam.
Collapse
Affiliation(s)
- E Teboul
- Department of Psychiatry, McGill University, Montreal, Quebec
| | | |
Collapse
|
16
|
Bond WS. Insomnia Management and Hypnotic Benzodiazepine Therapeutics. J Pharm Technol 1990. [DOI: 10.1177/875512259000600606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
17
|
Mamelak M, Csima A, Price V. The effects of a single night's dosing with triazolam on sleep the following night. J Clin Pharmacol 1990; 30:549-55. [PMID: 2355105 DOI: 10.1002/j.1552-4604.1990.tb03619.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This study was undertaken to determine whether a single night's use of triazolam by normal healthy sleepers leads to withdrawal insomnia on the subsequent night, and whether there is a dose response relationship to this phenomenon. Thirty normal sleepers of both sexes were randomly assigned to three parallel treatment groups. All subjects were studied for five consecutive nights by means of pre- and post-sleep questionnaires and all night polysomnography. Multiple sleep latency tests were conducted on the days following the second, third, and fourth nights in the laboratory. All subjects received placebo capsules on the first, second, fourth, and fifth nights in the laboratory and either placebo, 0.25 mg triazolam or 0.5 mg triazolam according to their assigned group on the third night. Both doses of the drug increased subjective estimates of sleep duration, but no objective increase was found. Neither dose altered daytime measures of sleepiness. No changes were found in any of the sleep parameters on withdrawal of the 0.25 mg dose of triazolam. However, discontinuation of the 0.5 mg dose did lead to significant objective and subjective withdrawal effects. It was concluded that higher doses of triazolam could lead to withdrawal effects in normal sleepers even when this drug was used for only a single night.
Collapse
Affiliation(s)
- M Mamelak
- Department of Psychiatry, Sunnybrook Medical Centre, University of Toronto, Ontario
| | | | | |
Collapse
|
18
|
Affiliation(s)
- J C Gillin
- Department of Psychiatry, University of California, San Diego, La Jolla 92093
| | | |
Collapse
|
19
|
Affiliation(s)
- D J Greenblatt
- Division of Clinical Pharmacology, Tufts University School of Medicine, Boston, MA
| | | | | |
Collapse
|
20
|
McClure DJ, Walsh J, Chang H, Olah A, Wilson R, Pecknold JC. Comparison of lorazepam and flurazepam as hypnotic agents in chronic insomniacs. J Clin Pharmacol 1988; 28:52-63. [PMID: 3280615 DOI: 10.1002/j.1552-4604.1988.tb03101.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Hypnotic efficacy and safety of 3 weeks of daily doses of 2 mg lorazepam or 30 mg flurazepam were compared in a double-blind cross-over study in eight chronic insomniacs between the ages of 29 and 60 years. Subjects were monitored in the sleep laboratory twice weekly for a total of 25 nights. Also, subjective estimates of sleep, vigilance tests, and adverse effects were recorded throughout the study. Findings indicated lorazepam performed better than flurazepam in most sleep parameters. With lorazepam there was improvement from baseline in percentage of sleep time (P less than .05); in total wake time after sleep onset (P less than .01) and in last third of night (P less than .05); in percentage of stage 2 (P less than .05) (weeks 1, 2, 3) and in percentage of night in stage 4 (weeks 2 and 3). Only total wake time from baseline improved (P less than .05) with flurazepam (week 2). Objective and subjective sleep parameters did not correlate well for either drug. Neither drug impaired REM sleep or vigilance test performance. Side effects (grogginess, lethargy; flurazepam only) were few and none was unexpected; neither rebound insomnia nor early morning insomnia occurred with either drug. In summary, both lorazepam 2 mg at bedtime and flurazepam 30 mg at bedtime were found to be effective and safe for treating chronic insomnia, as measured by parameters of sleep and daytime functioning. Lorazepam had more favorable effects on sleep than did flurazepam.
Collapse
Affiliation(s)
- D J McClure
- Sleep Research Unit, St. Mary's Hospital Centre, Montreal, Quebec, Canada
| | | | | | | | | | | |
Collapse
|
21
|
Greenblatt DJ, Harmatz JS, Zinny MA, Shader RI. Effect of gradual withdrawal on the rebound sleep disorder after discontinuation of triazolam. N Engl J Med 1987; 317:722-8. [PMID: 3306380 DOI: 10.1056/nejm198709173171202] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Sixty volunteers with insomnia participated in a randomized, double-blind, controlled clinical trial. After an initial six nights of placebo, 30 subjects (the abrupt-withdrawal group) received 0.5 mg of triazolam nightly for 7 to 10 nights, after which they received placebo. The other 30 subjects (the tapered-dosage group) received the same initial placebo treatment, then triazolam at 0.5 mg for seven nights, at 0.25 mg for two nights, and at 0.125 mg for two nights, and then placebo. As compared with the initial placebo period, the triazolam period significantly reduced the interval before the onset of sleep (sleep latency), and it prolonged sleep duration, reduced the number of awakenings, and improved the self-rated soundness of sleep in all cohorts. In the abrupt-withdrawal group, plasma levels of triazolam were undetectable the morning after the first night of placebo substitution, and subjects reported prolongation of sleep latency (57 minutes longer than base line), reduction in sleep duration (1.4 hours less than base line), and increased awakenings (1.2 per night above base line). The symptoms of rebound sleep disorder lasted one or possibly two nights, and there was a reversion toward base line on subsequent placebo nights. In the tapered-dosage group, however, plasma triazolam levels fell gradually to zero, and rebound symptoms were decreased or eliminated. Thus, rebound sleep disorder following abrupt discontinuation of triazolam can be attenuated by a regimen of tapering.
Collapse
|
22
|
Kales A, Bixler EO, Vela-Bueno A, Soldatos CR, Manfredi RL. Alprazolam: effects on sleep and withdrawal phenomena. J Clin Pharmacol 1987; 27:508-15. [PMID: 3655003 DOI: 10.1002/j.1552-4604.1987.tb03058.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Alprazolam was evaluated in chronic insomniacs in a 1-mg bedtime dose. The 16-night sleep laboratory protocol included four placebo-baseline nights followed by seven nights of drug administration and five placebo-withdrawal nights. On the first three drug nights (nights 5 to 7), the drug was highly effective in inducing and maintaining sleep with this short-term use. By the end of the one week of administration (nights 9 to 11), however, the drug had lost about 40% of its efficacy. During drug use, one subject reported some difficulty in controlling expression of inappropriate emotions when interacting with others, which suggested the presence of disinhibition. On the third night following drug termination, there was a significant increase in sleep difficulty above baseline levels (rebound insomnia). This worsening was of comparable magnitude to the peak improvement of sleep with drug administration. Thus, the clinical utility of alprazolam when administered to insomniac patients appears to be limited because of a relatively rapid development of tolerance and possible disinhibitory reactions during drug use and the occurrence of rebound insomnia following withdrawal.
Collapse
Affiliation(s)
- A Kales
- Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey
| | | | | | | | | |
Collapse
|
23
|
Soldatos CR, Sakkas PN, Bergiannaki JD, Stefanis CN. Behavioral side effects of triazolam in psychiatric inpatients: report of five cases. DRUG INTELLIGENCE & CLINICAL PHARMACY 1986; 20:294-7. [PMID: 3516616 DOI: 10.1177/106002808602000418] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Triazolam was administered to five psychiatric inpatients for a two-week period. This period was preceded by a one-week placebo baseline and followed by another week of placebo administration. All conditions were double blind. By the second week of active drug administration, psychopathology greatly intensified across all of the patients with the emergence of anxiety, memory impairment, confusion, paranoid ideation, and hallucinations. The drug-induced behavioral changes persisted during the initial withdrawal period, but then gradually subsided. Also following drug withdrawal, four patients showed a marked worsening of their sleeplessness for several nights.
Collapse
|
24
|
Griffiths RR, Lamb RJ, Ator NA, Roache JD, Brady JV. Relative abuse liability of triazolam: experimental assessment in animals and humans. Neurosci Biobehav Rev 1985; 9:133-51. [PMID: 2858078 DOI: 10.1016/0149-7634(85)90039-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The abuse liability of a drug is a positive, interactive function of the reinforcing and adverse effects of the drug. The relative abuse liability of the hypnotic benzodiazepine, triazolam, has been controversial. This paper reviews animal and human studies bearing on its relative abuse liability, including data on pharmacological profile, reinforcing effects, liking, speed of onset, discriminative stimulus effects, subjective effects, physiological dependence, rebound and early morning insomnia, drug produced anxiety, lethality in overdose, psychomotor impairment, interactions with ethanol, anterograde amnesia, impaired awareness of drug effect, and other psychiatric and behavioral disturbances. It is concluded that the abuse liability of triazolam is less than that of the intermediate duration barbiturates such as pentobarbital. Although there are considerable data indicating similarities of triazolam to other benzodiazepines, there is also substantial speculation among clinical investigators and some limited data suggesting that the abuse liability of triazolam is greater than that of a variety of other benzodiazepines, and virtually no credible data or speculation that it is less. Further research will be necessary to clarify definitively the abuse liability of triazolam relative to other benzodiazepines.
Collapse
|
25
|
Bixler EO, Kales JD, Kales A, Jacoby JA, Soldatos CR. Rebound insomnia and elimination half-life: assessment of individual subject response. J Clin Pharmacol 1985; 25:115-24. [PMID: 2859304 DOI: 10.1002/j.1552-4604.1985.tb02811.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Following abrupt withdrawal of five benzodiazepine hypnotics, the presence of rebound insomnia on individual subject nights was evaluated in comparison to a placebo group. During the first three nights of withdrawal, the frequency of occurrence of rebound insomnia for drugs with relatively rapid rates of elimination (triazolam, midazolam, and lormetazepam) was significantly higher than that for the placebo control group. In contrast, the frequency of withdrawal sleep difficulty for two slowly eliminated hypnotics (flurazepam and quazepam) was similar to that of the placebo control group during each of five successive three-night segments of a 15-night withdrawal period. These findings, based on individual subject-night data, confirm and extend previous reports using group mean values that demonstrate a frequent, immediate, and intense degree of rebound insomnia following abrupt withdrawal of relatively rapidly eliminated hypnotic drugs and an infrequent, delayed, and milder degree of sleep difficulty following withdrawal of slowly eliminated drugs.
Collapse
|