Zolpidem dependence case series: possible neurobiological mechanisms and clinical management

Case report: Additional grounds for tighter regulation? A case series of five women with zolpidem dependence from a Brazilian women-specific substance use disorder outpatient service

Objective

This study presents a case series of five women with zolpidem dependence treated at the Drug Dependent Women Treatment Center (PROMUD), one of the first women-specific substance use disorder outpatient services in Latin America.

Methods

This was an retrospective review of medical records of patients with a diagnosis of zolpidem dependence at the Institute of Psychiatry of Clinics Hospital of University of São Paulo between December 2021 and December 2023. Description of the cases followed the Case Report Statement, Checklist and Guidelines (CARE). The weekly zolpidem intake, comprising prescribed amounts and relapse episodes, was totaled to compute a mean daily dose. This was graphically illustrated to bring clinical insights.

Results

The patients, aged 25-45 years, displayed escalating oral zolpidem doses (range: 60-900 mg/day), with adverse effects such as memory and social impairment, falls, seizures. Commonalities among cases included initiating zolpidem use for primary insomnia and withdrawal symptoms, including rebound insomnia, social impairment, and craving. History of physical and psychological abuse were reported. Comorbid psychiatric conditions, particularly eating disorders (n=3), recurrent depression (n=1), borderline personality disorder traits (n=1), and attention deficit hyperactivity disorder (n=1), were identified. Although zolpidem abuse often correlates with the concurrent abuse of other substances, none of the reported cases in this study exhibited other substance use disorders. Concurrent use of sedatives, especially benzodiazepines and levomepromazine, was observed (n=2).

Conclusion

The surge in zolpidem prescriptions, driven by its perceived safety and low abuse potential compared to benzodiazepines, may lead to a global health issue of dependence. The medical community faces the challenge of managing this without standardized treatment protocols. Our case series underscores the effectiveness of the PROMUD program, which employs a multidisciplinary, women-specific approach with tailored group therapies and weekly psychiatric appointments to address and prevent relapse.

Electroencephalogram changes over time in zolpidem withdrawal seizure: A case study

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Case Report: High doses of Zolpidem and QT interval lengthening: Is there a relationship? A case series

Zolpidem is indicated in cases of severe insomnia in adults and, as for BDZs, its assumption should be limited to short periods under close medical supervision. Since several drugs cause corrected QT interval (QTc) elongation, the authors investigated whether high daily doses of Zolpidem could cause QTc elongation. The study was conducted in the Addiction Medicine Unit of the G.B. Rossi University Hospital in Verona. The data were collected from hospitalizations carried out between January 2015 and February 2020 and refer to a total of 74 patients, 38 males and 36 females, who were treated for detoxification from high doses of Zolpidem with the "Verona Detox Approach With Flumazenil." One patient out of 74 had QTc elongation (479 ms). The patient was male and took a daily dose of 50 mg of Zolpidem; he did not take concomitant therapies that could cause QTc lengthening. He had no electrolyte alterations, no contemporary or previous intake of barbiturates, heroin, cocaine, THC, alcohol, NMDA or nicotine which could cause an elongation of the QTc interval. The present study highlights the low risk of QTc elongation due to high dosages of Zolpidem; however, if, on one hand, we can affirm that Zolpidem is a safe drug, on the other, the widespread use of high dosages of this drug for prolonged periods of time is problematic and worrying.

Case report: Chronological symptom profile after cessation of overdose zolpidem in a patient with comorbid bipolar disorder-from anxiety, craving, paresthesia and influenza-like symptoms to seizures and hallucinations

INTRODUCTION

Insomnia is a major public health problem that determines the quality of life. Among the many causes of insomnia, psychological factors have an important influence on the process, duration of insomnia, help-seeking behavior, and treatment choice. Regarding medical treatment, zolpidem is always chosen to treat acute and transient insomnia due to its few side effects. Although some randomized controlled trials have verified its safety, zolpidem abuse and withdrawal reactions have been reported in recent years.

CASE REPORT

A 25-year-old unmarried man with a college degree who worked as a graphic designer was referred and admitted to the inpatient ward for a chief complaint of "alternative episodes of lowering and elevation of mood for 10 years, overdosage use of zolpidem for two years." He underwent a time-dependent withdrawal reaction after admission. It was characterized by rebound insomnia, anxiety, craving, skin paresthesia, influenza-like symptoms, tonic-clonic-type seizures, and hallucinations. At the 1-year follow-up, he did not exhibit any remaining withdrawal symptoms.

DISCUSSION

The acute cessation of overdosage zolpidem use causes a series of withdrawal symptoms that manifest in chronological order. Additionally, long-term benzodiazepine exposure has potential influences on zolpidem dependence/tolerance. However, patients with a history of abuse or dependence, or mental disorders seem to be at risk of drug abuse. Clinicians should be alert to the potential for zolpidem dependence and addiction. Once the acute cessation of overdosage zolpidem use occurs, the potential of the withdrawal reaction needs to be considered and addressed properly.

Zolpidem withdrawal seizure in an Iranian young woman: A case presentation

Background

Zolpidem is a non-benzodiazepine drug, approved by FDA for sleep induction. Zolpidem is thought to be a safer drug than benzodiazepines (BZD) because of no evidence of abuse or dependence potential, but several case reports of zolpidem abuse and dependence have been published along with a small number of cases demonstrating seizures after sudden zolpidem withdrawal.

Case presentation

A 32-year-old unmarried woman suffering from major depressive disorder had been taking zolpidem for insomnia for more than 1 year. She began to take zolpidem alone without mixing other kinds of hypnotics, and 50 mg of zolpidem used to be initially effective in treating her insomnia. In some days the dose increased up to 100 mg per day. In the end, she had to discontinue zolpidem abruptly because she could not afford it anymore. After 2 days, she suddenly showed facial spasm, mouth opening, tonic-clonic seizure, and loss of consciousness for about 1-2 minutes. Post-ictal confusion with clouded consciousness, psycho-motor retardation, persisted in 1 day. EEG in wakefulness revealed intermittent, generalized, diffused alpha wave and diffused sharp waves, and suggested seizure waves in the patient.

Conclusion

Our case suggested that the potential of zolpidem dependence and withdrawal seizure are also present in the Iranian population. The female-gender, high dosage and long-term use of zolpidem might be risk factors for the development of adverse effects.

Screening out the anti-insomnia components from Prunella vulgaris L. based on plasma pharmacochemistry combined with pharmacodynamic experiments and UPLC-MS/MS analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Prunella vulgaris L. (P. vulgaris) is a medicinal plant belonging to the Labiatae family, and its dried spikes is called as Xiakucao in China, which is a common traditional Chinese medicine with the activities of clearing the liver and expelling fire, improving eyesight, dispersing nodules and detumescence. Modern pharmacological studies have proved that P. vulgaris has various pharmacological activities such as immunomodulatory, antiviral, antibacterial and anti-insomnia activities.

AIMS OF THIS REVIEW

P. vulgaris have been reported to have anti-insomnia effects. Nevertheless, the pharmacodynamic substance basis of this anti-insomnia effect is still unclear. The aim of this study was to identify the active components responsible for evoking the anti-insomnia effect of P. vulgaris and to evaluate its anti-insomnia effect.

MATERIALS AND METHODS

In this study, we proposed a method combined with pharmacodynamic experiments, extraction and enrichment of chemical components, and the plasma pharmacochemistry to screen out the anti-insomnia components of P. vulgaris. Firstly, the active eluted fraction of the ethanol extract was screened out based on pharmacodynamic tracing method, and then the chemical composition was analyzed systematically by UPLC-MS/MS. Thirdly, pharmacodynamic tracing method and silica gel column chromatography were employed to screen out the active fraction of 70% ethanol eluted fraction, and its bioactive components in vitro and in vivo were identified by UPLC-MS/MS. Finally, screening out the anti-insomnia components of P. vulgaris by comparing the difference between in vivo and in vitro components, and three potentially bioactive ingredients were validated experimentally.

RESULTS

It was confirmed that the fraction eluted with 70% ethanol from macroporous adsorption resin column was responsible for the anti-insomnia efficacy, and 55 compounds were identified or preliminarily identified. Then totally 9 compounds in vitro and 12 compounds in vivo from the active fraction of 70% ethanol eluted fraction were tentatively identified. Among them, mangiferin, rosmarinic acid and salviaflaside were the prototype components of P. vulgaris, which indicated that the three compounds might play the key role in the anti-insomnia activities. In vivo, compared to blank control group, the three compounds significantly shortened the sleeping latency and prolonged the sleeping time produced by pentobarbital sodium.

CONCLUSIONS

This study clarified that mangiferin, rosmarinic acid and salviaflaside were considered as the anti-insomnia components of P. vulgaris. This is the first study on screening out the active ingredients responsible for evoking the anti-insomnia effect of P. vulgaris. The three compounds of P. vulgaris may help develop one or more drugs to prevent or treat insomnia. Further investigations are recommended to define the mechanism of the anti-insomnia activity of P. vulgaris.

'Z-trip'? A Comprehensive Overview and a Case-series of Zolpidem Misuse

Although believed safer compared to short-acting benzodiazepines (BZD), in the past few years a growing concern has developed relating to the abuse of Z-drugs, and specifically of zolpidem. Here we aim to review the evidence for the misuse of zolpidem and describe several related cases collected in Italy. A comprehensive overview is here carried by using several databases, and by combining the search strategy of free text terms and exploding a range of MESH headings relating to the topics of Zolpidem and Abuse and/or Misuse as follows: ((Zolpidem[Title/Abstract]) AND (Abuse[Title/Abstract]) OR (Misuse[Title/Abstract])), without time and/or language restrictions. Furthermore, a case series of 8 cases of zolpidem misuse and/or abuse, collected in different Italian psychiatric settings (psychiatric public hospital, psychiatric private rehabilitation clinic, and private practice), have been here described. According to our findings, zolpidem should be prescribed with the same caution as BZDs, especially in patients with a history of drug abuse or in the elderly. Behavioural modifications, including bizarre behaviours, psychomotor agitation, sleep-related complex behaviours have been reported. Monitoring of zolpidem use in selected populations is warranted. Psychiatrists and physicians should be aware of the misuse potential of zolpidem and adopt measures restricting its use.

A case of zolpidem dependence with extremely high daily doses

The human population has been witnessing an increase in the number of diseases which are a consequence of progressively increasing physical and mental stress. Insomnia is one such condition whose prevalence is rising all over the world. Apart from the conventional behavioral interventions and use of benzodiazepines, the use of non-benzodiazepine drugs has seen a surge in recent times. The various adverse effects associated with benzodiazepines, dependence potential being one of them, led to an ever increasing use of non-benzodiazepine sedatives like zolpidem and zopiclone all over the world. But with their continuous and ever increasing use, it is seen that even these drugs carry dependence potential. Numerous cases of zolpidem abuse have been reported in literature until now. Here, we are presenting the case of a zolpidem-dependent patient who consumed it in quantities of 2400 mg/day, a quantity not reported anywhere in literature and around 240 times more than its usual prescribed daily dosage.

Zolpidem stimulant effect: Induced mania case report and systematic review of cases

INTRODUCTION

Zolpidem is the most widely prescribed hypnotic agent worldwide. This easy-access drug seems to have a high addictive potential among specific populations and is now listed by the World Health Organization (WHO) as being as dangerous as benzodiazepines for dependence and abuse. Many side effects have been reported, but drug-induced mania is still extremely rare. We conducted a systematic review to study the zolpidem-induced stimulation, euphoric or manic effects.

METHODS

MEDLINE, PsycINFO, Science Direct, and Google Scholar were searched for articles in English, French, German, Italian and Spanish published up to the 15th October 2018.

RESULTS

Eighteen relevant cases were identified, highlighting the need for more reports; therefore, one case that occurred in our department was included. The mean usual dose was 363.31 mg (± 292.2), the minimum dose was 10 mg, the maximum dose was 2000 mg, and the mean intake duration was 35.20 months (±48.0). We found that 89.4% of cases were euphoric and 15.7% had drug-induced mania with delusions. A total of 15.7% of cases took zolpidem for relaxant and stimulant effects, 47% of cases suffered various depression or anxiety disorders, of which 62.5% used zolpidem to cope with depression or an anxiety disorder. A total of 26.3% of cases had concomitant drug dependence or abuse. Seventy-five percent of cases suffering from depression consumed zolpidem for more than 1 year, with significantly more increased daily doses than in non-depressed cases (p < .5).

CONCLUSIONS

The latest FDA recommendations for lowering zolpidem doses should be adopted by all countries. Zolpidem prescriptions should be contraindicated for populations with identified risk factors.

Sleep modulating agents

Sleep and wake are two fundamental states of human existence. Conditions such as insomnia and hypersomnia can have profound negative effects on human health. Many pharmacological interventions impacting sleep and wake are available or are under development. This brief digest surveys early approaches to sleep modulation and highlights recent developments in sleep modulating agents.

Severe Chronic Abuse of Zolpidem in Refractory Insomnia

ABSTRACT

Zolpidem is an imidazopyridine nonbenzodiazepine hypnotic drug with a high affinity to the α1 subunit of the gamma amino butyric acid A receptor It is the first pharmacological option in the short-term management of sleep-onset insomnia. Initially considered a safer drug compared to benzodiazepines because of lower liability for abuse and dependence, recently, an increasing body of reports has questioned zolpidem's proneness to misuse. In this report, we describe a case of serious zolpidem abuse requiring pharmacological washout during hospitalization because of previous withdrawal seizures in a patient with chronic sleep-onset and maintenance insomnia.

High-dose zolpidem dependence - Psychostimulant effects? A case report and literature review

Zolpidem, an imidazoline nonbenzodiazepine sedative drug, is used widely. Initial reports showed minimal abuse potential. However, multiple reports have appeared of dose escalation and abuse. Subjective effects of high-dose zolpidem are not known. In light of accumulating evidence of abuse potential, we hereby report a case of high-dose dependence and a review of relevant literature. A 33-year-old male presented with 5 years of daily use of 600-1700 mg of zolpidem tartrate. He reported subjective effects of euphoria, intense craving, and inability to stop use. Loss of receptor specificity, pharmacokinetic factors, and different receptor distributions can explain paradoxical stimulatory effects of high-dose zolpidem. Further studies are required to characterize subjective effects of high-dose zolpidem.

Association Between Zolpidem and Suicide: A Nationwide Population-Based Case-Control Study

OBJECTIVE

To evaluate the association between zolpidem and the risk of suicide.

PATIENTS AND METHODS

In this nationwide case-control study, the case group comprised 2199 people who committed suicide or were hospitalized due to suicide attempt between January 1, 2002, and December 31, 2011. To create a control group, we randomly selected 10 people matched to each case according to age, sex, urbanization, and occupation. We measured the risk of suicide/suicide attempt in association with zolpidem exposure by using adjusted odds ratios (ORs) and assessed the dose-response effect of zolpidem.

RESULTS

After adjustment for potential confounders such as the comorbidities of schizophrenia, major depression, bipolar disorder, anxiety, insomnia, substance use, and other mental disorders, the Charlson comorbidity index, and use of benzodiazepine or antidepressants, zolpidem exposure was found to be significantly associated with the risk of suicide/suicide attempt with an OR of 2.08 (95% CIs, 1.83-2.36). The risk increased with the level of zolpidem use. The ORs (95% CIs) for cumulative defined daily doses of less than 90, 90 to 179, and 180 mg or more were 1.90 (1.65-2.18), 2.07 (1.59-2.67), and 2.81 (2.33-3.38), respectively (for trend, P<.001). Subgroup analyses showed that the exposure to zolpidem consistently increased the OR in different age groups, sex, urbanization level, occupation, mental disorders, and Charlson comorbidity index levels and in groups of people with or without the presence of insomnia.

CONCLUSION

This study demonstrated a significant association between using zolpidem and suicide or suicide attempt in people with or without comorbid psychiatric illnesses (all P<.05).

Risk of arteriovenous fistula failure associated with hypnotic use in hemodialysis patients: a nested case-control study

PURPOSE

Hypnotic use might cause altered inflammatory processes, which have been suggested as being related to the mechanisms of arteriovenous fistula (AVF) failure. Therefore, we examined the association between the risk of AVF failure and hypnotic use in patients receiving hemodialysis (HD).

METHODS

A nested case-control study was conducted using data from the National Health Insurance Research Database of Taiwan. From 34 165 HD patients, 3676 patients receiving percutaneous transluminal angioplasty or surgical thrombectomy for AVF failure were matched to 14 704 control patients according to sex, age (±1 year), and the year of initial HD therapy. The risk of AVF failure was estimated based on conditional logistic regression after adjustment for the timing of AVF creation, HD frequency, comorbidities, and prescribed medications. Hypnotic use was measured prior to the date of AVF failure of case patients and the date of pseudo-AVF failure of controls.

RESULTS

Compared with matched controls, case patients were more likely to be exposed to hypnotics 30 days or an average daily defined dose > 0.5 within 90 days before the date of AVF failure, with an adjusted odds ratio of 1.21 (95% confidence interval [CI]: 1.09-1.35, p < 0.001) and 1.36 (95%CI: 1.13-1.63, p = 0.001), respectively. Risk of AVF failure associated with hypnotic use was also observed among HD patients who were male, were younger than 65 years, had hypertension, and did not use statins.

CONCLUSIONS

Hypnotic use among HD patients was associated with an increased risk of AVF failure. Copyright © 2016 John Wiley & Sons, Ltd.

Relationship Between Acute Benzodiazepine Poisoning and Acute Pancreatitis Risk: A Population-Based Cohort Study

We designed a population-based retrospective cohort study to investigate the association between the event of benzodiazepine (BZD) poisoning and the risk of acute pancreatitis.In the present study, 12,893 patients with BZD poisoning during 2000 to 2011 were enrolled and matched with 4 comparison patients according to mean age and sex. We determined the cumulative incidences and adjusted hazard ratios of acute pancreatitis.A significant association was observed between BZD poisoning and acute pancreatitis. After adjustment for potential risk factors, the patients with BZD poisoning had a 5.33-fold increased risk of acute pancreatitis compared with the controls without BZD poisoning (HR = 5.33, 95% CI = 2.26-12.60). The results revealed that acute pancreatitis in patients with BZD poisoning occurred in a follow-up time of ≤1 month (HR = 50.0, P < .001), and the risk of acute pancreatitis was no different between the patients with and without BZD poisoning when the follow-up time was >1 month (HR = 1.07, P > .05).This population-based study revealed the positive correlation between the event of BZD poisoning and an increased risk of acute pancreatitis. The findings warrant further large-scale and in-depth investigation.

Ursolic acid enhances pentobarbital-induced sleeping behaviors via GABAergic neurotransmission in mice

Prunella vulgaris is widely used as a herbal medicine for cancers, inflammatory diseases, and other infections. Although it has long been used, few studies have examined its effects on central nervous system function. Here, we first observed that ethanolic extracts of P. vulgaris (EEPV) prolonged pentobarbital-induced sleep duration in mice. It is known that EEPV consists of many active components including triterpenoid (ursolic acid and oleanolic acid), which have many biological activities. Therefore, we evaluated which EEPV components induced sleep extension in pentobarbital-mediated sleeping model in mice. Surprisingly, despite their structural similarity and other common functions such as anti-inflammation, anti-cancer, and tissue protection, only ursolic acid enhanced sleep duration in pentobarbital-treated mice. These results were attenuated by bicuculline treatment, which is a GABAA receptor antagonist. The present results suggest that ursolic acid from P. vulgaris enhances sleep duration through GABAA receptor activation and could be a therapeutic candidate for insomnia treatment.

Dependence, misuse, and beliefs regarding use of hypnotics by elderly psychiatric patients taking zolpidem, estazolam, or flunitrazepam

INTRODUCTION

To examine the prevalence rates and correlates of dependence on, misuse of, and beliefs regarding use of hypnotics in elderly psychiatric patients with long-term use of zolpidem, estazolam, or flunitrazepam.

METHODS

A total of 139 psychiatric outpatients 65 or more years of age who used zolpidem, estazolam, or flunitrazepam for at least 3 months were studied. The levels of hypnotic dependence and beliefs regarding hypnotic use (necessity and concern) were assessed. Three patterns of hypnotic misuse in the past 1 month were also explored. The correlates of high dependence, misuse, and unfavorable attitude and high concern toward hypnotic use were examined using logistic regression analyses.

RESULTS

A total of 28.8%, 7.9%, 12.2%, and 22.3% of participants reported high dependence on, misuse of, unfavorable attitude toward, and high concern toward hypnotic use, respectively. Males were more likely to report unfavorable attitude toward hypnotic use than females. Elders with significant depression were more likely to report high concern toward hypnotic use than those without significant depression. Elders with high concern toward hypnotic use were more likely to report high dependence on hypnotics than those with low concern. Elders with significant depression and taking zolpidem were more likely to misuse hypnotics than those without significant depression and taking estazolam or flunitrazepam, respectively.

DISCUSSION

Clinicians should monitor the possibility of dependence on and misuse of hypnotics among elderly psychiatric patients who had the correlates identified in this study.

Correlates of dependence and beliefs about the use of hypnotics among zolpidem and zopiclone users

BACKGROUND

Zolpidem and zopiclone are the two most commonly prescribed Z-drugs approved to treat insomnia.

OBJECTIVES

To examine the demographic and clinical correlates of dependence and beliefs about hypnotic use among long-term zolpidem and zopiclone users in psychiatric treatment for insomnia.

METHODS

A total of 392 psychiatric outpatients who received zolpidem or zopiclone treatment for at least 3 months for insomnia were studied. Participants' severity of hypnotic dependence and beliefs about the use of hypnotics to treat sleep problems were assessed. The correlation of dependence and beliefs about zolpidem and zopiclone treatment with demographic characteristics, hypnotic-using behaviors, co-use of addictive substances, and depressive symptoms were analyzed using multiple regression analysis models.

RESULTS

Zolpidem users reported more severe dependence and a lower level of necessity regarding the use of hypnotics than zopiclone users did. High equivalent doses of hypnotics and long duration of use were significantly associated with severe dependence and a low level of necessity. Severe depressive symptoms were signiciantly associated with severe dependence, a low level of necessity, and a low level of concern. Educational level was also associated with the levels of concern and necessity. Conclusions/Importance: There were differences in the level of dependence and belief about hypnotic use between zolpidem and zopiclone users. The correlates of dependence and belief identified in this study can serve as the basis for prevention and intervention programs.

Non-Benzodiazepine Receptor Agonists for Insomnia

Because of proven efficacy, reduced side effects, and less concern about addiction, non-benzodiazepine receptor agonists (non-BzRA) have become the most commonly prescribed hypnotic agents to treat onset and maintenance insomnia. First-line treatment is cognitive-behavioral therapy. When pharmacologic treatment is indicated, non-BzRA are first-line agents for the short-term and long-term management of transient and chronic insomnia related to adjustment, psychophysiologic, primary, and secondary causation. In this article, the benefits and risks of non-BzRA are reviewed, and the selection of a hypnotic agent is defined, based on efficacy, pharmacologic profile, and adverse events.

Zolpidem dependency and withdrawal seizure: a case report study

Introduction:

Zolpidem is a short acting inducer of sleep and thought to lack benzodiazepine properties such as anxiolysis, anticonvulsion, muscle relaxation and side effects such as dependency. Recently, some cases of Zolpidem abuse and dependency have been reported. In review of literature, we found that the lowest reported dosage of Zolpidem, which caused dependency, was 160 mg daily.

Case Presentation:

We reported a 30-year-old unmarried Iranian woman with dysthymic disorder and chronic insomnia treated with Zolpidem irregularly. She started to use Zolpidem with 5mg per day irregularly since a year ago but augmented its daily dosage gradually to 100 to 150 mg per day in divided doses. After a period of 16 hours without taking Zolpidem she developed a withdrawal syndrome, with generalized tonic-clonic seizures for two times. She was managed with supportive care and recovered completely.

Conclusions:

Zolpidem dependency and withdrawal seizure can occur with a dosage under last reported doses. Therefore, possibility of mentioned problems cannot be excluded at any dosage and physicians should pay more attention to potential of Zolpidem to create these adverse effects.

The effects of repeated zolpidem treatment on tolerance, withdrawal-like symptoms, and GABAA receptor mRNAs profile expression in mice: comparison with diazepam

RATIONALE

Zolpidem is a short-acting, non-benzodiazepine hypnotic that acts as a full agonist at α1-containing GABAA receptors. Overall, zolpidem purportedly has fewer instances of abuse and dependence than traditionally used benzodiazepines. However, several studies have shown that zolpidem may be more similar to benzodiazepines in terms of behavioral tolerance and withdrawal symptoms.

OBJECTIVES

In the current study, we examined whether subchronic zolpidem or diazepam administration produced deficits in zolpidem's locomotor-impairing effects, anxiety-like behaviors, and changes in GABAAR subunit messenger RNA (mRNA).

METHODS

Mice were given subchronic injections of either zolpidem (10 mg/kg), diazepam (20 mg/kg), or vehicle twice daily for 7 days. On day 8, mice were given a challenge dose of zolpidem (2 mg/kg) or vehicle before open field testing. Another set of mice underwent the same injection regimen but were sacrificed on day 8 for qRT-PCR analysis.

RESULTS

We found that subchronic zolpidem and diazepam administration produced deficits in the acute locomotor-impairing effects of zolpidem and increased anxiety-like behaviors 1 day after drug termination. In addition, we found that subchronic treatment of zolpidem and diazepam induced distinct but overlapping GABAAR subunit mRNA changes in the cortex but few changes in the hippocampus, amygdala, or prefrontal cortex. Levels of mRNA measured in separate mice after a single injection of either zolpidem or diazepam revealed no mRNA changes.

CONCLUSIONS

In mice, subchronic treatment of zolpidem and diazepam can produce deficits in the locomotor-impairing effects of zolpidem, anxiety-like withdrawal symptoms, and subunit-specific mRNA changes.

Zolpidem abuse and dependency in an elderly patient with major depressive disorder: a case report

OBJECTIVE

Zolpidem is a non-benzodiazepine hypnotic drug for treatment of insomnia. It has been introduced as a lower potential agent for dependency and abusive effects.

CASE SUMMARY

In this study, the reported case was a 62 years old female patient suffering simultaneously with Major Depressive Disorder and Opium Dependency. After abrupt discontinuation of zolpidem, 570 mg per day, she exhibited severe withdrawal symptoms, led her to be admitted to emergency department.

CONCLUSIONS

Zolpidem has a potency to be abused with high risk of dependency and withdrawal syndromes particularly among elderly patients with comorbid anxiety/depressive symptoms/disorders.

The misuse of Ambien among adolescents: prevalence and correlates in a national sample

The current research examines correlates of Ambien misuse among adolescents. Given the recent popularity of prescription drug misuse, the known risks associated with prescription drugs, the fact that Ambien is widely prescribed, and the relative lack of research on prescription sedative misuse, we believe this research is important. The current study fills this important gap in the literature by examining data from the 2009 National Survey on Drug Use and Health, which includes a sample of more than 17,000 adolescents ages 12 to 17 that is generalizable to the non-institutionalized population of the United States. The prevalence of lifetime Ambien misuse in the sample was 1.4%. The current research identified several significant risk factors for Ambien misuse: age, race, income, religiosity, delinquency, depression, social bonding, peer substance use, attitudes toward substance use, strain, and other substance use. Implications and limitations of the current research are discussed.

Zolpidem withdrawal delirium

The Z-category hypnotics are promoted for their relative safety. However, this view is challenged by the emerging clinical evidence in the form of zolpidem related intoxication delirium and seizures, and dependence and complicated withdrawal. We report the case of a zolpidem-naive alcohol-dependent inpatient that, while undergoing alcohol de-addiction, was prescribed zolpidem for insomnia and developed delirium during taper-off. He was successfully detoxified for alcohol, treated for delirium and put on disulfiram prophylaxis. The case highlights the need for being cautious while using zolpidem for insomnia in alcohol dependent subjects.

Detoxification of high-dose zolpidem using cross-titration with an adequate equivalent dose of diazepam

BACKGROUND

There have been numerous case reports of zolpidem abuse and dependence in the recent decade, giving rise to a focus on adverse withdrawal events such as seizure. No standard detoxification regimen has been proposed to date, despite the similarity of effects of zolpidem and benzodiazepines at high doses.

CASE DESCRIPTIONS

We describe the results, in a 53-year-old female patient, of undergoing three different zolpidem detoxification programs.

CONCLUSIONS

Because of her experiences, we recommend using the cross-titration strategy with an adequate equivalent dose of diazepam.

Modest abuse-related subjective effects of zolpidem in drug-naive volunteers

Recent case reports suggest that the short-acting benzodiazepine-like hypnotic, zolpidem, may have abuse potential among individuals who have no personal history of abusing drugs or alcohol, particularly at doses higher than those recommended for treating insomnia. This study recruited drug-naive volunteers to assess the subjective effects of multiple doses of zolpidem (0, 5, 10, or 20 mg) administered in a within-subject double-blind design. Participants (n=11) answered computerized questionnaires (Addiction Research Center Inventory, visual analog scales, and a hypothetical Drug versus Money Choice) to address the hypothesis that a supratherapeutic dose (20 mg) would increase ratings of abuse-related subjective effects, while lower therapeutic doses (5 and 10 mg) would not. Although participants rated some effects as negative at 10 and 20 mg, the highest dose engendered predominantly positive abuse-like effects such as 'High', 'Like', and 'Good Effects'. However, no dose of zolpidem was chosen over money ($0.35-$10) when participants made hypothetical choices between them. Results suggest that although individuals without a drug abuse history are not inclined to choose zolpidem when presented with an alternative reinforcer such as money, it may possess moderate abuse potential that limits its clinical utility.

Zolpidem, a clinical hypnotic that affects electronic transfer, alters synaptic activity through potential GABA receptors in the nervous system without significant free radical generation

Zolpidem (trade name Ambien) has attracted much interest as a sleep-inducing agent and also in research. Attention has been centered mainly on receptor binding and electrochemistry in the central nervous system which are briefly addressed herein. A novel integrated approach to mode of action is presented. The pathways to be discussed involve basicity, reduction potential, electrostatics, cell signaling, GABA receptor binding, electron transfer (ET), pharmacodynamics, structure activity relationships (SAR) and side effects. The highly conjugated pyridinium salt formed by protonation of the amidine moiety is proposed to be the active form acting as an ET agent. Extrapolation of reduction potentials for related compounds supports the premise that zolpidem may act as an ET species in vivo. From recent literature reports, electrostatics is believed to play a significant role in drug action.

The pyridinium cation displays molecular electrostatic potential which may well play a role energetically or as a bridging mechanism. An SAR analysis points to analogy with other physiologically active xenobiotics, namely benzodiazepines and paraquat in the conjugated iminium category. Inactivity of metabolites indicates that the parent is the active form of zolpidem. Absence of reactive oxygen species and oxidative stress is in line with minor side effects. In contrast, generally, the prior literature contains essentially no discussion of these fundamental biochemical relationships. Pharmacodynamics may play an important role. Concerning behavior at the blood-brain barrier, useful insight can be gained from investigations of the related cationic anesthetics that are structurally related to acetyl choline. Evidently, the neutral form of the drug penetrates the neuronal membrane, with the salt form operating at the receptor. The pathways of zolpidem have several clinical implications since the agent affects sedation, electroencephalographic activity, oxidative metabolites and receptors in the central nervous system. The drug acts at the GABA(A) receptor benzodiazepine site, displaying high and intermediate affinities to various receptor regions. Structural features for tight binding were determined. The sedative and anticonvulsant activities are due to its action on the alpha-1-GABA(A) receptors. One of the common adverse responses to zolpidem is hallucinations. Proposed mechanisms comprise changes in the GABA(A) receptor, pharmacodynamic interactions involving serotonin and neuronal-weak photon emission processes entailing redox phenomena. Reports cite cases of abuse with cravings based on anxiolytic and stimulating actions. It is important to recognize that insight concerning processes at the fundamental, molecular level can translate into beneficial results involving both positive and adverse side effects. In order for this to occur, interdisciplinary interaction is necessary. Suggestions are made for future research aimed at testing the various hypotheses.

Severe dependency on zolpidem in a patient with multiple sclerosis suffering from paraspasticity

Zolpidem, a non-benzodiazepine hypnotic, acts selectively via the alpha(1)-subunit of GABA(A) receptors at therapeutic doses. It is therefore thought to lack both benzodiazepine properties such as anxiolysis, anticonvulsion, muscle relaxation, and side effects such as dependency. We report a case of severe dependency of zolpidem taken because of percieved myorelaxation in a patient with multiple sclerosis and paraspasticity. The observations in the patient described here suggest that zolpidem looses alpha1-receptor selectivity at higher doses, thereby leading to the same risks and benefits such as benzodiazepines. This should be taken into account by doctors when prescribing higher doses. Zolpidem may improve symptoms of spasticity in high doses via affection of GABA alpha2-receptor and alpha3-receptor subunits.

[Use of zolpidem and zopiclone on private prescriptions between 1993 and 2007]

OBJECTIVE

Aim of this study was to analyse the amount of so-called private prescriptions of zolpidem and zopiclone (Z drugs) over a 15-year period in Germany. Any doctor can prescribe drugs privately. Private prescriptions are fully funded by the patients. At present the total number of doctors' prescriptions in Germany is undocumented because this information is not recorded in insurance claims data. This may be one reason why physicians prescribe drugs that are associated with abuse and dependence (such as Z drugs) more frequently on private prescriptions.

METHODS

We compared utilization data from statutory health insurance claims with the purchasing statistics from public pharmacies over the years 1993-2007.

RESULTS

Throughout the study period, purchases of zolpidem and zopiclone increased from 1.4 million to 3.7 million packages and 0.8 million to 3.9 million packages, respectively. A constantly rising proportion of private prescriptions for zolpidem resp. zopiclone were issued between 1993 (+6% resp. +6%), 1999 (+43% resp. +34%), and 2007 (+122% resp. +72%).

CONCLUSION

Since their approval in Germany, zopiclone and especially zolpidem have frequently been dispensed on private prescriptions.

A therapeutic dose of zolpidem reduces thalamic GABA in healthy volunteers: a proton MRS study at 4 T

BACKGROUND

Zolpidem is a nonbenzodiazepine sedative/hypnotic that acts at GABA(A) receptors to influence inhibitory neurotransmission throughout the central nervous system. A great deal is known about the behavioral effects of this drug in humans and laboratory animals, but little is known about zolpidem's specific effects on neurochemistry in vivo.

OBJECTIVES

We evaluated how acute administration of zolpidem affected levels of GABA, glutamate, glutamine, and other brain metabolites.

MATERIALS AND METHODS

Proton magnetic resonance spectroscopy ((1)H MRS) at 4 T was employed to measure the effects of zolpidem on brain chemistry in 19 healthy volunteers. Participants underwent scanning following acute oral administration of a therapeutic dose of zolpidem (10 mg) in a within-subject, single-blind, placebo-controlled, single-visit study. In addition to neurochemical measurements from single voxels within the anterior cingulate (ACC) and thalamus, a series of questionnaires were administered periodically throughout the experimental session to assess subjective mood states.

RESULTS

Zolpidem reduced GABA levels in the thalamus, but not the ACC. There were no treatment effects with respect to other metabolite levels. Self-reported ratings of "dizzy," "nauseous," "confused," and "bad effects" were increased relative to placebo, as were ratings on the sedation/intoxication (PCAG) and psychotomimetic/dysphoria (LSD) scales of the Addiction Research Center Inventory. Moreover, there was a significant correlation between the decrease in GABA and "dizzy."

CONCLUSIONS

Zolpidem engendered primarily dysphoric-like effects and the correlation between reduced thalamic GABA and "dizzy" may be a function of zolpidem's interaction with alpha1GABA(A) receptors in the cerebellum, projecting through the vestibular system to the thalamus.

Pharmacology of ramelteon, a selective MT1/MT2 receptor agonist: a novel therapeutic drug for sleep disorders

An estimated one-third of the general population is affected by insomnia, and this number is increasing due to more stressful working conditions and the progressive aging of society. However, current treatment of insomnia with hypnotics, gamma-aminobutyric acid A (GABA(A)) receptor modulators, induces various side effects, including cognitive impairment, motor disturbance, dependence, tolerance, hangover, and rebound insomnia. Ramelteon (Rozerem; Takeda Pharmaceutical Company Limited, Osaka, Japan) is an orally active, highly selective melatonin MT(1)/MT(2) receptor agonist. Unlike the sedative hypnotics that target GABA(A) receptor complexes, ramelteon is a chronohypnotic that acts on the melatonin MT(1) and MT(2) receptors, which are primarily located in the suprachiasmatic nucleus, the body's "master clock." As such, ramelteon possesses the first new therapeutic mechanism of action for a prescription insomnia medication in over three decades. Ramelteon has demonstrated sleep-promoting effects in clinical trials, and coupled with its favorable safety profile and lack of abuse potential or dependence, this chronohypnotic provides an important treatment option for insomnia.

A therapeutic dose of zolpidem has limited abuse-like effects in drug-naïve females: a pilot study

Zolpidem has abuse potential, particularly among individuals with histories of drug abuse. This double-blind, placebo-controlled, cross over pilot study investigated the subjective effects of zolpidem (10 mg) in drug-naïve females. Over the course of a 5-h period vital signs were monitored and a series of computerized questionnaires was administered. Results indicate that zolpidem engendered subjective effects characteristic of hypnotic drugs, but reduced ratings of drug liking, willing to take again, and willing to pay for, relative to placebo. Thus, a therapeutic dose of zolpidem may have limited potential for misuse among females who have no experience with drugs of abuse.

Abuse and dependence liability of benzodiazepine-type drugs: GABA(A) receptor modulation and beyond

Over the past several decades, benzodiazepines and the newer non-benzodiazepines have become the anxiolytic/hypnotics of choice over the more readily abused barbiturates. While all drugs from this class act at the GABA(A) receptor, benzodiazepine-type drugs offer the clear advantage of being safer and better tolerated. However, there is still potential for these drugs to be abused, and significant evidence exists to suggest that this is a growing problem. This review examines the behavioral determinants of the abuse and dependence liability of benzodiazepine-type drugs. Moreover, the pharmacological and putative biochemical basis of the abuse-related behavior is discussed.

Diagnosis and treatment of insomnia

PURPOSE

The diagnostic criteria and treatment of insomnia are reviewed.

SUMMARY

Insomnia is most often described as a subjective complaint of poor sleep quality or quantity despite adequate time for sleep, resulting in daytime fatigue, irritability, and decreased concentration. Insomnia is classified as idiopathic or comorbid. Comorbid insomnias are associated with psychiatric disorders, medical disorders, substance abuse, and specific sleep disorders. Idiopathic insomnia is essentially a diagnosis of exclusion. A wide array of terminology exists for defining the duration of insomnia symptoms, which may add to the confusion regarding insomnia classification. Acute insomnia refers to sleep problems lasting from one night to a few weeks, whereas chronic insomnia refers to sleep problems lasting at least three nights weekly for at least one month. Diagnostic tools for identifying insomnia are multifactorial. Nonpharmacologic interventions for insomnia include sleep-hygiene education, stimulus-control therapy, relaxation therapy, and sleep-restriction therapy. The most effective pharmacologic therapies for insomnia are benzodiazepines, benzodiazepine-receptor agonists, melatonin-receptor agonists, and antidepressants. Choice of a specific agent should be based on patient-specific factors, including age, proposed length of treatment, primary sleep complaint, history of drug or alcohol abuse, and cost.

CONCLUSION

Many treatment options are available for patients with insomnia. Behavioral therapies should be initiated as first-line treatment in most patients. For patients who require the addition of pharmacologic therapy, the drugs with the most evidence for benefit include benzodiazepines, benzodiazepine-receptor agonists, melatonin-receptor agonists, and antidepressants. Selection of a specific agent must take into account numerous patient-specific factors.

Hochverbrauch von Zolpidem und Zopiclon

BACKGROUND

Case reports indicate dose increase, abuse, and dependence concerning zolpidem and zopiclone (so-called Z-drugs).

METHODS

We conducted a cross-sectional study between 1 July and 31 December 2004 using claims data of the German health insurer Gmuender ErsatzKasse to examine high usage of these drugs.

RESULTS

A total of 6959 subjects bought at least one packet of zolpidem or zopiclone, including 20.9% containing 90 daily doses (DDD) or more. High usage, defined as at least 180 DDD, was identified in 501 subjects (7.2%). Compared to other use, high usage was associated with GP visits only for the prescription of Z-drugs (odds ratio 2.01, 95% confidence interval 1.52-2.67), neuroleptics (odds ratio 2.53, 95% confidence interval 2.02-3.18), and polypharmacy (odds ratio 2.40, 95% confidence interval 1.84-3.15).

CONCLUSION

Zolpidem and zopiclone are often prescribed in higher doses or for long-term use. Such therapy regimens should be viewed critically.

Evidence of zolpidem abuse and dependence: results of the French Centre for Evaluation and Information on Pharmacodependence (CEIP) network survey

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.

Dependence on zolpidem: two case reports of detoxification with flumazenil infusion

Zolpidem is a hypnotic drug that is chemically distinct from benzodiazepines (BDZ). It has been suggested that it acts selectively on gamma-aminobutyric acid receptors. However, recent evidence has shown that the behavioural effects of zolpidem are generally similar to those of BDZs. Flumazenil is usually considered to be a BDZ antagonist. Nonetheless, in chronic BDZ users, it acts as a partial, bland agonist. We describe two cases of zolpidem dependence that were detoxified by the use of flumazenil infusion. BDZ dependence is usually treated with tapering of the medication. As an alternative, abrupt discontinuation of the medication and rapid detoxification using flumazenil has been used. Flumazenil may represent an alternative to detoxification treatment by employing a tapering approach, or by replacement therapy with BDZs with a long half-life, particularly where patients are hard to treat or have low compliance to treatment.

Effects of ramelteon (TAK-375) on nocturnal sleep in freely moving monkeys

We investigated the effects of (S)-N-[2-(1,6,7,8-tetrahydro-2H-indeno-[5,4]furan-8-yl)ethyl]propionamide (ramelteon, TAK-375), a novel MT1/MT2 receptor agonist, on nocturnal sleep in freely moving monkeys and compared these results with those of melatonin and zolpidem. Treatment with ramelteon (0.03 and 0.3 mg/kg, p.o.) significantly shortened latency to sleep onset and significantly increased total duration of sleep. Treatment with melatonin (0.3, 1, and 3 mg/kg, p.o.) also decreased sleep latency, but the effect was weak; the only significant reduction was seen with the 0.3 mg/kg dose on latency to light sleep. Melatonin had no significant effects on the duration of sleep. Zolpidem had no significant effects on latency to sleep onset in this study at any dose (1, 3, 10, and 30 mg/kg, p.o.). The highest dose (30 mg/kg) of zolpidem had a tendency to increase slow wave sleep; however, it also induced apparent sedation and myorelaxation. Treatment with ramelteon and melatonin had no evident effect on the general behavior of the monkeys. Spectral analysis (fast Fourier transform, FFT) of both ramelteon and melatonin revealed sleep patterns that were indistinguishable from those of naturally occurring sleep. The EEG power spectra of zolpidem were qualitatively different from that of naturally occurring physiological sleep. Results of the present study support the investigation of ramelteon as a sleep-promoting agent in humans.