Withdrawal reactions after stopping hypnotics in patients with insomnia

Hypnotic drugs are widely prescribed medications, especially for the elderl y. Currently, the most commonly prescribed are the benzodiazepines and newe r similar compounds such as zopiclone and zolpidem, Some of the benzodiazep ines are long-acting (e.g, flurazepam and nitrazepam), some medium-acting ( e.g, temazepam) and some short-acting (e.g, triazoram). However, duration o f action is prolonged in the elderly and is also dose-dependent, Insomnia can be attributed to many causes, of which physical and psychiatri c disorders are the most common. However, many patients with insomnia are c hronically symptomatic without apparent cause ('primary' insomnia), Long te rm usage of a prescribed hypnotic is a consequence, and is unfortunately co mmon, A series of withdrawal reactions can occur on discontinuation of hypnotic m edication. Relapse comprises the recurrence of the insomnia with its consti tuent symptoms and signs which the patient originally experienced and for w hich the medication was prescribed. It will occur if the insomnia does not resolve during symptomatic hypnotic treatment, Rebound is a worsening of in somnia beyond pretreatment levels on attempted drug withdrawal. It may be d etected on polysomnographic recordings or by questionnaire. Withdrawal reac tions comprise a characteristic set of symptoms and signs temporally correl ated to the discontinuation and not reported prior to treatment. They are g enerally taken as a marker for physical dependence Finally, abuse is the us e of high doses for recreational purposes, outside the medical context; sup plies may be obtained illicitly. Rebound occurs especially with shorter-acting benzodiazepines given in high er doses. Zopiclone is less likely to be associated with rebound, and zolpi dem also provides little evidence for this phenomenon. Withdrawal is usuall y uneventful with these drugs, and both can be used as transitional therapi es in the more difficult task of discontinuing benzodiazepines in long term users. However, dosage considerations are important with all hypnotics and treatment, especially in the elderly, should be at the lowest effective do se and for the shortest duration.