Z drugs for chronic insomnia?

[whopper]

Gotcha, do you believe that all patients with anxiety can be treated to remission without benzos?

Nothing in medicine is 100%. I've seen, however, with buspirone, some atypicals, propranolol, treating ADHD along with the conventional SSRI or SNRI (if they work) you're going to reduce the need for benzos to a degree where it should be about 4% or less of your patients on a daily dosage. I've seen plenty of ADHD patients, once treated, no longer having anxiety problems or greatly mitigated anxiety. I have about less than 10% on a dosage where they take a benzo but about once a week for panic attacks or non-chronic issues such as fear of flying.

This is in a private practice setting. In an ER or Medicaid setting it's much more risky giving out benzos. A problem with Medicaid patients are as a demographic this group has less education, more impulsivity and less to lose by risking abusing their meds. So while in theory perhaps some of then can genuinely benefit from a low dose benzo, someone in that group could sell the med (that they may have even needed) to pay for food or some other necessity.

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[WisNeuro]

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?

The vast majority are treatable with behavioral methods. In therapy, it's the best outcomes we have for pretty much any class of disorders. Also, while self-report is important, when it comes to self-report of cognition and benefit from psychoactive substances, there is a wealth of literature suggesting that self-report is very often flawed in many circumstances. Which, is why we should rely on objective markers instead. As to whether or not you change the regimen or refer out, that's up to you. Personally, I would not choose to provide someone with a treatment that I believed actively harmed then and would likely continue to do so over time.

 

[allantois]

I’m also not sure one would be better off atypicals than low dose benzo. We need to maximize non-medication options

 

[forchinet121]

The vast majority are treatable with behavioral methods. In therapy, it's the best outcomes we have for pretty much any class of disorders. Also, while self-report is important, when it comes to self-report of cognition and benefit from psychoactive substances, there is a wealth of literature suggesting that self-report is very often flawed in many circumstances. Which, is why we should rely on objective markers instead. As to whether or not you change the regimen or refer out, that's up to you. Personally, I would not choose to provide someone with a treatment that I believed actively harmed then and would likely continue to do so over time.

The patient doesn’t want to do the work of therapy, you would stop prescribing their medication and tell them to go elsewhere? This is my point of theory vs practice

 

[WisNeuro]

The patient doesn’t want to do the work of therapy, you would stop prescribing their medication and tell them to go elsewhere? This is my point of theory vs practice

No, it would have been clear before they met me the first time that I would not continue that regimen and that I would only prescribe it with a plan to taper with therapy as a component. You get to decide how you practice within certain bounds. The patient is free to go elsewhere if they do not like what you offer. No one is forcing you to do something that is harmful for the patient in perpetuity. You and the patient both have a choice.

 

[clausewitz2]

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.

This is the kicker for me. BZDs interfere with the gold standard, absolutely best first-line treatments for the fear-based anxiety disorders (rather than more worry-based). I find it incredibly difficult to justify this for anyone who has the cognitive capabilities to engage with anything exposure-based.

I have a couple of patients on chronic BZDs that I initiated but they are recurrent catatonia folks, the sorts who go off their Ativan and then two weeks later they are making bird noises standing in the middle of their room stock still and not eating for days.

 

[WisNeuro]

This is the kicker for me. BZDs interfere with the gold standard, absolutely best first-line treatments for the fear-based anxiety disorders (rather than more worry-based). I find it incredibly difficult to justify this for anyone who has the cognitive capabilities to engage with anything exposure-based.

I have a couple of patients on chronic BZDs that I initiated but they are recurrent catatonia folks, the sorts who go off their Ativan and then two weeks later they are making bird noises standing in the middle of their room stock still and not eating for days.

And I'd agree that there are a small percentage of people like these in which its appropriate. But this is a very small percentage, relative to the amount of people who are actually on maintenance benzos. We can find the anecdotal tiny precentages, but the vast majority are on these inappropriately.

 

[Stagg737]

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).

The various guidelines for treatment of insomnia (AASM, ACP, VA/DOD, BAP, etc) almost uniformly recommend z-drugs as a first-line pharmacologic treatment for insomnia, but the guidelines are also fairly consistent that the data isn't particularly good and have a heavy bias towards newer, non-generic meds that I find somewhat suspicious (example that Silenor is recommended but Sinequan is not). I'd agree with most above that Z-drugs are generally preferable to benzos and that there is a difference in their use for insomnia.

From a more personal standpoint, do I think chronic z-drugs are a good option? No, but I have encountered a handful of individuals where it was just the best option to keep them generally stable without episodes of decompensation. These were mostly VA patients who reported that Ambien was the only thing that allowed them to get decent sleep as they just didn't dream (or at least didn't recall dreaming) when using it. I may continue z-drugs for patients, but I'm pretty clear that I won't go up on the dose for those using it chronically.

I do think it has a place as a short-term medication and have used it with quite a bit of success a handful of times. However, I make it very clear to those patients that it is a short-term option, that they should not take it more than 2-3 days in a row, and that they will get a single Rx (typically 15 tabs or less) and that there will be no refills. These are also patients who have come to me with more acute insomnia and I don't start patients with chronic insomnia on z-drugs.

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.

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.

I'm decently versed in insomnia treatments, but I love hearing from you all who are more highly trained in the area and always appreciate the insights. I'd never looked into the scale and am not sure if I'd even heard of it, but I'll probably be nerding out looking into it this weekend.

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.

No Rugby Brand? I don't prescribe melatonin for insomnia, but I swear they sprinkle low doses of Ambien in their formulation given how much more effective melatonin through our VA was than anywhere else I worked.

And I'd agree that there are a small percentage of people like these in which its appropriate. But this is a very small percentage, relative to the amount of people who are actually on maintenance benzos. We can find the anecdotal tiny precentages, but the vast majority are on these inappropriately.

Idk that the percentages are that tiny, as I have had quite a few patients I recall who benefitted from longer-term benzos for issues like recurrent catatonia, EPS, or some neurological disorders. I do agree that the vast majority of people chronically taking benzos for anxiety disorders are on them inappropriately, and it's exceptionally rare to find someone with an anxiety disorder where a chronic benzo is truly necessary.

 

[allantois]

When I used to see Medicaid patients, I couldn’t even Rx them ramelteon or doxepin and the rest of sleep meds until Rxing 2/3 of the following: ambiem, restoril, dalmane (wtf??).. sigh

 

[clozareal]

No Rugby Brand? I don't prescribe melatonin for insomnia, but I swear they sprinkle low doses of Ambien in their formulation given how much more effective melatonin through our VA was than anywhere else I worked.

It wasn't on the ConsumerLab tested brands list but perhaps I'll try it!

 

[Bartelby]

Thanks everyone for your perspectives! It sounds like generally (but not universally) people are more comfortable with Z-drugs than benzodiazepines, which makes sense. I still wish we had more clear data about chronic use, but it sounds like most steer clear of that for the most part.

I'll be honest, I work with a lot of patients whose sleep improves significantly with basic sleep hygiene, CBTi, and adequate treatment of the Axis I disorder. I still have a not insignificant number of patients with more chronic symptoms, often personality disordered, and I have not found it unusual to give long-term trazodone, doxepin, melatonin, Remeron, or similar for sleep in that population. It seems to help, though who knows how they would do if I refused to prescribe medication for sleep long-term and insisted only on cognitive-behavioral approaches for chronic insomnia. In that population I would still tend toward the non-controlled options where possible.

 

[Styrene]

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.

I have written a similar paper but arguing the converse. Currently under peer review. I take a look at more of the evidence showing harms, about 45 citations I was able to incorporate. We must look at the overall trends in prescribing to see the dire problem, not just semi-opinion on invented points of disagreement. The evidence is incomplete on both sides. During my pgy3 year 2022-23, I have not started a single patient on benzodiazepines. They are reverse CBT effectively. I can see short-term use cases being reasonable some times--I just haven't seen a single case where the benefit seemed to outweigh the risk.

Many patients have requested benzodiazepines, and I told them I do not prescribe those medications, but I feel for their suffering and will be there each step of the way as they recover without the use of a medication that may cause them harm. All of the patients eventually recovered and thanked me for doing that. It is not easy, but this is how I will continue to practice at least for as long as I do outpatient work.

I have also seen several patients referred from primary care for anxiety already started on Xanax. I switched them all to Klonopin right away and then tapered using shared decision-making. Sometimes as slow as 0.25 mg/month or even 0.125 at a time. All of the patients were successful.

It cannot be overstated how important it is the way these conversations are had. There is no research on benzodiazepine deprescribing in psychiatric care settings (the mechanisms of it), but I have done small things. I will begin a study of subjective attitudes and beliefs about benzodiazepines of patients and psychiatrists next academic year.

 

[littlefred]

I have written a similar paper but arguing the converse. Currently under peer review. I take a look at more of the evidence showing harms, about 45 citations I was able to incorporate. We must look at the overall trends in prescribing to see the dire problem, not just semi-opinion on invented points of disagreement. The evidence is incomplete on both sides. During my pgy3 year 2022-23, I have not started a single patient on benzodiazepines. They are reverse CBT effectively. I can see short-term use cases being reasonable some times--I just haven't seen a single case where the benefit seemed to outweigh the risk.

Many patients have requested benzodiazepines, and I told them I do not prescribe those medications, but I feel for their suffering and will be there each step of the way as they recover without the use of a medication that may cause them harm. All of the patients eventually recovered and thanked me for doing that. It is not easy, but this is how I will continue to practice at least for as long as I do outpatient work.

I have also seen several patients referred from primary care for anxiety already started on Xanax. I switched them all to Klonopin right away and then tapered using shared decision-making. Sometimes as slow as 0.25 mg/month or even 0.125 at a time. All of the patients were successful.

It cannot be overstated how important it is the way these conversations are had. There is no research on benzodiazepine deprescribing in psychiatric care settings (the mechanisms of it), but I have done small things. I will begin a study of subjective attitudes and beliefs about benzodiazepines of patients and psychiatrists next academic year.

I have prescription tendencies very similar to what you state on your post, so we're on the same page. Just wanted to point out a paper one of my mentors put out there, not saying it's a meta-analysis with regards to benzodiazepine chronic prescribing benefits

Like many things in psychiatry we can find studies that answer the same question in completely different ways, but I think it has to do with the little understanding that we have of the brain. Congrats on the paper and look forward to reading it when it gets published.

 

[Styrene]

I have prescription tendencies very similar to what you state on your post, so we're on the same page. Just wanted to point out a paper one of my mentors put out there, not saying it's a meta-analysis with regards to benzodiazepine chronic prescribing benefits

Like many things in psychiatry we can find studies that answer the same question in completely different ways, but I think it has to do with the little understanding that we have of the brain. Congrats on the paper and look forward to reading it when it gets published.

I do also recognize my strong intellectual bias on this matter. But I'm just going with it.

 

[Shotokan-Kata]

Biofeedback would be a better option for insomnia. There is evidence based literature that proves it.

 

[Stagg737]

Biofeedback would be a better option for insomnia. There is evidence based literature that proves it.

That's a very strong, and very incorrect, statement:

"Comparing to placebo and absence of treatment, some studies suggest possible benefits from the use of biofeedback for chronic insomnia in decreasing sleep onset latency and number of awakenings; however, there was marked divergence among included studies. There was no evidence of improvement in total sleep time, sleep efficiency and subjective sleep quality. Moreover, the maintenance of long-term benefits lacks evidence for any outcome."

Biofeedback Therapies for Chronic Insomnia: A Systematic Review - PubMed

The treatment of insomnia is still a challenge in clinical practice. This systematic review of randomized and quasi-randomized clinical trials aims to summarize the evidence for the use of biofeedback techniques in the treatment of chronic insomnia. Studies that compared biofeedback with other...

pubmed.ncbi.nlm.nih.gov

Additionally, AASM reports they cannot make recommendations regarding biofeedback d/t insufficient evidence. If you have strong literature I'd be interested in seeing it (and I'm sure the AASM would as well).

 

[clozareal]

Does biofeedback work for anything other than pain? It also doesn't work in ADHD.

 

[Stagg737]

Does biofeedback work for anything other than pain? It also doesn't work in ADHD.

There is some evidence for efficacy in treatment of PTSD and anxiety disorders when done with a professional, but not for independent use.

Neurofeedback and Biofeedback for Mood and Anxiety Disorders: A Review of Clinical Effectiveness and Guidelines - NCBI Bookshelf

https://journals.sagepub.com/doi/pdf/10.1177/155005940003100105

 

[WisNeuro]

There is some evidence for efficacy in treatment of PTSD and anxiety disorders when done with a professional, but not for independent use.

Neurofeedback and Biofeedback for Mood and Anxiety Disorders: A Review of Clinical Effectiveness and Guidelines - NCBI Bookshelf

https://journals.sagepub.com/doi/pdf/10.1177/155005940003100105

Before making this statement, I would strongly suggest reading the papers that the articles cite. Pay close attention to the control or comparison groups. They are simply terrible, or vastly underpowered (e.g., n=8). Also, no sham conditions to adequately test out placebo effects.

 

[Stagg737]

Before making this statement, I would strongly suggest reading the papers that the articles cite. Pay close attention to the control or comparison groups. They are simply terrible, or vastly underpowered (e.g., n=8). Also, no sham conditions to adequately test out placebo effects.

I didn't say the evidence was good, lol. And generally don't recommend biofeedback for anything because of that.

 

[WisNeuro]

Yeah, considering the failures that we've seen in other areas with Bio/NF, I'd be skeptical of anything in the anxiety realm, especially as at this point it sure looks like people are intentionally running poor studies to look at "efficacy."