Long-term benzodiazepine use in sleep disorders – adapted from American Journal of Medicine 1996;100;333-7 – Tips from Other Journals
Physicians are often reluctant to prescribe benzodiazepines to patients with sleep disorders because of fears about dependence and tolerance. Schenck and Mahowald assessed the potential for medication abuse in patients receiving long-term benzodiazepine therapy.
The study included 170 patients who were evaluated and treated at a sleep disorder clinic over the course of 12 years. Patients underwent medical evaluation and completed questionnaires about their sleep cycles. Polysomnography also was performed for each patient. Each patient received at least a six-month course of benzodiazepines for the treatment of a sleep disorder.
Sixty-nine patients who were sleepwaLkers or who had sleep terrors received 0.25 mg or 0.5 mg of clonazepam one to two hours before sleep. Fifty-two patients with rapid-eye-movement sleep behavior disorder received 0.25 to 0.5 mg of clonazepam immediately before sleep. Twenty-five patients with chronic psychophysiologic or idiopathic insomnia received either clonazepam or another benzodiazepine. Finally, 24 patients with restless leg syndrome/ periodic limb movement disorder received the same dose of clonazepam on the same schedule as the group with sleep terrors. The dosage was increased every few days until control of the parasomnia was achieved or adverse effects were noted. The outcomes measured were either control of the parasomnia or maintenance of satisfactory sleep.
Psychometric testing showed that the study patients were not more depressed or anxious than the general population. Most of the patients (86 percent) achieved control of their sleep disorder with the benzodiazepine treatment prescribed. Nearly three-quarters of the patients were taking the same dosage or a lower dosage of benzodiazepine at the most recent follow-up visit as the dosage that they received at the first-month follow-up visit. Drug discontinuation or substantial reduction in dosage did not cause withdrawal symptoms but did cause immediate reemergence of the symptoms of the sleep disorder.
Only 15.9 percent of patients experienced side effects of benzodiazepine treatment, and only 10 of these 27 patients had to stop taking the medication because of the adverse effect. A small percentage of patients (1.8 percent) were found to have taken the benzodiazepine in amounts exceeding what was prescribed. Of the 170 patients, 28 (16.4 percent) were known to have a past history of alcohol or substance abuse, but only 2.4 percent of the patients had a relapse of the substance abuse disorder.
The authors conclude that use of benzodiazepines for sleep disorders is not associated with dosage escalation, abuse of the medication or a high risk of adverse effects. However, the authors point out that good sleep hygiene and standard, nonpharmacologic methods for treating sleep disorders should always be the first-line treatment for sleep problems. (Schenck CH, MahowaId MW. Long-term, nightly benzodiazepine treatment of injurious parasomnias arid other disorders of disrupted nocturnal sleep in 170 adults. Am J Med 1996;100:333-7.)
COPYRIGHT 1996 American Academy of Family Physicians
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