Any way to reset tolerance to ambien? Dr. Steve?

[DaveT]

So it's gotten to the point that the ambien just doesn't have any effect on me. The tolerance development was very slow, it's just that I was taking it every night for a long time. So I'm planning an ambien holiday to regain some sensitivity to the medication but I'm wondering about how long that will take.

[Pharmacist.steve]

The only way that I know to deal with any tolerance is abstain from taking the drug. I am not aware of any "formula" that would suggest the appropriate time frame for a particular drug and/or person. I would suspect that the easiest way is to find another drug that works and take it for a couple of months or until tolerance develops and then go back

[lobelsteve]

It typically takes 7-8 days. I either write for Lunesta or Sonata for 1 month and then restart Ambien. If I have samples in, I can sample out either of those for several days. That's all that it takes. Then it works like new again.

I do not believe in the use of daily benzo's. I only write them for getting into the MRI or onto the plane.

[Kira]

I do not believe in the use of daily benzo's. I only write them for getting into the MRI or onto the plane.

Dr Steve, I've heard you say this before. Not trying to be argumentative, just genuinely curious... but I'm wondering why you feel this way, what's the rationale/evidence base, etc. Also... do you not believe in prescribing them in your practice to pain patients... or do you not believe in any docs prescribing them daily, even in other specialties (ie certain epilepsy or psych pts)?

[sis2831]

have you tried Lunesta...some people i know who have been on ambien actually like Lunesta better....I have had good luck with the ambien, so i am not ready to switch

[Kathi49]

I am as curious as Kira is Dr. Steve.

[Kandra]

I am as curious as Kira is Dr. Steve.

Well, I'm curious too as I take Klonopin .5 BID and Ativan .5 PRN when I'm experiencing an aura/simple seizure. The Ativan is rarely used....but my neurologist seems to feel they're necessary...


K.

[lobelsteve]

The literature does not support the use of this class of medication for more than occasional, intermittent use. IMHO, the risks always outweigh the benefits for using this medication except for situational anxiety and hospice.
Fortunately, I am not your doctor for this medication and many PCP's have no problem Rx'ing Xanax qid and Valium bid, and Restoril for sleep (all in the same patient). Benzo's are more widely abused than opioids, have a higher incidence of withdrawal, and a potential for a fatal withdrawal.

The start of the data:

The Committee on the Review of Medicines (UK)

The Committee on the Review of Medicines carried out a review into benzodiazepines due to significant concerns of tolerance, drug dependence and benzodiazepine withdrawal problems and other adverse effects. The committee found that benzodiazepines do not have any antidepressant or analgesic properties and are therefore unsuitable treatments for conditions such as depression, tension headaches and dysmenorrhoea. Benzodiazepines are also not beneficial in the treatment of psychosis. The committee also recommended against benzodiazepines being used in the treatment of anxiety or insomnia in children. The committee was in agreement with the Institute of Medicine (USA) and the conclusions of a study carried out by the White House Office of Drug Policy and the National Institute on Drug Abuse (USA) that there was little evidence that long term use of benzodiazepine hypnotics were beneficial in the treatment of insomnia due to the development of tolerance. Benzodiazepines tended to lose their sleep promoting properties within 3–14 days of continuous use and in the treatment of anxiety the committee found that there was little convincing evidence that benzodiazepines retained efficacy in the treatment of anxiety after 4 months continuous use due to the development of tolerance. The committee found that the regular use of benzodiazepines caused the development of dependence characterised by tolerance to the therapeutic effects of benzodiazepines and the development of the benzodiazepine withdrawal syndrome including symptoms such as anxiety, apprehension, tremor, insomnia, nausea, and vomiting upon cessation of benzodiazepine use. Withdrawal symptoms tended to develop within 24 hours upon cessation of short acting; and 3–10 days after cessation of longer acting benzodiazepines. Withdrawal effects could occur after treatment lasting only 2 weeks at therapeutic dose levels however withdrawal effects tended to occur with habitual use beyond 2 weeks and were more likely the higher the dose. The withdrawal symptoms may appear to be similar to the original condition. The committee recommended that all benzodiazepine treatment be withdrawn gradually and recommended that benzodiazepine treatment be used only in carefully selected patients and that therapy be limited to short term use only. It was noted in the review that alcohol can potentiate the central nervous system depressant effects of benzodiazepines and should be avoided. The central nervous system depressant effects of benzodiazepines may make driving or operating machinery dangerous and the elderly are more prone to these adverse effects. In the neonate high single doses or repeated low doses have been reported to produce hypotonia, poor sucking, and hypothermia in the neonate and irregularities in the fetal heart. Benzodiazepines should be avoided in lactation. Withdrawal from benzodiazepines should be gradual as abrupt withdrawal from high doses of benzodiazepines may cause confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens. Abrupt withdrawal from lower doses may cause depression, nervousness, rebound insomnia, irritability, sweating, and diarrhea.[37]

[edit] Drug misuse and addiction

Benzodiazepines can cause serious addiction problems. Organic brain syndrome occurs in approximately 30% of benzodiazepine misusers causing an induction or a worsening of somatic symptomatology such as anxiety and depression. After withdrawal and a period of abstinence symptomatology improved in 80% of patients.[38] A survey in Senegal of doctors found that many doctors feel that their training and knowledge of benzodiazepines is generally poor. Due to the serious concerns of addiction national governments were recommended to urgently seek to raise knowledge via training about the addictive nature of benzodiazepines and appropriate prescribing of benzodiazepines.[39] Drug misusers addicted to benzodiazepines develop a high degree of tolerance, coupled with dosage escalation, often increasing their dosage to very high levels. Long-term use of benzodiazepines has the potential to cause both physical and psychological dependence, and are at risk of severe withdrawal symptoms. Tolerance and dependence to benzodiazepines develop rapidly with users of benzodiazepines, demonstrating benzodiazepine withdrawal syndrome after as little as 3 weeks of continuous use. Benzodiazepines, and in particular temazepam, are sometimes used intravenously, which done incorrectly or done in an unsterile matter can lead to medical complications including abscesses, cellulitis, thrombophlebitis, arterial puncture, deep vein thrombosis, hepatitis B and C, HIV or AIDS, overdose and gangrene. Benzodiazepines are also sometimes abused intranasally which may have additional health consequences. Once benzodiazepine dependence has been established a clinician should first establish the average daily consumption of benzodiazepines and then convert the patient to an equivalent dose of diazepam before beginning a gradual reduction program. Additional drugs, such as antianxiety drugs like buspirone or β blockers, and carbamazepine, should not be added into the withdrawal program unless there is a specific indication for their use.[40][41]

A 2004 US government study of nationwide ED visits conducted by SAMHSA found that sedative-hypnotics in the USA are the most frequently misused pharmaceutical drug with 35% of drug related visits to the Emergency Department involving sedative hypnotics. Benzodiazepines accounted for the majority of these. Benzodiazepines are more commonly misused than opiate pharmaceuticals which accounted for 32% of visits to the emergency department. Males and females misuse benzodiazepines equally. Of drugs used in attempted suicide, benzodiazepines are the most commonly used pharmaceutical drug with 26% of attempted suicides involving benzodiazepines. Alprazolam is the most commonly misused benzodiazepine, followed clonazepam, lorazepam and diazepam as the 4th most commonly misused benzodiazepine in the USA.[42]

http://www.google.com/search?q=benzodiazepine+dependence&ie=utf-8&oe=utf-8&aq=t&rls=org.mozilla:en-US:official&client=firefox-a

http://snipurl.com/cf0i6

[DaveT]

Thanks for all the replies. Steve -- given your discomfort with BZDs, are you comfortable with patients taking non-BZD on a daily basis (ambien, etc...)? Thanks for the info -- I'll talk to my doctor about switching to one of the others for a couple of weeks. Just out of curiosity, in your practice, how long are patients typically able to stay one sleeping aid nightly until it loses effectiveness?

[lobelsteve]

Ambien and Lunesta are not BZD's and rarely lose effect long term.
Anyone failing these meds needs to see a sleep specialist. Many things cause a poor nights sleep and that's why those docs have their own clinics.
I like a setup like Scot Leibowitz in Marietta Georgia.

http://www.cdssleep.com/

[mot]

Steve is 1000% right on benzos. They are poison long term.
Read this:
http://www.benzo.org.uk/
The thing that disturbs me is that Ambien is way too close to benzos for daily use in my opinion and in the opinion of the world's foremost authority on benzo addiction Dr. Heather Ashton (http://www.benzo.org.uk/manual/index.htm)

Here is the benzo euilvelency chart including zolpidem (ambien) with a two hour half life it is as potent as 20 mg. of valium.
http://www.benzo.org.uk/bzequiv.htm

M

[Kathi49]

Steve,

I have a question. IF you had a patient on .75mg of Klonopin (such as myself), WHAT would be or what would YOU use as a tapering schedule? I agree with the article that Valium could be substituted as a person tapers. It is a serious question and one that I have not had answered to my satisfaction. I know full well the withdrawals from Klonopin and it is horrid. But I am not one that does well on the AD's nor Neurontin or Lyrica. And another thing about the AD's. My PM wants me to try Cymbalta again; 30mg. Should I be concerned since I take Vicodin (but a low dose) and Serotonin Syndrome? Just a thought as I saw it listed on the patient info. sheet. And I am not trying to be a smart-A either. I would really like to have answers to the Klonopin taper. Maybe I worry too much but I went through pure he@@ when on Neurontin and at one time Depakote. And for whatever the reason the AD's cause me to become depressed when I wasn't to begin with. So, it gets confusing. Klonopin has worked well however for the small fiber pn or rather the burning sensations.

[lobelsteve]

Steve,

I have a question. IF you had a patient on .75mg of Klonopin (such as myself), WHAT would be or what would YOU use as a tapering schedule? I agree with the article that Valium could be substituted as a person tapers. It is a serious question and one that I have not had answered to my satisfaction. I know full well the withdrawals from Klonopin and it is horrid. But I am not one that does well on the AD's nor Neurontin or Lyrica. And another thing about the AD's. My PM wants me to try Cymbalta again; 30mg. Should I be concerned since I take Vicodin (but a low dose) and Serotonin Syndrome? Just a thought as I saw it listed on the patient info. sheet. And I am not trying to be a smart-A either. I would really like to have answers to the Klonopin taper. Maybe I worry too much but I went through pure he@@ when on Neurontin and at one time Depakote. And for whatever the reason the AD's cause me to become depressed when I wasn't to begin with. So, it gets confusing. Klonopin has worked well however for the small fiber pn or rather the burning sensations.

I'm not your doc so I can give medical advice to you.
If I had a patient taking 0.75mg Klonopin I would reduce the dose by 0.25mg weekly. I'd also start Zofran 8mg and Clonidine 0.1mg bid to ease the psychological and physical components of withdrawal (whether that was occurring or not).


As far as Serotonin Syndrome, it is grossly overcautioned. However, it can be fatal so vigilance is warranted. I would not be concerned with opioids and Cymbalta or Zoloft,Lexapro,Celexa,Paxil,Prozac,Effexor. Ultram may increase the serotonin with these meds but I have never seen it. I suppose if I maxed out doses of Cymbalta at 120mg and Ultram at 400mg per day in 10000 patients I would unfortunately see this.

[Kathi49]

Thanks Steve,

That is exactly what my Neurologist had me do; cut by .25mg weekly. On day 7...BAM...horrible withdrawals and off to the ER! However, she did not add Zofran and Clonidine. Although I do have a bottle of Zofran for nausea. I think I will mention this to her at my next appointment. So, I thank you for that info. :) In all honesty I don't think she thought this would hit me so hard since I was on a small dose and she said as much. Anyway, part of me says if ain't broke don't try to fix it. Then again, I don't want to be on Klonopin forever. Oh, and about the Valium. I know the Ashton Manual suggests it. But when I mentioned it to my Neurologist, she felt it would just be another benzo to have to wean off of. Plus the fact...how do you REALLY get a TRUE equivalency? So, I think you can understand why I felt my questions weren't answered satisfactorily.

[mot]

Hi,
I went through the Ashton taper and 1 mg. of Clonazepam is equal to 20 mg. of valium. .25mg. is way too large a cut, no wonder you are suffering. This is why very few people ever can get off benzos.
The reason that you taper with valium is its long half life. It is easier on the system, though no matter what benzo withdrawal is most often no picnic.
I would read up on the Ashton Manual and save yourself a lot of heartache.
Cuts should be in the 1-2mg. range of valium (after valium crossover) and be done every 10-14 days, whatever is more tolerable.

Good luck,

M

[Kathi49]

Thanks mot,

I am not suffering right now...the withdrawal was awhile back and I decided to just stay on Klonopin. I have read the Ashton Manual a few times and that's where I originally read that Valium could be used.*

[Kira]

except for situational anxiety and hospice

also:
-status seizures/clusters
-adjunctive tx for certain pts with tx-refractory epilepsy
-various anesthesia uses (induction, conscious sedation, etc)
-ICU use (ventilated pts, burn pts, trauma pts, etc)
-certain severe psychiatric conditions (not just anyone with a little anxiety... but some people w/ severe & disabling panic attacks/agoraphobia/etc)
-etc, etc, etc

If you're okay with benzos to help with situational anxiety (like your airplane & MRI examples)... then I would hope you'd be okay with short-term/occasional benzos to help with much more serious things like status epilepticus, disabling severe panic disorders, and so on. I would much rather see a kid with severe epilepsy get a script for prn rectal diazepam than a man who hates airplanes get a script for prn xanax so he can fly to Florida for vacation...

[lobelsteve]

also:
-status seizures/clusters
-adjunctive tx for certain pts with tx-refractory epilepsy
-various anesthesia uses (induction, conscious sedation, etc)
-ICU use (ventilated pts, burn pts, trauma pts, etc)
-certain severe psychiatric conditions (not just anyone with a little anxiety... but some people w/ severe & disabling panic attacks/agoraphobia/etc)
-etc, etc, etc

If you're okay with benzos to help with situational anxiety (like your airplane & MRI examples)... then I would hope you'd be okay with short-term/occasional benzos to help with much more serious things like status epilepticus, disabling severe panic disorders, and so on. I would much rather see a kid with severe epilepsy get a script for prn rectal diazepam than a man who hates airplanes get a script for prn xanax so he can fly to Florida for vacation...

You are justifying and rationalizing.

I do not treat any of those things, so it is not my problem. I do not Rx insulin, heart medication, birth control pills, etc. BZD's are widely overprescribed for outpatient use and do more overall harm than good. I believe they should be Schedule II and prescribed by specialists in Neurology and Psychiatry only.

[Kira]

I do not treat any of those things, so it is not my problem.

Yes, but your original comment was about daily benzos always being bad... and I specifically asked the following:

do you not believe in prescribing them in your practice to pain patients... or do you not believe in any docs prescribing them daily, even in other specialties (ie certain epilepsy or psych pts)?

[countrygirl]

So you are saying it's ok to take the ambien long term? I read the post of yours about bzds? but it left me confused a little.

I've been taking ambien for about six months. I also take xanax at night too. Is this a bad combination? I know you read my post on the nerve pain I've been having and where I posted I was weaning off the ms contin.

So what I am now on is 15mg of ms contin 2x a day, with msir for breakthrough that I really only take if I have to and never more than 20ml in one day. The ambien is 10mg 1x at night, and the xanax is 1mg 1x at night.

I respect your opinion and I would like to know what you think about this combination. I am trying very hard to get off all of my medications, especially the morphine as I have had severe intestinal problems, like a colonoscopy with the removal of two precancerous polyps and my stomach lining is shot for all the anti inflamatories I used to be on. Or so the gastro doc said.

I hate being dependent on drugs and now with this pinched nerve they are adding more to the pot, neurontin and some kind of anti inflam.

Looking forward to your reply.