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Treatment of zolpidem abuse and dependence in an insomniac patient
Zolpidem is a gamma-aminobutyric acid agonist that binds on the benzodiazepine site of its pentameric receptor. It has a hypnotic action with only minor anxiolytic, myorelaxant and anticonvulsant properties. Although zolpidem has a low dependency risk, there is current evidence in literature that at higher than recommended doses, its pharmacology resembles that of benzodiazepines and consequently potential for abuse.
The purpose of this report is to show a case of zolpidem dependence in which high doses of zolpidem were used not only to improve insomnia but also to induce anxiolytic effects.
A 50-year-old woman with chronic insomnia complaint for 15 years (initiated after a period of alcohol and cocaine abuse) was seen in our Sleep Center. At that moment, for insomnia treatment, she received a prescription of zolpidem 10mg at night with improvement of the initial symptoms. The patient started to use zolpidem without medical prescription in adverse life situations, like when her mother passed away. Two years before the patient was evaluated at our Sleep center, she sought medical help for insomnia and started to use low doses of quetiapine and clonazepam, but also maintained the use of zolpidem. During the last year, while she was feeling sad, she was taking at least 150mg/day of zolpidem trying to get the anxiolytic effect of the drug.
When she started the treatment under our medical care, she was given an outpatient treatment with valproic acid 500mg/day, quetiapine 100mg/day and initial doses of clonazepam 3mg/day, at which time she was able to stop using zolpidem. As a side effect, it was seen an important weight gain and valproic acid was replaced by topiramato 50mg/day. Her anxiety symptoms are now stable and she maintains a good sleep pattern.
It is now known that zolpidem can be misused by some insomniac patients to induce an anxiolytic effect. At high doses, zolpidem may lose its selectivity for hypnotic effects, and show all the other effects of common benzodiazepines. Patients with a past history of any substance abuse may be at risk for zolpidem abuse.
insomnia, zolpidem, abuse
Relato de Caso
FMUSP - Sao Paulo - Brasil
Marcela Yanagimori, Thais Cano, Rosa Hasan, Daniel Suzuki Borges, Andrea Cecília Toscanini, Alexandre Pinto de Azevedo