From The Carlat Psychiatry Blog, ,

There’s good reason to be careful prescribing Z-drugs. Here’s an overview of Dr. Reban Aziz’s recent article in The Carlat Addiction Treatment Report.

Safety Tips

1. Go short-term or intermittent to reduce the potential for adverse events and withdrawal.
2. Avoid for SUD or complex sleep disorders. 
3. Use as last resort after considering other meds and non-medication therapies.
4. Educate patients to prevent driving impairment, complex sleep behaviors, and overdose. 

Potential Dangers

• Adverse drug events. Including falls, head injuries, sedation, and vertigo. Zolpidem can also increase the likelihood of fractures resulting from falls in elderly patients (Kang DY et al, J Prev Med Public Health 2012;45(4):219–226). Zolpidem was implicated in 12% of all ED visits and, in such visits, 21% of the involved individuals were 65 years or older (Hampton LM et al, JAMA Psychiatry 2014;71(9):1006–1014).
• Dangerous complex sleep behaviors. Including overdosing, falling, getting burned, shooting themselves, and wandering outside in cold weather. From 1992 to 2019, voluntarily reported cases to the FDA indicated that Z-drugs were attributed to 66 serious cases of complex sleep behaviors, 20 of which resulted in death. (www.fda.gov/consumers/consumer-updates/taking-z-drugs-insomnia-know-risks).
• Motor vehicle accidents. A zolpidem blood level of 50 ng/mL can increase the risk of motor vehicle accidents by inhibiting a person’s driving ability. The FDA determined that a higher percentage of individuals experience morning impairment after using extended-release zolpidem than that of patients who use short-acting zolpidem (www.fda.gov/media/84992/download). 
• Withdrawal. Prolonged usage of zolpidem is directly associated with an increased probability of withdrawal. Zolpidem is the top withdrawal offender, but all Z-drugs, including zopiclone and eszopiclone, can induce withdrawal symptoms. (Schifano F et al, Int J Neuropsychopharmacol 2019;22(4):270–277).
• Risk of an opioid overdose. Patients who are exposed to opioids, benzodiazepines, and non-benzodiazepine sedative-hypnotics at any point are 60% more likely to overdose than patients who are only exposed to opioids. 

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