Insomnia in an adult who has taken a hypnotic long term

Many adults take hypnotics for prolonged periods and become dependent—this may occur after as little as 2 to 4 weeks of continuous hypnotic use. Problem long-term hypnotic use is especially prevalent among older people, even though they are most at risk of harm from hypnotics—see Hypnotic use in older people.

Note: Avoid long-term hypnotic use—try to stop it whenever possible.

Avoid long-term hypnotic use—it is associated with daytime sedation, cognitive impairment, accidents, falls and hip fractures. The hypnotic efficacy of benzodiazepines appears to reduce within 4 weeks.

Regularly review patients who take long-term hypnotics—discuss and try to stop long-term hypnotic use whenever possible.

Stopping long-term hypnotic use requires:

patient cooperation and education
a tailored dose reduction plan: reduce the dose of the benzodiazepine, zolpidem or zopiclone by 25% of the original dose every 1 to 4 weeks; consider slowing the dose reduction for the final dose reduction or if problematic discontinuation symptoms occur
support from family, carers or significant others
identification and management of contributing or causative factors to poor sleep
nonpharmacological alternatives to assist with sleep—see Psychological and behavioural interventions for insomnia
regular contact between the patient and the treating clinician while sleep cycle stabilises—support and encourage the patient and monitor for signs of withdrawal.

Reconnexion is an Australian organisation that provides patients with information, support and counselling for benzodiazepine dependence, and information for healthcare professionals; see URL.

Consider referral to a specialist if the hypnotic cannot be successfully stopped without a relapse of insomnia (allowing for a period of rebound insomnia after stopping the drug).