Skip to main content
SpringerLink
Log in

Hypnotic Dependence and Withdrawal

  • Chapter
  • First Online:
Acceptance and Commitment Therapy for Insomnia

  • 167 Accesses

Abstract

The use of hypnotic drugs has always been an important topic given the enormous commercial success of these drugs since their launch and the potential risk of significant side effects, with negative impacts on patients. Dependence syndrome or substance use disorder is relatively common among users of hypnotic drugs, especially benzodiazepines and Z-drugs, the classes associated with this condition. The harmful effects of benzodiazepines and Z-drugs have been widely documented in the literature and in clinical practice and have sparked debate about the adequate prescription of these substances by physicians and their proper use by the general population. So far there are no guidelines for the treatment of hypnotic dependence, but consensual recommendations exist that should guide patient management. The treatment, which must be individualized, involves gradual discontinuation of the hypnotic drug, the use of other drugs to treat withdrawal symptoms, and a psychotherapeutic approach. Cognitive behavioral therapy and motivational interviewing are widely used techniques, with a higher level of evidence recommending the former. Care should also be taken in the follow-up after drug discontinuation in order to minimize the risk of relapse or return to inappropriate hypnotic use.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  • Allison, C., & Pratt, J. (2003). Neuroadaptive process in GABAergic and glutamatergic systems in benzodiazepine dependence. Pharmacology & Therapeutics, 98(2), 171–195.

    Article  Google Scholar 

  • American Psychiatry Association. (1990). Benzodiazepine dependence, toxicity, and abuse: A task force report of the American Psychiatric Association. American Psychiatric Pub.

    Google Scholar 

  • American Psychiatry Association. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Association.

    Book  Google Scholar 

  • Ashton, H. (1991). Protracted withdrawal syndromes from benzodiazepines. Journal of Substance Abuse Treatment, 8(1–2), 19–28.

    Article  PubMed  Google Scholar 

  • Ashton, H. (2002). Benzodiazepine abuse. In W. Caan & J. de Belleroche (Eds.), Drink, drugs and dependence: From science to clinical practice (pp. 197–212). Routledge.

    Google Scholar 

  • Avidan, A. Y., & Neubaner, D. N. (2017). Chronic insomnia disorder. Continuum (Minneap Minn), 23(4), 1064–1092.

    PubMed  Google Scholar 

  • Baandrup, L., Ebdrup, B. H., Rasmussen, J. Ø., et al. (2018). Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users. The Cochrane Database of Systematic Reviews, 3, CD011481.

    PubMed  Google Scholar 

  • Baldwin, D. S. (2022). Clinical management of withdrawal from benzodiazepine anxiolytic and hypnotic medications. Addiction, 117(5), 1472–1482.

    Article  PubMed  Google Scholar 

  • Baldwin, D. S., Aitchison, K., Bateson, A., et al. (2013). Benzodiazepines: Risks and benefits – A reconsideration. Journal of Psychopharmacology (Oxford, England), 27(11), 967–971.

    Article  PubMed  Google Scholar 

  • Barrons, R., & Roberts, N. (2010). The role of carbamazepine and oxcarbazepine in alcohol withdrawal syndrome. Journal of Clinical Pharmacy and Therapeutics, 35(2), 153–167.

    Article  PubMed  Google Scholar 

  • Bashir, K., King, M., & Ashworth, M. (1994). Controlled evaluation of brief intervention by general practitioners to reduce chronic use of benzodiazepines. British Journal of General Practice, 44(386), 408–412.

    Google Scholar 

  • Bateson, A. (2002). Basic pharmacologic mechanisms involved in benzodiazepine tolerance and withdrawal. Current Pharmaceutical Design, 8(1), 5–21.

    Article  PubMed  Google Scholar 

  • Berrymen, S. N., Jennings, J., Ragsdale, S., Lofton, T., Huff, D. C., & Rooker, J. S. (2012). Beers criteria for potentially inappropriate medication use in older adults. Medsurg Nursing, 21(3), 129–132.

    Google Scholar 

  • Chapoutot, M., Peter-Derex, L., Schoendorff, B., Faivre, T., Bastuji, H., & Putois, B. (2021). Telehealth-delivered CBT-I programme enhanced by acceptance and commitment therapy for insomnia and hypnotic dependence: A pilot randomized controlled trial. Journal of Sleep Research, 30(1), e13199.

    Article  PubMed  Google Scholar 

  • Collins, P. Y., Patel, V., Joestl, S. S., et al. (2011). Grand challenges in global mental health. Nature, 475(7354), 27–30.

    Article  PubMed  PubMed Central  Google Scholar 

  • Cormack, M. A., Dietze, P., Lee, N., Dunlop, A., & Taylor, D. (1994). Evaluation of an easy, cost-effective strategy for cutting benzodiazepine use in general practice. British Journal of General Practice, 44(378), 5–8.

    Google Scholar 

  • Cosci, F., & Chouinard, G. (2020). Acute and persistent withdrawal syndromes following discontinuation of psychotropic medications. Psychotherapy and Psychosomatics, 89(5), 283–306.

    Article  PubMed  Google Scholar 

  • Darker, C. D., Sweeney, B. P., Barry, J. M., Farrell, M. F., & Donnely-Swift, E. (2015). Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. The Cochrane Database of Systematic Reviews, 5, CD009652.

    Google Scholar 

  • De Gier, N., Gorgels, W., Lucassen, P., Oude Voshar, R., Mulder, J., & Zitman, F. (2011). Discontinuation of long-term benzodiazepine use: 10-year follow-up. Family Practice, 28(3), 253–259.

    Article  PubMed  Google Scholar 

  • De las Cuevas, C., Sanz, E., & de la Fuente, J. (2003). Benzodiazepines: More “behavioural” addiction than dependence. Psychopharmacology, 167(3), 297–303.

    Article  PubMed  Google Scholar 

  • El Rafihi-Ferreira, R., Morin, C. M., Toscanini, A. C., Lotufo, N. F., Brasil, I. S., Gallinaro, J. G., Borges, D. S., Conway, S. G., & Hasan, R. (2020). Acceptance and commitment therapy-based behavioral intervention for insomnia: A pilot randomized controlled trial. Brazilian Journal of Psychiatry, 43(5), 1–6. https://doi.org/10.1590/1516-4446-2020-0947

    Article  Google Scholar 

  • El Rafihi-Ferreira, R., Morin, C. M., Hasan, R., Brasil, I. S., Zago Ribeiro, J. H., Júnior, & Cecília Toscanini, A. (2022). A pilot randomized controlled trial (RCT) of acceptance and commitment therapy versus cognitive behavioral therapy for chronic insomnia. Behavioral Sleep Medicine, 1–15, 193. https://doi.org/10.1080/15402002.2022.2071272

    Article  Google Scholar 

  • Engin, E., Benham, R. S., & Rudolph, U. (2018). An emerging circuit pharmacology of GABAA receptors. Trends in Pharmacological Sciences, 39(8), 710–732.

    Article  PubMed  PubMed Central  Google Scholar 

  • Faccini, M., Leone, R., Opri, S., et al. (2016). Slow subcutaneous infusion of flumazenil for the treatment of long-term, high-dose benzodiazepine users: A review of 214 cases. Journal of Psychopharmacology, 30(10), 1047–1053.

    Article  PubMed  Google Scholar 

  • Gerada, C., & Ashworth, M. (1997). ABC of mental health: Addiction and dependence – I: Illicit drugs. BMJ, 315(7103), 297–300.

    Article  PubMed  PubMed Central  Google Scholar 

  • Golombok, S., Higgitt, A., Fonagy, P., Dodds, S., Saper, J., & Lader, M. (1987). A follow-up study of patients treated for benzodiazepine dependence. The British Journal of Medical Psychology, 60(2), 141–149.

    Article  PubMed  Google Scholar 

  • Griffin, C. E., 3rd., Kaye, A. M., Bucno, F. R., et al. (2013). Benzodiazepine pharmacology and central nervous system-mediated effects. The Ochsner Journal, 13(2), 214–223.

    PubMed  PubMed Central  Google Scholar 

  • Gustavsen, I., Bramness, J. G., Skurtveit, S., Engeland, A., Neutel, I., & Mϕrland, J. (2008). Road traffic accident risk related to prescriptions of the hypnotics zopiclone, zolpidem, flunitrazepam and nitrazepam. Sleep Medicine, 9(8), 818–822.

    Article  PubMed  Google Scholar 

  • Huang, B., Dawson, D. A., Stinson, F. S., et al. (2006). Prevalence correlates and comorbidity of nonmedical prescription drug use and drug use disorders in the United States. The Journal of Clinical Psychiatry, 67(07), 1062–1073. https://doi.org/10.4088/JCP.v67n0708

  • Jones, C. M., & McAninch, J. K. (2015). Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines. American Journal of Preventive Medicine, 49(4), 493–501.

    Article  PubMed  Google Scholar 

  • Kan, C. C., Hilberink, S. R., & Breteler, M. H. (2004). Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach. Comprehensive Psychiatry, 45(2), 88–94.

    Article  PubMed  Google Scholar 

  • Kawasaki, S. S., Jacapraro, J. S., & Rastegar, D. A. (2012). Safety and effectiveness of a fixed-dose phenobarbital protocol for inpatient benzodiazepine detoxification. Journal of Substance Abuse Treatment, 43(3), 331–334.

    Article  PubMed  Google Scholar 

  • Lader, M. (1991). History of benzodiazepine dependence. Journal of Substance Abuse Treatment, 8(1–2), 53–59.

    Article  PubMed  Google Scholar 

  • Lader, M. (2011). Benzodiazepines revisited – Will we ever learn? Addiction, 106(12), 2086–2109.

    Article  PubMed  Google Scholar 

  • Lader, M. (2014). Benzodiazepines harm: How can it be reduced? British Journal of Clinical Pharmacology, 77(2), 295–301.

    Article  PubMed  PubMed Central  Google Scholar 

  • Lader, M., Tylee, A., & Donaghue, J. (2009). Withdrawing benzodiazepines in primary care. CNS Drugs, 23(1), 19–34.

    Article  PubMed  Google Scholar 

  • Lappalainen, P., Langrial, S., Oinas-Kukkonen, H., Muotka, J., & Lappalainen, R. (2019). ACT for sleep – Internet-delivered self-help ACT for subclinical and clinical insomnia: A randomized controlled trial. Journal of Contextual Behavioral Science, 12, 119–127.

    Article  Google Scholar 

  • Lembke, A., Papac, J., & Humphreys, K. (2018). Our other prescription drug problem. The New England Journal of Medicine, 378(8), 693–695.

    Article  PubMed  Google Scholar 

  • Lintzeries, N., & Nielsen, S. (2010). Benzodiazepines, methadone and buprenorphine: Interactions and clinical management. The American Journal on Addictions, 19(1), 59–72.

    Article  Google Scholar 

  • Lüscher, C., & Ungless, M. A. (2006). The mechanistic classification of addictive drugs. PLoS Medicine, 3(11), e437.

    Article  PubMed  PubMed Central  Google Scholar 

  • Mariani, J. J., Malcolm, R. J., Mamczur, A. K., et al. (2016). Pilot trial of gabapentin for the treatment of benzodiazepine abuse or dependence in methadone maintenance patients. The American Journal of Drug and Alcohol Abuse, 42(3), 333–340.

    Article  PubMed  PubMed Central  Google Scholar 

  • Maust, D. T., Lin, L. A., & Blow, F. C. (2019). Benzodiazepine use and misuse among adults in the United States. Psychiatric Services (Washington, D.C.), 70(2), 97–106.

    Article  PubMed  Google Scholar 

  • Miller, P. S., & Aricescu, A. R. (2014). Crystal structure of a human GABAA receptor. Nature, 512(7514), 270–275.

    Article  PubMed  PubMed Central  Google Scholar 

  • Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change (3rd ed.). Guilford.

    Google Scholar 

  • Miller, S. C., Fiellin, D. A., Rosenthal, R. N., et al. (2018). The ASAM principles of addiction medicine (6th ed., pp. 797–803). ASAM.

    Google Scholar 

  • Mol, A. J., Oude Voshaar, R. C., Gorgels, W. J., Breteler, M. H., van Balkom, A., van de Lisdonk, E., et al. (2007). The role of craving in relapse after discontinuation of long-term benzodiazepine use. Journal of Clinical Psychiatry, 68(12), 1894–1900.

    Article  PubMed  Google Scholar 

  • Moloney, M. E., Konrad, T. R., & Zimmer, C. R. (2011). The medicalization of sleeplessness: A public health concern. American Journal of Public Health, 101(8), 1429–1433.

    Article  PubMed  PubMed Central  Google Scholar 

  • Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Nonpharmacological interventions for insomnia: A meta-analysis of treatment for insomnia: A meta-analysis of treatment efficacy. The American Journal of Psychiatry, 151(8), 1172–1180.

    Article  PubMed  Google Scholar 

  • Morin, C. M., Belánger, L., Bastien, C., & Vallières, A. (2005). Long-term outcome after discontinuation of benzodiazepine for insomnia: A survival analysis of relapse. Behaviour Research and Therapy, 43(1), 1–14.

    Article  PubMed  Google Scholar 

  • Mugunthan, K., McGuire, T., & Glasziou, P. (2011). Minimal interventions to decrease long-term use of benzodiazepines in primary care: A systematic review and meta-analysis. The British Journal of General Practice, 61(590), e573–e578.

    Article  PubMed  PubMed Central  Google Scholar 

  • O’Connor, K., Belánger, L., Marchand, A., Dupuis, G., Elie, R., & Boyer, R. (1999). Psychological distress and adaptational problems associated with discontinuation of benzodiazepines. Addictive Behaviors, 24(4), 537–541.

    Article  PubMed  Google Scholar 

  • O’Connor, K., Marchand, A., Belánger, L., Mainguy, N., Landry, P., Savard, P., et al. (2004). Psychological distress and adaptational problems associated with benzodiazepine withdrawal and outcome: A replication. Addictive Behaviors, 29(3), 583–593.

    Article  PubMed  Google Scholar 

  • Okumura, Y., Shimizu, S., & Matsumoto, T. (2016). Prevalence, prescribed quantities, and trajectory of multiple prescriber episodes for benzodiazepines: A 2-year cohort study. Drug and Alcohol Dependence, 158, 118–125.

    Article  PubMed  Google Scholar 

  • Olfson, M., King, M., & Schoenbaum, M. (2015). Benzodiazepine use in the United States. JAMA Psychiatry, 72(2), 136–142.

    Article  PubMed  Google Scholar 

  • Paulos-Guarnieri, L., Linares, I. M. P., & El Rafihi-Ferreira, R. (2022). Evidence and characteristics of Acceptance and Commitment Therapy (ACT)-based interventions for insomnia: A systematic review of randomized and non-randomized trials. Journal of Contextual Behavioral Science, 23, 1–14. https://doi.org/10.1016/j.jcbs.2021.11.001

    Article  Google Scholar 

  • Peng, L., Morford, K. L., & Levander, X. A. (2022). Benzodiazepines and related sedatives. The Medical Clinics of North America, 106(1), 113–129.

    Article  PubMed  Google Scholar 

  • Petitjean, S., Ladewig, D., Meier, C. R., Amrein, R., & Wiesbeek, G. A. (2007). Benzodiazepine prescribing to the Swiss adult population: Results from a national survey of community pharmacies. International Clinical Psychopharmacology, 22(5), 292–298.

    Article  PubMed  Google Scholar 

  • Saal, D., Dong, Y., Bonci, A., & Malenka, R. C. (2003). Drugs of abuse and stress trigger a common synaptic adaptation in dopamine neurons. Neuron, 37(4), 577–582.

    Article  PubMed  Google Scholar 

  • Sanna, E., Busonero, F., Talani, G., Carta, M., Massa, F., Peis, M., Maciocco, E., & Biggio, G. (2002). Comparison of the effects of zaleplon, zolpidem and triazolam at various GABAA receptor subtypes. European Journal of Pharmacology, 451(2), 103–110.

    Article  PubMed  Google Scholar 

  • Schilano, F., Chiappini, S., Corkery, J. M., et al. (2019). An insight into Z-drug abuse and dependence: An examination of reports to the European Medicines Agency Database of suspected adverse drug reactions. The International Journal of Neuropsychopharmacology, 22(4), 270–277.

    Article  Google Scholar 

  • Schweizer, E., Rickels, K., de Martinis, N., Case, G., & García-España, F. (1998). The effect of personality on withdrawal severity and taper outcome in benzodiazepine dependent patients. Psychological Medicine, 28(3), 713–720.

    Article  PubMed  Google Scholar 

  • Schwitz, A. (2021). Benzodiazepines: The time for systematic change is now. Addiction, 116(2), 219–221.

    Article  Google Scholar 

  • Sirdifield, C., Chipcase, S. Y., Owen, S., & Siriwardena, A. N. (2017). A systematic review and meta-synthesis of patients’ experiences and perceptions of seeking and using benzodiazepines and Z-drugs: Towards safer prescribing. The Patient, 10(1), 1–15.

    Article  PubMed  Google Scholar 

  • Smith, A. J., & Tett, S. E. (2010). Improving the use of benzodiazepines – Is it possible? A non-systematic review of interventions tried in the last 20 years. BMC Health Services Research, 10(1), 1–12.

    Article  Google Scholar 

  • Soyka, M. (2017). Treatment of benzodiazepine dependence. The New England Journal of Medicine, 376(12), 1147–1157.

    Article  PubMed  Google Scholar 

  • Tan, K. R., Brown, M., Labouèbe, G., et al. (2010). Neural bases for addictive properties of benzodiazepines. Nature, 463(7282), 769–774.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ten Wolde, G. B., Dijkstra, A., van Empelen, P., van den Houit, W., Neven, A. K., & Zitman, F. (2008). Long-term effectiveness of computer-generated tailored patient education on benzodiazepines: A randomized, controlled trial. Addiction, 103(4), 662–670.

    Article  PubMed  Google Scholar 

  • Trauer, J. M., Qlan, M. Y., Doyle, J. S., et al. (2015). Cognitive-behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Annals of Internal Medicine, 163(3), 191–204.

    Article  PubMed  Google Scholar 

  • U.S. Food and Drug Administration. (2020). FDA requiring boxed warning updated to improve safe use of benzodiazepine drug class. Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class. Accessed 9 Dec 2022.

  • Voshaar, R. O., Gorgels, W., Mol, A., van Balkom, A., Breteler, M., van de Lisdonk, E., et al. (2003). Predictors of relapse after discontinuation of long-term benzodiazepine use by minimal intervention: A 2-year follow-up study. Family Practice, 20(4), 370–372.

    Article  PubMed  Google Scholar 

  • Voshaar, R. C., Gorgels, W. J., Mol, A. J., van Balkom, A. J., Mulder, J., van de Lisdonk, E. H., Breteler, M. H., & Zitman, F. G. (2006). Predictors of long-term benzodiazepine abstinence in participants of a randomized controlled benzodiazepine withdrawal program. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 51(7), 445–452. https://doi.org/10.1177/070674370605100706

    Article  PubMed  Google Scholar 

  • Wagner, A. K., Zhang, F., Soumerai, S. B., et al. (2004). Benzodiazepine use and hip fractures in the elderly: Who is at greatest risk? Archives of Internal Medicine, 164(14), 1567–1572.

    Article  PubMed  Google Scholar 

  • World Health Organization. (2018). The International Classification of Diseases (ICD-11). http://www.icd.who.int. World Health Organization. Accessed 12 Oct 2022.

Download references

Author information

Authors and Affiliations

  1. Institute of Medical Assistance to State Civil Servants of São Paulo (IAMSPE), Sao Paulo, Brazil

    Israel Soares Pompeu de Sousa Brasil

  2. Institute of Psychiatry, Hospital das Clínicas, FMUSP, Sao Paulo, Brazil

    Rosa Hasan

Authors
  1. Israel Soares Pompeu de Sousa Brasil
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rosa Hasan
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Department of Clinical Psychology, Universidade de São Paulo, São Paulo, São Paulo, Brazil

    Renatha El Rafihi-Ferreira

Rights and permissions

Reprints and permissions

Copyright information

© 2024 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

de Sousa Brasil, I.S.P., Hasan, R. (2024). Hypnotic Dependence and Withdrawal. In: El Rafihi-Ferreira, R. (eds) Acceptance and Commitment Therapy for Insomnia. Springer, Cham. https://doi.org/10.1007/978-3-031-50710-6_6

Download citation

Publish with us

Policies and ethics

Search

Navigation