Psycho-Babble Medication Thread 102248

Shown: posts 1 to 11 of 11. This is the beginning of the thread.

 

Anyone Taken Ambien AND a Benzo for Sleep?

Posted by fachad on April 7, 2002, at 9:44:27

It seems like for me to get to sleep using a benzo I need really high doses. 30mg temazepam didn’t phase me, and 2mg Ativan does a little more, but not much. I guess I could try 4 mg Ativan, but that seems like a fairly high dose.

I'm now wondering if it would make more sense to take Ambien to initiate sleep, and a very small dose benzo(like 1mg Ativan) to maintain sleep.

Has anyone one done this successfully and with your pdoc's approval?

 

Re: Anyone Taken Ambien AND a Benzo for Sleep? » fachad

Posted by Alan on April 7, 2002, at 16:08:46

In reply to Anyone Taken Ambien AND a Benzo for Sleep?, posted by fachad on April 7, 2002, at 9:44:27

I've not tried it but sounds reasonable. I've heard of those that take ambien and when waking in the middle of the night, take a second full dose. Nothing wrong with that as long as it's not long term....

BZD's aren't really designed for sleep disturbance problems long term. If you don't have an anxiety disorder, then it's best not to use BZD's for this purpose as the same dosage over time will become less effective. Have you had a sleep study done to rule out sleep apnea?

Perhaps a small dosage of a sedating TCA or Trazadone would be helpful? Some even get a sedating rest from Benadryl (I get the paradoxical reaction unfortunately - the jitters).

Best,

Alan

 

ALAN - Long Term BZDs OK for Anxiety not Sleep? » Alan

Posted by fachad on April 7, 2002, at 21:00:51

In reply to Re: Anyone Taken Ambien AND a Benzo for Sleep? » fachad, posted by Alan on April 7, 2002, at 16:08:46

ALAN wrote: BZDs aren't really designed for sleep disturbance problems long term. If you don't have an anxiety disorder, then it's best not to use BZDs for this purpose as the same dosage over time will become less effective.

fachad replies: Huh? Is this the same Alan that vociferously defends the safety, efficacy, and appropriateness of long term BZDs for anxiety?

Alan, your post genuinely intrigues me. If you have the time and the inclination, please review the stuff below for correctness and answer a few questions for me.

Please make comments on any errors of fact or interpretation; I'm genuinely open-minded and would like to know what a seasoned BZD expert thinks.

Just so you know, I have a "gut feeling" that you are correct, but I'm trying to determine if that feeling is rational and based on evidence, or if it is residual guilt secondary to indoctrination by the anti-benzo community.

(1) "BZDs aren't really designed for sleep disturbance problems long term."

Maybe it's just a semantic nuance, but I don't think BZDs were designed for any particular indication at all. They were just discovered and then marketed for all sorts of things, including insomnia and anxiety.

Years after the BZDs were discovered, natural BZD receptors were identified in the brain. Later specific subtypes of the BZD receptors were identified. Different subtypes mediate the BZD influence on anxiety, sleep, muscle relaxation, etc.

(2) "If you don't have an anxiety disorder, then it's best not to use BZDs for this purpose as the same dosage over time will become less effective"

This appears to me to be a variant of the classic anti-benzo "you'll develop tolerance" argument. The argument generally runs that tolerance will develop and dose will have to be escalated and dependence will develop and you will be in a worse mess for having started BZDs, so you should never start them in the first place.

But in this case, are you saying that the BZD receptor subtype that mediates the hypnotic effect will develop tolerance, but the BZD receptor subtype that meditates the anxiolytic effect does not develop tolerance?

That premise seems odd, but not impossible. Again, I am just trying to figure out if that conclusion is based on empirical data, clinical experience, anecdotal evidence, or anti-benzo bias.

Based on the considertions outlined above, do you still maintain that it's appropriate to use BZDs long term for management of anxiety disorders but not for sleep disorders?

-fachad

 

Re: Anyone Taken Ambien AND a Benzo for Sleep?

Posted by Elizabeth on April 8, 2002, at 1:14:54

In reply to Anyone Taken Ambien AND a Benzo for Sleep?, posted by fachad on April 7, 2002, at 9:44:27

I tried taking 10 mg Ambien + 1 mg Xanax for sleep (yes, with pdoc's approval). I found that 20 mg Ambien worked better, although it didn't last as long. But in your situation, it might make sense.

> I guess I could try 4 mg Ativan, but that seems like a fairly high dose.

How about 3 mg?

-elizabeth

 

Does 20mg Ambien Last Longer than 10mg? » Elizabeth

Posted by fachad on April 8, 2002, at 8:41:28

In reply to Re: Anyone Taken Ambien AND a Benzo for Sleep?, posted by Elizabeth on April 8, 2002, at 1:14:54

Does 20mg Ambien last longer than 10mg, or does it just hit you harder for the same duration?


> I tried taking 10 mg Ambien + 1 mg Xanax for sleep (yes, with pdoc's approval). I found that 20 mg Ambien worked better, although it didn't last as long. But in your situation, it might make sense.
>
> > I guess I could try 4 mg Ativan, but that seems like a fairly high dose.
>
> How about 3 mg?
>
> -elizabeth

 

Re: ALAN - Long Term BZDs OK for Anxiety not Sleep? » fachad

Posted by alan on April 10, 2002, at 12:21:41

In reply to ALAN - Long Term BZDs OK for Anxiety not Sleep? » Alan, posted by fachad on April 7, 2002, at 21:00:51

> ALAN wrote: BZDs aren't really designed for sleep disturbance problems long term. If you don't have an anxiety disorder, then it's best not to use BZDs for this purpose as the same dosage over time will become less effective.
>
> fachad replies: Huh? Is this the same Alan that vociferously defends the safety, efficacy, and appropriateness of long term BZDs for anxiety?
>
> Alan, your post genuinely intrigues me. If you have the time and the inclination, please review the stuff below for correctness and answer a few questions for me.
>
> Please make comments on any errors of fact or interpretation; I'm genuinely open-minded and would like to know what a seasoned BZD expert thinks.
>
> Just so you know, I have a "gut feeling" that you are correct, but I'm trying to determine if that feeling is rational and based on evidence, or if it is residual guilt secondary to indoctrination by the anti-benzo community.
>
> (1) "BZDs aren't really designed for sleep disturbance problems long term."
>
> Maybe it's just a semantic nuance, but I don't think BZDs were designed for any particular indication at all. They were just discovered and then marketed for all sorts of things, including insomnia and anxiety.
>
> Years after the BZDs were discovered, natural BZD receptors were identified in the brain. Later specific subtypes of the BZD receptors were identified. Different subtypes mediate the BZD influence on anxiety, sleep, muscle relaxation, etc.
>
> (2) "If you don't have an anxiety disorder, then it's best not to use BZDs for this purpose as the same dosage over time will become less effective"
>
> This appears to me to be a variant of the classic anti-benzo "you'll develop tolerance" argument. The argument generally runs that tolerance will develop and dose will have to be escalated and dependence will develop and you will be in a worse mess for having started BZDs, so you should never start them in the first place.
>
> But in this case, are you saying that the BZD receptor subtype that mediates the hypnotic effect will develop tolerance, but the BZD receptor subtype that meditates the anxiolytic effect does not develop tolerance?
>
> That premise seems odd, but not impossible. Again, I am just trying to figure out if that conclusion is based on empirical data, clinical experience, anecdotal evidence, or anti-benzo bias.
>
> Based on the considertions outlined above, do you still maintain that it's appropriate to use BZDs long term for management of anxiety disorders but not for sleep disorders?
>
> -fachad
***********************************************
Excellent questions and I can see how what I said could have been misinterpreted.

If you have underlying anxiety that is causing the sleepnesses then yes it is appropriate - although they disrupt sleep archetechture enough that they may end up causing huge sleep deficits.

But many times sleep disorders are a symptom of something else too - depression, apnea, etc. And bzd's lose their "start up" sedating effects after a week or two so many mistake that for the anxiolytic effect wearing off and unnecessarily up their dose.

As far as receptor subtypes are concerned, your theory sounds plausable and is probably accurate. I know of no credible studies about this though.

That's why I recommended TCA's in small dose and trazadone (anywhere between 50 - 200mg) since there is no tapering needed or significant change in sleep archetechture.

But I still believe that sleep disorders can be the result of something other than that of an anxiety (primary) disorder and those cases are best dealt with with the meds that I mention since there is usually a long tapering process with bzd's for sleep that will include along with it probable relapses back into insomnia.

Alan

 

Re: Does 20mg Ambien Last Longer than 10mg? » fachad

Posted by Elizabeth on April 11, 2002, at 9:07:07

In reply to Does 20mg Ambien Last Longer than 10mg? » Elizabeth, posted by fachad on April 8, 2002, at 8:41:28

> Does 20mg Ambien last longer than 10mg, or does it just hit you harder for the same duration?

Good question. I don't know because I didn't experience any effect at all on 10 mg.

-elizabeth

 

Re: Long Term BZDs » alan

Posted by Elizabeth on April 11, 2002, at 10:10:03

In reply to Re: ALAN - Long Term BZDs OK for Anxiety not Sleep? » fachad, posted by alan on April 10, 2002, at 12:21:41

> If you have underlying anxiety that is causing the sleepnesses then yes it is appropriate - although they disrupt sleep archetechture enough that they may end up causing huge sleep deficits.

I don't think the disruption will necessarily cause serious problems. (Antidepressants disrupt sleep architecture a lot too, after all, and nobody's saying we shouldn't be using those long-term.)

> But many times sleep disorders are a symptom of something else too - depression, apnea, etc.

That's something you have to watch out for. Benzos can actually be dangerous for people with sleep apneas. It's usually okay to use benzos for insomnia associated with depression, as long as you treat the depression too.

> And bzd's lose their "start up" sedating effects after a week or two so many mistake that for the anxiolytic effect wearing off and unnecessarily up their dose.

It's hard to separate the sedative and anxiolytic effects of benzos. I think that, as a rule, you shouldn't expect a sedative-hypnotic drug to "knock you out" -- you need to lie down and turn the lights off and do your best to relax, too! I think this may be why many people report rapid tolerance to sedative-hypnotics. Of course, benzos do lose their sedating effects with time (this is an advantage when they're used to treat daytime anxiety). The short-acting benzos tend to cause tolerance more/faster than the long-acting ones.

> As far as receptor subtypes are concerned, your theory sounds plausable and is probably accurate. I know of no credible studies about this though.

It's not just fachad's theory. Ambien binds selectively to a particular subtype of benzodiazepine receptor, and it lacks many of the effects of benzos (muscle relaxant, anticonvulsant, etc.).

> That's why I recommended TCA's in small dose and trazadone (anywhere between 50 - 200mg) since there is no tapering needed or significant change in sleep archetechture.

I had tolerance problems with both of these, having to raise the dose every couple of days in order to maintain the sedative-hypnotic effects. (I got up to 400 mg of trazodone before giving up on it; in a pinch I even used it in the daytime once as an antihistamine.) I also know of a few other people who also found that they stopped working after a little while. Also, TCAs and trazodone can both cause withdrawal symptoms -- not as bad as benzo withdrawal, of course, but TCA withdrawal in particular can be very unpleasant.

Trazodone tends to increase the time spent in sleep stages III and IV and decrease state II sleep. Interestingly, it can increase the time spent in REM sleep. It doesn't increase REM density as the SSRIs do. TCAs have various effects on sleep architecture. In particular, they decrease the amount and percentage of time spent in REM sleep. They also tend to increase slow-wave sleep. Benzodiazepines decrease the percentage of time spent in slow-wave sleep and REM sleep, increase the percentage in stage II sleep, and increase REM latency. There is also an increase in the number of REM cycles, although they are shortened. So anyway, it's hardly accurate to say that TCAs and trazodone cause no "significant change in sleep architecture."

-elizabeth

 

Re: Anyone Taken Ambien AND a Benzo for Sleep?

Posted by Ponder on April 13, 2002, at 17:25:32

In reply to Anyone Taken Ambien AND a Benzo for Sleep?, posted by fachad on April 7, 2002, at 9:44:27

I have done Ambien 10 and Ativan 1 for sleep with my doctor's blessing, although he hoped I would not have to do that often. I have a PRN script for Ativan and sometimes take it early evening. Then with Ambien at bedtime, I usually sleep pretty well.

> It seems like for me to get to sleep using a benzo I need really high doses. 30mg temazepam didn’t phase me, and 2mg Ativan does a little more, but not much. I guess I could try 4 mg Ativan, but that seems like a fairly high dose.
>
> I'm now wondering if it would make more sense to take Ambien to initiate sleep, and a very small dose benzo(like 1mg Ativan) to maintain sleep.
>
> Has anyone one done this successfully and with your pdoc's approval?

 

Re: Long Term BZDs » Elizabeth

Posted by alan on April 14, 2002, at 11:51:26

In reply to Re: Long Term BZDs » alan, posted by Elizabeth on April 11, 2002, at 10:10:03

> > If you have underlying anxiety that is causing the sleepnesses then yes it is appropriate. But many times sleep disorders are a symptom of something else too - depression, apnea, etc.
>
> That's something you have to watch out for. Benzos can actually be dangerous for people with sleep apneas. It's usually okay to use benzos for insomnia associated with depression, as long as you treat the depression too.
>
> > And bzd's lose their "start up" sedating effects after a week or two so many mistake that for the anxiolytic effect wearing off and unnecessarily up their dose.
>
> It's hard to separate the sedative and anxiolytic effects of benzos. I think that, as a rule, you shouldn't expect a sedative-hypnotic drug to "knock you out" -- you need to lie down and turn the lights off and do your best to relax, too! I think this may be why many people report rapid tolerance to sedative-hypnotics. Of course, benzos do lose their sedating effects with time (this is an advantage when they're used to treat daytime anxiety).
> -elizabeth
***************************************
I think my main point, regardless of sleep architechture issues (the result of which may be detrimental to some while not others) was that tolerance develops rapidly to the sedative effects of the BDZs. If you are treating panic-anxiety and it is the anxiety which is keeping you awake then you will sleep regardless of tolerance. On the other hand, if you are taking Klonopin for it's sedative properties you can expect this will wear off quickly with regular use.

Alan

 

Re: Long Term BZDs » alan

Posted by Elizabeth on April 16, 2002, at 21:29:04

In reply to Re: Long Term BZDs » Elizabeth, posted by alan on April 14, 2002, at 11:51:26

> I think my main point, regardless of sleep architechture issues (the result of which may be detrimental to some while not others) was that tolerance develops rapidly to the sedative effects of the BDZs.

Sure, I was just pointing out that lots of things alter our sleep architecture in different ways, so the benzos shouldn't be singled out for this.

> If you are treating panic-anxiety and it is the anxiety which is keeping you awake then you will sleep regardless of tolerance. On the other hand, if you are taking Klonopin for it's sedative properties you can expect this will wear off quickly with regular use.

This is kind of what I was getting at when I said not to expect sedative-hypnotics to "knock you out." They'll quiet things down if you're feeling nervous, wired, ruminating, thoughts racing, etc., but you have to get in bed and try to sleep, too -- you can't expect them to keep *making* you sleep for very long. For that matter, you can't expect Ambien to knock you out either (again, except maybe at first). I've never taken benzos for insomnia (well, I tried a few of them but they didn't do anything) so I'm not sure to what extent they retain their effects over time, though.

-elizabeth


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