MY QUESTIONS ARE:
48 yo F that has struggled with insomnia for 18 years. It got significantly worse recently when she found out that her daughter has been struggling with anxiety and having suicidal thoughts. In the past she has regulated this with ambien and alcohol. She would have multiple drinks a night to get to sleep. She currently has troubles falling asleep and staying asleep. She will wake about 3 hours after falling asleep. This has not been helped with protein before sleep. She is also very anxious, anxiety worsens with the dark at night. Her overall anxiety has decreased with a flower essence and homeopathic arsenicum, and liquid serenity herbal formula.
She is now using klonopin at 1/4 of a mg and ambien at 2.5 mg nightly to get to sleep on and off for about 1 month now. Occasionally she will use alcohol instead. She tried stopping for one night and using just the liquid serenity and cortisol manager (ITI) but got no sleep that night.
Could she have a rebound effect from jumping on and off klonopin like that? It seems like now she is starting to increase the klonopin dosing a little. She wanted to continue to use it during the holidays. I don’t have a lot of experience with klonopin. When do you start to see withdrawal effects? Is it okay to give her herbs at the same time? I figure they will just increase the effects of the drugs.
I thought that possibly blood sugar management could have been an issue contributing to her sleep as she had two readings of low fasting insulin and c-peptide in the past :
- fasting c-peptide =1 (L), insulin= 1.6 (L), glucose=81, HgA1c = 5.2
- fasting c-peptide = .8 (L), insulin =0.6 (L), glucose = 71, HgA1c = 5
My theory on this was that perhaps since she has used alcohol to help her get to sleep for so long and her ALT is 35. So maybe the liver isn’t able to make glycogen and this is waking her up? And this could be the cause of low c-peptide and insulin???
She did have an adrenal test in the past done and her cortisol was normal. I haven’t gotten her to commit to any more testing yet, still working on it.
In the past she noted that she has tried passionflower, valerian, kavanise, and melatonin. None of which seemed to help. I’ve also had her on nightly castor oil packs. We have talked sleep hygiene and blood sugar management too.
Any thoughts or tips – Especially experience with working with pt’s on Klonopin! – Much appreciated!!
ANSWERS:
[PLEASE NOTE THIS IS FOR THOSE REALLY TOUGH TAPER CASES – NOT FOR THE EASY ONES… BUT THIS ONE LOOKS LIKE A TOUGH ONE ON PAPER]
Cases like this are some of the toughest drug weaning situations ever. Big things to consider:
1.) Expectations
- Time of weaning: Can take months to literally years depending on length of Sleep med Rx and any other Rx or ETOH etc. (largely due to GABA modification effect). Patients need to know they have to go slow to be successful
- How fast one can make weaning decreases: Some people once the ball is rolling can go down every 3-5 weeks and some every 8-12 weeks. (Once this is established then you can try faster cuts in meds as tolerated.)
- If patients don’t know this they will expect more and fail…
2.) Time of disease and additional substances
- ETOH or Cannabinoids etc: Most sleepless folks self-medicate. What she has told you about the ETOH is likely true and an understatement. Assume at least that. ETOH has similar GABA receptor modification to Ambien and the other “non-benzo sleep aids” plus the Benzo types so it makes the trip to weaning longer.
- Length on Ambien etc is huge also, but the fact her breakthrough had to be Tx with Klonopin is meaningful (in a “the GABAa complex is pretty fried” kind of way).
3.) Starting Therapy
- I’d leave her on the meds as is for 4 – 8 weeks while you help the GABAa start to heal (see those notes) but Taurine 1-4 grams a day as tolerated (they will be on Taurine a long time) and 75-150 mg P5P in the evening — for starters.
- During the first months also support (again the notes help here) the GABAb and Glycine channels as they “back up” GABAa (which is fried) and while not as “good” for sleep as GABAa drugs will make the trip shorter. I use Rx Baclofen for GABAb binding (they use it for ETOH and Benzo detox in Europe). 10 mg bedtime then up to 10 mg dinner + 20 HS. Also if tolerated Glycine 1-4 grams with some magnesium dinner and HS.
- Any nutrients to support the sleepy pathways are fine (decrease Histamine, support Melatonin and Serotonin, GAD….) It doesn’t matter if “Melatonin (or fill in the blank) didn’t work for me” – of course not on its own, but in these bad cases you need all the help you can get.
- Don’t worry about not using herbs at the same time. I’d start any you feel need for right away and taper off later.
- Follow the adrenal and blood sugar Tx too – that just will have to be going on in the background regardless of how it seems to help or not.
4.) Tapering
- Last in First out usually best. Klonopin is as bad as anything to taper. After the 4-8 weeks of prep above have her try 1/8 mg Klonopin QHS for a month then every other night. If at 4 weeks the every other night thing is too rough keep at 1/8 mg for 8 weeks. Have her go 1 week at every other night before judging. As the decreases in meds happen if there are rocky spots then add nutrients or herbs as temporary fixes and taper later. IF you can go to every other night then after 8 weeks try Klonopin 1/8 mg 3 nights a week (M-Th-Sa) for 4-8 weeks then stop it. Once Klonopin is done give 2-4 weeks with no changes. Then start on the Ambien. Similar, do a 25% taper about every 8 weeks (faster if tolerated) and then at the tiniest dose go to every other night.
It is a reasonable big picture way to start and in hundreds of like cases the most successful route I have found. DrA
Other related content:
- Weaning Patients off Medications Series
- Neuropharmacology series