Case Report Detoxification of high-dose zolpidem using cross-titration with an adequate equivalent dose of diazepam ☆ Shao-Chien Chen, M.D. a , Hsi-Chung Chen, M.D., Ph.D. a,b, ⁎ , Shih-Cheng Liao, M.D. a , Mei-Chih Meg Tseng, M.D., M.Sc. a , Ming-Been Lee, M.D. a a Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan b Center of Sleep Disorders, National Taiwan University Hospital, Taipei, Taiwan Received 19 June 2011; accepted 20 September 2011 Abstract Background: There have been numerous case reports of zolpidem abuse and dependence in the recent decade, giving rise to a focus on adverse withdrawal events such as seizure. No standard detoxification regimen has been proposed to date, despite the similarity of effects of zolpidem and benzodiazepines at high doses. Case Descriptions: We describe the results, in a 53-year-old female patient, of undergoing three different zolpidem detoxification programs. Conclusions: Because of her experiences, we recommend using the cross-titration strategy with an adequate equivalent dose of diazepam. © 2012 Elsevier Inc. All rights reserved. Keywords: Zolpidem; Benzodiazepines; Detoxification; Diazepam; Withdrawal 1. Introduction Zolpidem is a nonbenzodiazepine hypnotic differing from benzodiazepines (BZDs) in its highly selective action on γ- aminobutyric acid A (GABA A ) receptors with α1 subunits. Zolpidem is rapidly absorbed, reaching peak plasma concentration within 0.8 to 2.6 h. Its therapeutic dose is up to 10 mg/day. Supratherapeutic doses of zolpidem have been associated with complex sleep behavior [1], unusual anxiolytic effects and memory loss [2]. Symptoms of withdrawal from high-dose zolpidem are similar to BZD withdrawal symptoms, varying from anxiety to autonomic nervous system dysfunction to severe, generalized tonic– clonic seizures [3]. All these findings indicate that, at supratherapeutic doses, zolpidem, losing its selectivity for GABA A receptors, has the same pharmacodynamic and addictive characteristics as the BZDs. Effective strategies for detoxification from high-dose short-half-life BZDs have been established, following two principles: tapering gradually and using equivalent doses of long-acting BZDs as substitutes [4,5]. The standard detoxification method for zolpidem has been a subject of strong debate. Whether the detoxification strategy for short- half-life BZDs can be applied to zolpidem is uncertain. 2. Case report A 53-year-old female patient with no previous history of substance abuse first sought psychiatric help for depressed mood at age 46. Subsequently she presented for follow-up appointments irregularly and was treated incompletely. At age 49, she suffered from insomnia and started taking zolpidem 10 mg at bedtime. During the following 6 months, for maintaining a satisfying full night's sleep, she increased her total intake to 30 mg/day in divided doses. She discovered that daytime ingestion of zolpidem enabled her to be energetic and free from unspecified discomfort, causing her to gradually increase her daily dose. When going without zolpidem, she experienced withdrawal symptoms of palpitations, tremor and anxiety. Consequently, during the following 2 years, she increased her daily zolpidem consumption to 100 to 160 mg/day for daytime vitality and anxiety control. Despite regular psychiatric visits to obtain prescriptions for antidepressants and hypnotics, she Available online at www.sciencedirect.com General Hospital Psychiatry 34 (2012) 210.e5 – 210.e7 ☆ Disclosure: None of the authors have any conflicts of interest to declare. ⁎ Corresponding author. Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan. Tel.: +886 2 23123456x66787; fax: +886 2 23813208. E-mail address: hsichungchen@ntu.edu.tw (H.-C. Chen). 0163-8343/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2011.09.012