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Research Fellow Division of Psychology and Behavioral Immunobiology Swiss Federal Institute of Technology Zürich, SES C4 Scheuchzerstraße 17 8092 Zürich, Switzerland fax 0041 1 632 1355 krueger{at}ifv.gess.ethz.ch
Senior Registrar Department of Clinical Psychiatry and Psychotherapy Hannover Medical School Hannover, Germany
Senior Registrar Department of Clinical Psychiatry and Psychotherapy Hannover Medical School
Published Online, March 1, 2005. www.theannals.com, DOI 10.1345/aph.1E520
1 subtype of the benzodiazepine
receptor. The drug is approved for the short-term treatment of insomnia and is
considered as almost devoid of abuse and dependence potential. We report the
case of a patient who took high-dose zolpidem for pain relief and encountered
serious withdrawal effects. Case Report. A 39-year-old white woman had been taking zolpidem 600 mg/day for about 2 years due to chronic facial pain. With the exception of zolpidem and thyroid hormones (hypothyroidism), the woman had received no further medication. Zolpidem had been prescribed by several physicians and obtained from other sources until the intake was abruptly discontinued by the patient due to supply problems. Within 24 hours, 2 epileptic seizures were observed by relatives. A further generalized convulsion of about 6 minutes occurred in the emergency department and was terminated by administration of intravenous diazepam 10 mg. Her substance use history was significant for intermittent use of barbiturates and diazepam during adolescence due to an anxiety disorder (not further specified). Experiences of illegal drugs/alcohol or previous detoxification treatments were not reported (actual toxicology without abnormal findings).
Six years previously, the patient had developed severe facial pain after excessive treatment of the skin with various external cleansing lotions of unknown composition. Presently, a symmetrical burning pain, including all sensory branches of the trigeminal nerve, with an intensity of 8 out of 10 on a visual analog rating scale (VAS) and persistence during the most part of the day was described. Trigger points were not mentioned, but there was increased sensitivity to cold and touch. Extensive examinations, including electrophysiologic and imaging techniques, were within the normal range. The symptomatology was considered painful polyneuropathy of neurotoxic genesis on the basis of excessive dermal treatment.
Various treatment efforts in the past, including tricylic and other
antidepressants, non-opioidergic and opioidergic analgesics, memantine,
glucocorticoids, anticonvulsive agents, -lipoic acid, lidocaine,
benzodiazepines, and blockade of the superior cervical ganglion, were
ineffective. However, the patient noted substantial pain relief (VAS score 1)
with zolpidem therapy, which had been prescribed as temporary sleep medication
starting with 10 mg/day. Over the past 2 years, the dose of zolpidem was
gradually escalated by the patient to reach optimal pain relief.
Detoxification was accomplished using a standardized 10-day tapering protocol of oxazepam (starting with 20 mg for 4 days) in combination with carbamazepine (starting with 200 mg for 3 days), which was successfully completed.1,2 However, the pain reappeared and did not respond to any further treatment efforts.
Discussion. Our case further corroborates the assumption of a definite abuse and dependence potential for zolpidem and a possible loss of benzodiazepine-1 receptor specificity at high doses, with the majority of reported patients having a history of former drug or alcohol abuse and/or other psychiatric conditions.3 Furthermore, this case illustrates an exceptional off-label effectivity of high-dose zolpidem in a patient with therapy-resistant facial pain, although this regimen holds high medical risks. Remarkably, 2 reports of temporary improvements of catatonia and aphasia after a single dose of zolpidem indicate a mode of action apart from hypnotic properties.4,5 Thus, further investigations of the pharmaco-dynamic properties of zolpidem might be useful. Nevertheless, zolpidem should be prescribed with the awareness of a definite dependence potential.
References
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