Taper of zopliclone for 84 year old.

[[Pa...]]

Hi all,

a little background. My mother was prescribed Benzos back in the 60’s. She took them, was never warned against them, of course. In her late 50’s and early 60’s she took them daily then decided she needed to stop. There is a lot more to the story, but basically she tapered over a 10 month period. I’m proud of her! But I believe she suffered nerve damage in her face from it. She blames it on the dentist. 
 

Years later she started on Ambien (sublinox in Canada) we had to send her to rehab to get off it as she had scaled up her use significantly. They did a quick withdrawal. It was a messy time but she said it was the only thing that provided relief to the pain in her head. 
 

Today, at 84, we are faced with tapering her down from Zopliclone. The drs in the hospital have put her on a quick taper and she is in hell. These drugs are torture. I wish I had done all this reading before she was released two days ago. 
 

I want to go to her GP and show her the Ashton Manuel and hope she will support my desire for a long slow taper to reduce her misery like she did before. Fingers crossed. 
 

Here is my problem. I was all set to write out a schedule using Valium and show it to her physician, but then I read on another website that anyone over 65 shouldn’t be put on Valium because of its long term effects in the body. 
 

Should I request a slow taper with just the zopliclone? I’m worried it’s short half life is causing her interdose withdrawal and thought the Valium might smooth out her withdrawal torture. 
 

She is currently on 7.5 mg zopliclone. Down from 11.5 mg.  (But really she was taking more, then going without for a few days before her prescription could be filled)
 

they also took her off of her t3s and she wants to go back on them as well as restless leg medicine to help with the tremors of withdrawal. 
 

A month ago she stopped taking pregabalin. 
 

thanks. 

[[Pa...]]

Hello Patti, welcome to BenzoBuddies,

I'm so sorry to hear about your mother, she's been through so much!  May I ask why she decided to taper off the Zopiclone, has she been suffering symptoms of tolerance to the medication?  

What is t3's and what was her restless medicine and why would they take her off of those medications?

I'm sorry for these questions, I just need to understand a little better before making suggestions.

We're glad you're here, I hope we can help you get this sorted out. 

@[Pa...]

[[Li...]]

12 hours ago, [[P...] said:

Should I request a slow taper with just the zopliclone? I’m worried it’s short half life is causing her interdose withdrawal and thought the Valium might smooth out her withdrawal torture. 

Hello @[Pa...].  Was your mother fully informed of the difficulties of discontinuing this medication at her age, especially given her prior use of benzodiazepines, problematic withdrawal from Ambien, and recent use/cessation of pregabalin?  Did she agree to the rapid taper?

Per the article linked below: 

“…  regulators and guidelines must respect that patients who are already physically dependent on benzodiazepines [and z-drugs] should never be forced against their will to withdraw.”

“Given how difficult the process can be for some people it may be the lesser of two harms is to stay on the drugs, especially for older people who have been on the drugs for decades.”

If she has been fully informed of the risks and does indeed decide she wants to come off the zopiclone, she should do so very gradually according to how she responds to reductions —  not according to a fixed algorithm or schedule and certainly not via a rapid taper.

To learn more about safe, gradual, patient-guided deprescribing, check out the recently published Maudsley Deprescribing Guidelines: Antidepressants, Benzodiazepines, Gabapentinoids and Z-drugs by Horowitz and Taylor.  You can order it online from Amazon in electronic or print format. Information specific to tapering zopiclone is presented on pages 490-494.  I’ve also included a link below to selected pages from the text.

Links:
Benzodiazepines in Canada: Is a Withdrawal Crisis Looming
https://www.madinamerica.com/2024/02/benzodiazepines-in-canada-is-a-withdrawal-crisis-looming/

The Maudsley Deprescribing Guidelines - Mark Horowitz, David M. Taylor
https://books.google.com/books/about/The_Maudsley_Deprescribing_Guidelines.html?id=WJLqEAAAQBAJ

Edited March 5 by [Li...]
Additional info

[[Pa...]]

I'm sorry for my late reply. I thought I would get email notifications if someone responded. I'm glad I checked this sight.

To answer you questions Pamster:

My mom is tapering from Zoplicone because she is having interdose withdrawals and tolerance issues. She has not been taking them correctly. Taking a larger dose than her prescription than having nothing for a few days making her symptoms worse.

 

T3's are Tylenol with codeine. And her wrestles leg medicine is Pramipexol. Over the last year she has reduced the Pramipexol with her dr.

[[Pa...]]

Hi Libertas,

Mom agreed that she needed to get off the Zopliclone but didn't agree to a rapid taper. She knows you shouldn't do this. She also didn't agree to being taken off Tylenol with Codeine (T3) But to be fair, when she entered the hospital it wasn't in her records that she was taking that pill so was unwittingly removed from it. She is now taking it again (at a lower dose since she was off it for 6 days) so we can concentrate on the Zopliclone.

Truthfully, I would let mom stay on the zopliclone if it worked for her. But with interdose withdrawals and tolerance she is starting to updose and and is being tortured in-between doses or tortured when she uses up the week of pills she has in 3 days and has no more to take. She and I have talked and she agrees she wants to get off of them.

 

Thank you for the link. I will check those out. I finished the Ashton manual last night and made note of her recommendations for Zopliclone. I was just worried when I also read in a "Step by Step Guide Reducing from Benzodiazapines and Recover from Withdrawal" from Australia that you shouldn't give long acting benzos to people over 65.

I wondered if I shouldn't ask for Valium to help my mom taper from her Dr. even though its a pretty low dose. I am meeting with a pharmacist today to ask this question as well.

 

Thanks.

[[Li...]]

Hello again @[Pa...].  

Thank you for the additional information.  Please do check out the new Maudsley Deprescribing Guidelines (MDGs), especially the section on zopiclone. 

The ‘issue’ with diazepam is that it has been identified as a PIM (Potentially Inappropriate Medication) for older adults.  However, an argument could be made that it may be appropriate to use in your mother’s case. So, in your shoes, I would ask my mother’s doctor and pharmacist about it.

Here’s what the MDGs has say about switching to diazepam from zopiclone:

An alternative to a direct taper from zopiclone is to switch to diazepam before tapering from this drug as outlined in “Switching to longer-acting benzodiazepines to taper.” However, as zopiclone has a short half-life and is dosed once a day, it might be that less physical dependence will be produced in response to this drug than diazepam (present for the entire day).  Therefore, it may be easier to directly taper from zopiclone than switching to diazepam. For people who report interdose withdrawal symptoms from z-drugs, a switch to a longer-acting benzodiazepine might be reasonable (p. 493). 

PS You can change your notification settings by clicking the bell icon in upper right corner of this page.

 

 

[[Pa...]]

Thank you so much. I really appreciate your input. 

[[Pa...]]

Hi @[Pa...], thanks for providing more information, but I need to ask a sensitive question and I hope you'll understand there is no judgement.  Do you feel your mother will be able to taper, can she resist the urge to take a pill to make the pain go away?  The reason I ask is because you mentioned she often runs out of her prescription and then has to go without.  If she isn't able to taper on her own, is there someone there with her who could help administer the medication?

 

[[Pa...]]

Hi Pamster,

Your question is a good one and truthfully, I don't know. I will admit yesterday wasn't a good day. My mom has taken her weeks worth of pills. She should have had 3 pills left and her 87 year old husband, who has had her pills under lock and key, has given them to her.

He has given them to her for 3 reasons, one, it seems even the most basic of pill boxes has confused him. Two, mom was in torture from the hospital doctor reducing her meds too fast and he hates to see her suffer. And three, he is unable to refuse my mom when she asks him for pills, and now tonight she has no zopliclone and will be tortured again.

I admit, I feel defeated. I have been in the process of ordering a medacube. It looks like a wonderful product and will take any confusion out of taking pills and wont allow her to take too many pills as they are locked up and I will be the one locking them in there. It also allows her to take as needed pills like restless leg medicine. But it is very, very expensive and my mom doesn't really want it. And I know she doesn't want it because she likes to be in control of her pills, even though she takes them incorrectly, and seems to have some confusion with the blister pack; its like the Price is Right Punch a Bunch game. And my cynical side comes out too, I also think she secretly likes the high she gets from overtaking some pills, like the sleeping pill, or gravol etc.

So today I will take her to her Dr and try and get her to agree to putting mom back on her 11.25 mg of Zopliclone and she can taper from there if she is able. And truthfully, I don't even know if 11.25 mg is the right amount to give her body rest from withdrawals, but that is what her prescription was before the hospital visit. I don't think her Dr will go higher as apparently mom has asked in the past.

I told her yesterday that I just can't emotionally handle her ending up in the hospital anymore for overdosing and committed her to using the medacube and she agreed. I was also very clear that I'm content for her to stay on her current prescriptions for the rest of her life (even though these drugs really won't let you stay on them without tolerance creating issues), but she says she wants to taper.

If some how she gets pills through other means and circumvents the medicube, I will have a $3000 CAD paper weight.

[[Pa...]]

I did have a great, informed conversation with the pharmacist. She had just come back from a Zopliclone class and how to do a long patient led taper. She also said the Dr. would never prescribe Valium for mom's taper. It is a drug they haven't filled in their pharmacy for years.

[[Li...]]

@[Pa...]  I hope your mother understands and appreciates how fortunate she is to have you as her advocate!

Tip of the hat for talking with the pharmacist.   Did she give you details about what a long, patient led taper would entail?   For example, did she specifically state that your mom’s response to the reductions would determine the amount, size, and timing of the reductions?  Did she give you an example of a slow taper schedule showing the amount to be taken at each step and the approximate number of weeks for each step?    

I ask because many pharmacists and prescribers have been taught that a ‘slow taper’ is 4 - 6 or at most 8 weeks.  This is too fast for some individuals plus it does not take into account the key principle of patient-led tapering which is that reductions should be guided by the patient’s response.  If withdrawal symptoms become intolerable after a reduction, then the taper schedule should be adjusted. 

I just reviewed the slow taper schedule for zopiclone in the Maudsley Deprescribing Guidelines.   It uses 7.5mg in tablets for Step 1 but switches to a liquid dosage form for Steps 2 to 17.  

Would either your mother or father be capable of making a do-it-youself suspension using zoplicone tablets on a daily basis?

If not, would getting smaller dose compounding capsules/tablets made by a compounding pharmacist be an option?  Your mother’s doctor would have to write a prescription for these plus you would need to find a compounding pharmacy with the necessary equipment and expertise to make the capsules.

[[Pa...]]

I'm really torn about your mother due to her age, it seems cruel to condemn her to years of pain.  She says she wants to taper, but does she understand the taper is just the first step, that recovery comes next and recovery can last as long or longer than the taper?  

I'm also concerned about her history of taking more than she should, some of us are incapable of tapering for whatever reason and if this is going to cause battles with you and her husband, I can see more stress in her life and stress is the number one contributor to increased symptom severity. 

How bad is her tolerance, would her doctor increasing her medication lift her out?  How is her overall health?  I don't want to sound like I'm giving up on her but I'm uncomfortable thinking of her suffering without the possibility she'll ever see full recovery. 

[[Pa...]]

All good questions. The pharmacist was very aware of the long taper needed and the possibility of needing to compound to smaller and smaller doses if it’s too hard on my mom. They wouldn’t be able to do it on their own, but I would help. That recommendation is interesting to switch to a liquid so quickly. 

[[Pa...]]

Pamster…you ask some very good questions. 
 

Her dr won’t increase her medication. Mom has already asked. And today we went to her dr and she won’t even go back to the 11.25mg mom was on. She says she can’t change what the hospital dr did. But she did write a script for 7.5mg. Which is good because the hospital dr had her down to 3.75mg on the next scrip fill. 

i talked to the dr about a gentle tapering and showed her the method given by the pharmacist. She didn’t discuss it with me, just took the paper and said she would talk to the dr at the hospital. She says she can’t change what he did. Which doesn’t really make sense to me. 
 

truthfully, I don’t think she will even allow mom to stay on it long term. And I can understand her issues, mom has been hospitalized a number of times for taking too many pills. You kind of lose trust. 

[[Pa...]]

Also, how do you just stay on a med forever when you have tolerance and start having interdose withdrawals? 
 

it seems like it’s a losing proposition either way. 
 

Most of her hospital visits have been from taking too many pills. But she did have breast cancer, she did have low sodium brought on by diuretics. And she needs her knee replaced. And she had blood pressure and cholesterol pills. 
 

Today was another not great day. With the dr probably not allowing her to taper as she sees fit, even though I said it’s torture and showed her the papers. Mom is going to suffer. 
 

And mom not wanting to lose control of her meds. Saying she can do it. But she has shown when her resistance is low, or for whatever reason that she can’t. 
 

also, she’s been told that she needs a sleep apnea machine. But she won’t go and get it. I don’t understand why not. She complains about sleep the most, but cynically I think all she wants is a pill. 
 

I’m sorry to just sound like I’m complaining. I’ve gone from frustrated, to deep sympathy for her, to we can fix this! To resistance from help (mostly for the machine to help with meds), to her pleading “please don’t stop helping me” when I saw she had taken her weeks worth of pills in four days, to wanting to give up because the dr isn’t doing to help and mom just really wants to do what she has always done and I don’t think I can stop her current suffering and the suffering that will be coming  

I really do appreciate all of your input. Thank you. 

[[Pa...]]

Hello @[Pa...],

I was thinking about your mother as I was trying to go to sleep last night and I have some thoughts.  First, I'm so sorry for the position you're in, you care about your mother and want to help but someone is standing in your way, her. 

I have no doubt she's in pain, but I also see manipulation, she's saying and doing whatever it takes to protect her supply of the medication.  Her body is dependent, but I also see addictive behavior which compounds her problem because as I mentioned, some of us are incapable of tapering.  I say this because its true in my case.  My behavior was similar to hers and while I didn't know the drug had to be tapered when I quit cold turkey, I know I wouldn't have been able to taper because as a recovering alcoholic, its usually all or nothing. 

This is where I would typically suggest a detox facility which are problematic because they tend to withdraw clients too quickly resulting in severe symptoms, but its medically safe because they monitor vitals and use support medications which can help somewhat.  However, her age is a huge factor so I don't feel this is a good option, and I'm sorry to say I have no others to suggest.

I guess my point in writing this is to speak to you about your involvement and choices.  I can see you care deeply for and about her but I'm not sure you can fix this.  I hate to see you spend the money on the medicube when her number one priority will be trying to figure out a way around it.  

As for her doctor saying she can't undo what the doctor in the hospital has done, I suspect she's looking for a way to distance herself from your mothers behavior, there is a lot of focus right now on the over-prescribing of benzodiazepines and many doctors are worried they'll face the same scrutiny as the opioid epidemic.  Once doctors recognize addictive behavior, they seem to pull back. 

I hope you understand that my comments about your mothers behavior aren't meant to be judgmental, I certainly have no right to any moral superiority but her behavior feels familiar to me.   And if you don't agree, I do apologize for making assumptions.  I just wanted you to know I'm sad for you to feel this powerless and for your mom because of the pain and the hopelessness she must feel.

 

 

 

[[Pa...]]

Thank you Pamster. I read your kind comments with tears as deep down I feel it’s true as well and I feel helpless, horribly sad for my mom and her situation, but also aware that you can only truly help people who want help, otherwise all you can do is love them. 
 

I haven’t given up yet.
 

I was talking to my cousin today about our mothers, who are sisters, and wondering what happened in their past. So many of those siblings have had addiction issues. Maybe it’s just genetics. 
 

Thanks again for your kind words. I’m wishing you the very best. 

[[Pa...]]

And I should finish off with, my mom was and is a wonderful mother to me. I had a golden childhood. 

[[Pa...]]

3 hours ago, [[P...] said:

And I should finish off with, my mom was and is a wonderful mother to me. I had a golden childhood. 

I'm sure she was and is a wonderful mother, your love for her and your willingness to help her shows me you have a good relationship, unfortunately, there is a destructive substance in her life right now that is controlling her actions.  And I know from experience the pain she feels thinking you might think less of her but we can't have it all, we can't choose the drug and expect our family to understand, it doesn't work that way. 

Your recognition of your limitations surrounding her behavior lets me know you understand that only she has the power to change it, I'm glad you have a family member to talk to about this.

I'm not giving up on her, we all have a choice and I'm hoping she'll make the right one so please let us know if you need help with a taper plan.