Zopiclone + Seniors = Bad Mix
by Rudy Sanchez, B.Sc.Pharm, RPH
The most popular prescription drug for insomnia may not
be the best choice for seniors.
If you or someone you know is a senior and is one of the
millions of patients taking these oval blue pills to help you sleep, you should
read on. (Note: we are not talking about the “other” popular blue pill).

Zoomers are active, vital and healthy...not groggy, tired and sedentary.
What is our definition of a senior? Someone who actually
watched the Beatles on the Ed Sullivan TV show, not on YouTube. Or maybe it is
someone who has no idea what YouTube is.
Read on to find out…
-why zopiclone is a poor choice
for seniors
-why you should not drive the
morning after taking zopiclone
-why you may not be as smart as
you were if you take zopiclone
-why zopiclone may land you in
the hospital with a broken hip
-why it is so hard to get off the
drug
-what are some alternatives if
you are on zopiclone and want off
What is zopiclone?

Pharmacists and biochemists love molecular structures.. everyone say MEH
Zopiclone belongs to a class of drugs called
cyclopyrrilones which also include eszopiclone (Lunesta), zolpiderm (Ambien)
and zaleplon (Sonata). They are also called Z Drugs, because they all start
with Z and it’s a convenient, neat marketing tool for drugs that helps you get
the ZZZ’s. So clever, these pharmaceutical people.

increase in GABA activity produces relaxation
The inventors of the drugs were been able to classify
them as non-benzodiazepine, removing them from the tainted reputation of
Xanax. The developers of the drug found a different mechanism of action. Whereas benzodiazepine
drugs mimic GABA (gamma-amino butyric acid) at the receptors, the
cyclopyrrilones increase the transmission of GABA. The net effect is the same:
they both increase the effect of GABA. Side effects and drug cessation symptoms
are similar between zopiclone and benzodiazepine. It is not necessarily a better drug, but the
marketing of a non-benzo is definitely better.

remember the Xanax controversy?
Why is GABA so important? It is the most plentiful
neurotransmitter in the brain and reduces excitability of neurons. It manages
this by increasing the passage of chloride ions into the neuron cells, leading
to decreased neuronal activity, increased relaxation and decreased anxiety.

GABA ia a major inhibitory neurotransmitter in the brain





Think of GABA as the anti-caffeine. You know how caffeine makes you awake, energetic and jittery? Caffeine does this by neutralizing GABA in the brain. So consider GABA as caffeine in reverse.

think of GABA as the anti-caffeine (and caffeine as anti-GABA)
Shortly after the introduction of the zopiclone, a study by Gaillot (1987) measured zopiclone
plasma levels in seniors. When compared to non-seniors, plasma levels were higher by 168% and the plasma half-life of the drug increased from 5.1
hours to 8.1 hours. In seniors, not only does the drug stay around longer, it also
reaches more than double the blood level. Gaillot (1987) explains that this
double whammy is a result of the extensive hepatic (liver) metabolism of the
drug. Reduced liver metabolism in seniors causes the difference. The real
effect of this is morning sedation and grogginess through the day after.

zopiclone impairs driving for up to 11 hours after taking it
A study by Leufkens in 2009 compared the effects of
zopiclone, temazepam and a placebo on the driving ability of the elderly and
found that zopiclone impairs the driving ability for 11 hours after it is
taken. This poses a hazard for the typical senior who sleeps at 11 o’clock and
drives at 9:00 the next morning to go to
Tim Horton’s .. because he needs that cup of doubledouble. He/she is more likely to have driving impairment
this much later.
Zopiclones evil twin makes it more addicting. Part of
zopiclones action is through its active metabolite, desmethylzopiclone, which
is even more powerful than the parent compound. Although the hypnotic (sleep
inducing) activity of the drug is from the unchanged parent drug, the active
metabolite desmethylzopiclone inhibits NMDA (N-methyl-D-asparate) in the brain
as well as blocking nicotinic acetylcholine receptors. NMDA is an excitatory
neurotransmitter and has been studied in
the breeding of “Doogie Mice”. These mice learn very quickly ( the reference is
to Doogie Howser, MD) since their NMDA receptors are stimulated. NMDA is
responsible for learning and remembering new information. Suppression of NMDA
activity by the zopiclone metabolite leads to degradation of these learning
skills. Is it possible that zopiclone makes you dumber? Blocking of the nicotinic acetylcholine
receptors causes anti-chollinergic side effects such as dry mouth, loss of
balance and bladder infections. Most seniors already suffer from these
conditions.

doogie mice are smarter from NMDA receptor stimulation
One of the main side effects of zopiclone is a
disturbance of motor coordination. This
is a result of three effects: the
blocking of the nicotinic acetylcholine receptors by desmethylzopiclone causes
dizziness. Secondly, the prolonged grogginess is from the extended half-life. Thirdly, the inhibition of GABA transmission
affects body balance through a mechanism called the sway effect. A study by Mets (2010) measured the impairment
of body balance and concluded that the elderly patients on zopiclone are more
likely to fall, leading to possible fractures. Combined with increased
incidence of osteoporosis in the elderly
(especially in female seniors), the sway
effect makes zopiclone more dangerous.

In North America, every 18 seconds, a senior is admitted in the hospital due to a fall
How long do all these negative effects last? More bad
news. A study by Puustinen (2014)
measured cognitive and psychomotor impairment in elderly patients who
have been taking zopiclone and found that the problem persists for six months
after the drug is stopped.

female seniors are more likely to have osteoporosis
What to do?
Do not stop your zopiclone suddenly. Talk to your
physician. There is complete list of drugs that are not recommended for the
elderly. It was first published by Dr. Mark Beers in 1991 and in this list,
there are recommended alternative prescription drugs. Called The Beers List, it recommends low dose
trazodone and low dose doxepin as alternatives.
Please do not ask your doctor for his beer list, that is another thing
entirely.

The Beers List, not the beer list
Marigold Compounding Pharmacy can work with your doctor
to successfully navigate the withdrawal from the drug so that the cessation
symptoms are reduced. Sometimes
described as the wash in-wash out method, it involves compounding dilutions of
the zopiclone (as little as 5% increments) over a period of ten to twenty
weeks. This is available with a prescription order from you doctor and can be
compounded by Marigold Compounding Pharmacy.

learn progressive muscle relaxation
Non-drug therapy is also recommended by Dr. Beers. Some
considerations are sleep hygiene techniques, meditation, Traditional Chinese
Medicine, homeopathic medicine,
teas, progressive muscle
relaxation, magnesium and medicinal herbs. In combination, these strategies
have been found successful in restoring sleep.

magnesium helps sleep and is a common deficiency
References:
Gaillot J, Le Roux Y, Houghton GW, Dreyfus JF. Critical factors
for
pharmacokinetics of zopiclone in the elderly and in patients
with liver and renal
insufficiency. Sleep. 1987;10 Suppl 1:7-21. PubMed PMID:
3438645.
Verbeeck RK. Pharmacokinetics and dosage adjustment in patients with hepatic
dysfunction. Eur J Clin Pharmacol. 2008 Dec;64(12):1147-61. doi:
10.1007/s00228-008-0553-z. Epub 2008 Sep 2. Review. PubMed PMID: 18762933.
Leufkens TR, Vermeeren A. Highway driving in the elderly the morning after
bedtime use of hypnotics: a comparison between temazepam 20 mg, zopiclone 7.5 mg,
and placebo. J Clin Psychopharmacol. 2009 Oct;29(5):432-8. doi:
10.1097/JCP.0b013e3181b57b43. PubMed PMID: 19745642.
Puustinen J, Lähteenmäki R, Polo-Kantola P, Salo P, Vahlberg T, Lyles A,
Neuvonen PJ, Partinen M, Räihä I, Kivelä SL. Effect of withdrawal from long-term
use of temazepam, zopiclone or zolpidem as hypnotic agents on cognition in older
adults. Eur J Clin Pharmacol. 2014 Mar;70(3):319-29. doi: 10.1007/s00228-013-1613-6. Epub 2013 Dec 12. PubMed PMID: 24337417.
Mets MA, Volkerts ER, Olivier B, Verster JC. Effect of hypnotic drugs on body
balance and standing steadiness. Sleep Med Rev. 2010 Aug;14(4):259-67. doi:
10.1016/j.smrv.2009.10.008. Epub 2010 Feb 18. PubMed
PMID: 20171127







