Are there concerns with prescribing Ativan (lorazepam) for sleep issues during travel abroad?

Concerns with Prescribing Ativan for Traveling Abroad and Sleep Issues

Ativan (lorazepam) should not be routinely prescribed for travel-related sleep issues due to significant risks of dependence, withdrawal, and rebound insomnia, with melatonin being the preferred first-line agent for jet lag-related sleep disturbances.

Risks of Lorazepam for Travel-Related Sleep Issues

Lorazepam carries several important risks when used for travel-related sleep issues:

• Physical dependence and addiction: The FDA label explicitly warns that lorazepam can lead to dependence even when taken as prescribed 1
• Respiratory depression: Particularly concerning when combined with the hypoxic environment of airplane cabins, as lorazepam can worsen respiratory function in patients with compromised breathing 1
• Rebound insomnia and anxiety: Studies show that withdrawal from lorazepam can cause sleep problems worse than baseline, with sleep latency increasing by 60-77% above baseline levels during withdrawal 2
• Cognitive and psychomotor impairment: Can compromise complex skills such as navigation in unfamiliar environments 3
• Paradoxical reactions: Including excitement, agitation, and worsening anxiety, particularly in elderly patients 1

Preferred Alternatives for Travel-Related Sleep Issues

First-Line Options:

1. Melatonin (3-5mg): Take 30-60 minutes before desired bedtime at destination, especially when crossing 5+ time zones 4

   • Start 2-3 days before departure for trips crossing 7+ time zones
   • Most effective medication for travelers with minimal side effects

2. Non-pharmacological approaches:

   • Morning light exposure when traveling eastward, evening light exposure when traveling westward 4
   • Maintain consistent sleep/wake times aligned with destination time zone
   • Use earplugs and eye masks to optimize sleep environment
   • Stay hydrated but limit fluid intake before sleep

Second-Line Options (if melatonin ineffective):

1. Ramelteon 8mg: Effective for sleep onset issues with minimal next-day effects 4
2. Zolpidem 5-10mg: For short-term use if sleep onset is the primary issue 4

Special Considerations for Air Travel

• Avoid alcohol consumption during flights as it can worsen jet lag and sleep quality 5, 4
• Avoid benzodiazepines for routine jet lag management due to potential harm 4
• Maintain mobility during flights to reduce risk of venous thromboembolism 5
• Consider oxygen supplementation for patients with significant respiratory conditions if travel is necessary 5

Algorithm for Managing Travel-Related Sleep Issues

1. Assess baseline sleep and respiratory status:

   • If patient has sleep apnea, COPD, or other respiratory conditions, avoid lorazepam 1
   • If patient has history of substance abuse or addiction, avoid lorazepam 1

2. Evaluate travel plans:

   • Number of time zones to be crossed
   • Duration of stay
   • Necessity of alertness upon arrival

3. Recommend appropriate intervention:

   • 1-2 time zones: Sleep hygiene measures alone
   • 3+ time zones: Melatonin + sleep hygiene
   • Only consider second-line agents if:
     • Patient has previously failed melatonin
     • Travel is essential
     • No contraindications exist

Important Warnings

• Benzodiazepines like lorazepam can worsen respiratory function during air travel due to the reduced cabin pressure 5, 1
• Risk of drug interactions with travel medications is high (45% of travelers using chronic medications) 6
• Studies show benzodiazepines may interfere with therapeutic adaptation to new environments, potentially worsening anxiety upon medication discontinuation 7
• Short-term use only: FDA warns against using lorazepam for longer than 4 months 1

Conclusion

While lorazepam may provide short-term relief for travel-related sleep issues, its risks generally outweigh its benefits. Melatonin offers a safer alternative with good efficacy for jet lag. If a prescription sleep aid is absolutely necessary, consider ramelteon or short-term zolpidem before resorting to benzodiazepines like lorazepam.