Zopiclone Tapering Guidelines
Yes, zopiclone should be tapered rather than abruptly discontinued to avoid withdrawal symptoms and rebound insomnia. 1
Rationale for Tapering Zopiclone
While zopiclone was initially thought to have a lower dependence potential than benzodiazepines 2, clinical experience has shown that it can cause withdrawal symptoms and dependence, particularly with prolonged use or higher doses 3. Despite some earlier studies suggesting minimal withdrawal effects 4, 5, more recent evidence indicates that tapering is necessary to prevent:
- Withdrawal symptoms (palpitations, sweating, irritability, hallucinations)
- Rebound insomnia (worsening of sleep beyond baseline levels)
- Autonomic symptoms (tachycardia, diaphoresis)
Recommended Tapering Protocol
The most effective strategy for zopiclone discontinuation is a gradual dose reduction approach 1:
- Initial reduction: Begin with a 10-25% reduction of the most recent dose
- Subsequent reductions: Continue with 10-25% reductions every 2-4 weeks
- Lower doses: Slow the tapering to 5-10% reductions at lower doses
Duration of Tapering
- Short-term use (<1 year): Consider tapering over 2-4 weeks
- Long-term use (≥1 year): More gradual taper of 10% per month or slower
- Elderly patients: Require more gradual tapering (5% or less per month)
Monitoring During Tapering
Weekly monitoring is necessary during the active tapering period 1 to assess:
- Emergence of withdrawal symptoms
- Changes in mood or anxiety
- Sleep quality and potential rebound insomnia
- Medication adherence to the tapering schedule
Managing Withdrawal Symptoms
If withdrawal symptoms emerge during tapering:
- Temporarily slow or pause the taper
- Return to the previous dose if symptoms are severe
- Restart tapering with smaller incremental reductions when stabilized
Adjunctive Medications for Withdrawal Management
The following medications may help manage specific withdrawal symptoms 1:
- For insomnia: Trazodone or non-benzodiazepine sleep aids
- For anxiety: Gabapentin or mirtazapine
- For autonomic symptoms: Propranolol
- For gastrointestinal discomfort: Loperamide (with caution)
Non-Pharmacological Support
Implement these strategies to improve tapering success 1:
- Cognitive-behavioral therapy for insomnia (CBT-I)
- Relaxation techniques
- Patient education about withdrawal symptoms
- Supportive psychotherapy
Special Considerations
- High-dose users: May require more careful monitoring and slower tapering
- History of substance abuse: Regular assessment for signs of misuse is necessary
- Elderly patients: Close monitoring for confusion, falls, and cognitive changes
Potential Pitfalls
- Tapering too quickly: Can precipitate withdrawal symptoms and lead to treatment failure
- Inadequate monitoring: May miss early signs of withdrawal requiring adjustment
- Underestimating dependence: Even at therapeutic doses, zopiclone can cause dependence with long-term use 6
- Discontinuation in inpatient settings: Abrupt discontinuation during short hospital stays may result in unmonitored return of symptoms after discharge 7
By following a structured tapering approach with appropriate monitoring and support, the risks associated with zopiclone discontinuation can be minimized while improving the likelihood of successful discontinuation.