What about using zopiclone for shift worker insomnia?

Zopiclone for Shift Worker Insomnia

Zopiclone is not recommended as first-line therapy for shift worker insomnia; cognitive behavioral therapy for insomnia (CBT-I) should be considered first, with zopiclone used only as a short-term adjunct when CBT-I alone is unsuccessful. 1

First-Line Treatment Approach

• CBT-I should be considered the first-line treatment for all forms of chronic insomnia, including shift work-related insomnia, due to its demonstrated efficacy in improving sleep quality and reducing insomnia symptoms 1
• CBT-I has shown moderate-quality evidence for improving global outcomes, reducing sleep onset latency, and improving sleep efficiency without the risks associated with pharmacologic treatments 1
• Various delivery methods for CBT-I (individual/group therapy, web-based modules, self-help books) have demonstrated effectiveness 1

Role of Pharmacologic Therapy Including Zopiclone

When to Consider Medication

• Pharmacologic therapy should only be considered when CBT-I alone has been unsuccessful, using a shared decision-making approach that discusses benefits, harms, and costs 1
• Short-term use (4-5 weeks) is the only FDA-approved duration for hypnotic medications 1

Zopiclone Efficacy and Safety Profile

• Zopiclone has demonstrated efficacy in treating insomnia in shift workers, with studies showing increased sleep duration and improved subjective sleep quality 2
• In shift workers specifically, zopiclone (7.5mg/day) has been shown to significantly increase sleep duration and reduce awakening episodes 2
• Zopiclone is generally at least as effective as benzodiazepines in treating insomnia, with potentially fewer adverse effects 3
• Like other non-benzodiazepine hypnotics, zopiclone causes less disruption of normal sleep architecture than benzodiazepines 4

Potential Concerns with Zopiclone

• Common adverse effects include bitter aftertaste (reported in approximately 3.6% of patients) 3
• Despite initial claims of lower dependence potential, cases of zopiclone dependence and abuse have been reported in the literature 5
• Withdrawal symptoms can occur upon discontinuation, including palpitations, sweating, irritability, hallucinations, and impulsive behavior 5
• Long-term use is not recommended due to potential for tolerance development, though data on this are conflicting 3

Algorithm for Management of Shift Worker Insomnia

1. First step: Implement CBT-I and sleep hygiene measures 1

   • Stimulus control (only go to bed when sleepy, maintain regular schedule)
   • Sleep restriction therapy
   • Relaxation techniques
   • Cognitive therapy to address dysfunctional beliefs about sleep

2. If CBT-I alone is insufficient after adequate trial:

   • Consider short-term (≤4 weeks) use of zopiclone at lowest effective dose 3, 4
   • Start with 7.5mg before intended sleep period 2
   • Monitor for effectiveness and side effects

3. For patients not responding to zopiclone:

   • Consider alternative non-benzodiazepine hypnotics such as zolpidem, zaleplon, or eszopiclone 1
   • For patients with primarily sleep initiation difficulties, consider agents with shorter half-lives 1

Special Considerations and Cautions

• Zopiclone should be used at the lowest effective dose and for the shortest duration possible 1
• Patients should be counseled about potential risks including next-morning impairment and possible sleep behaviors (sleepwalking, sleep driving) 1
• Caution is advised in older adults and those with respiratory conditions including sleep apnea 1
• Regular assessment for dependence, tolerance, and adverse effects is essential during treatment 5
• Patients should be advised that discontinuation should be gradual to minimize rebound insomnia 3

Comparative Effectiveness

• Evidence is insufficient to determine the comparative effectiveness of zopiclone versus other non-benzodiazepine hypnotics (zolpidem, zaleplon, eszopiclone) 1
• All non-benzodiazepine hypnotics appear to have similar efficacy profiles but may differ in their pharmacokinetic properties and side effect profiles 4