Can I put refills on Ambien (zolpidem) and Clonazepam for a patient with a history of insomnia or anxiety?

Refill Restrictions for Ambien and Clonazepam

No, you cannot put refills on Ambien (zolpidem) or clonazepam prescriptions in most jurisdictions, as both are Schedule IV controlled substances that require specific prescribing regulations, though temporary COVID-19 allowances permitted limited refills in some regions.

Regulatory Classification

Both medications are classified as Schedule IV controlled substances, which typically restricts refill practices 1:

• Zolpidem (Ambien): Listed as a Schedule IV controlled substance with specific prescribing requirements 1
• Clonazepam: Also a Schedule IV controlled substance, though not FDA-approved specifically for insomnia 1

Standard Prescribing Limitations

Duration and Dosing Restrictions

Zolpidem should be prescribed with the following constraints 1:

• Recommended for short-term use only (≤4 weeks) 1, 2
• Standard adult dosing: 10 mg at bedtime (maximum 10 mg) 1
• Elderly/debilitated patients: 5 mg at bedtime 1
• No short-term usage restriction noted for eszopiclone, but zolpidem specifically limited 1

Clonazepam considerations 1:

• Not FDA-approved for insomnia indication 1
• May be considered if duration of action is appropriate or comorbid conditions exist that benefit from the medication 1
• Regular use can lead to tolerance, addiction, depression, and cognitive impairment 1

Temporary COVID-19 Policy Exceptions

During the COVID-19 pandemic, some jurisdictions temporarily allowed 1:

• Pharmacists to extend prescriptions for controlled substances for limited periods
• Pharmacists to act on verbal orders for refills of controlled substances
• Practitioners to prescribe opioids (and by extension, other controlled substances) without in-person evaluation under specific conditions

Critical caveat: These were temporary emergency measures and may no longer be in effect 1.

Clinical Risks of Long-Term Use

Zolpidem-Specific Concerns

The evidence demonstrates significant risks with ongoing use 3, 2, 4:

• Increased fall risk (OR 4.28, P<0.001) in hospitalized patients 3
• Hip fracture risk (RR 1.92,95% CI 1.65-2.24) 3
• Complex sleep behaviors (sleepwalking, sleep-driving, sleep-eating) regardless of dose 3
• Suicide risk (OR 2.08,95% CI 1.83-2.63) independent of psychiatric comorbidity 3
• Rebound insomnia with sleep onset latency increased by 13.0 minutes after discontinuation 3
• Severe dependence reported with chronic abuse up to 6,000 mg/day 4

Clonazepam-Specific Concerns

Evidence shows problematic patterns with extended use 1, 5:

• Tolerance, addiction, depression, and cognitive impairment with regular use 1
• Paradoxical agitation occurs in approximately 10% of patients 1
• Rebound insomnia on 3rd withdrawal night with significant increases in wake time 5
• Maintained efficacy noted but withdrawal complications documented 5

Recommended Prescribing Approach

Instead of refills, implement this protocol:

1. Initial prescription: Write for 7-14 days maximum 1

2. Require follow-up evaluation before any additional prescriptions to assess 1:

   • Adequate response and adverse events
   • Aberrant behaviors or signs of dependence
   • Functional improvements and quality of life
   • Need for alternative non-pharmacological interventions

3. Prioritize cognitive-behavioral therapy as first-line with medications as adjunctive only 1, 3

4. Consider non-controlled alternatives for longer-term management 1:

   • Sedating antidepressants (trazodone, mirtazapine) for treatment failures or comorbid depression
   • Melatonin receptor agonists (ramelteon) - non-scheduled with no short-term usage restriction

5. Document justification if prescribing beyond 4 weeks, including why non-pharmacological approaches have failed 1

Common Prescribing Pitfalls

• Avoid automatic refills without reassessment, as this facilitates dependence 3, 4
• Do not combine benzodiazepines with high-dose olanzapine due to fatality risk 1
• Never prescribe during pregnancy - zolpidem is FDA Category C with increased risks of low birth weight (OR 1.39), preterm delivery (OR 1.49), and cesarean delivery (OR 1.74) 3
• Reduce doses in elderly patients - women have higher plasma concentrations than men (28 vs. 20 ng/mL for 10mg IR) 3
• Warn about alcohol and CNS depressants - additive psychomotor impairment 1