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Patients who present with adverse effects secondary to sedative-hypnotic medications require a thorough evaluation, including an appraisal of whether adverse effects outweigh benefits of continuing treatment. Adverse effects include the development of excessive sedation or memory problems that interfere with functioning or increase risk of falls in the elderly, potential for adverse interaction with alcohol or other sedative medications, and compulsive/uncontrollable side effects involved in maintenance therapy with alternative antianxiety medications such as antidepressants, mood stabilizers, or neuroleptics. In the instances when adequate symptom control cannot be achieved without adverse effects, the alternative treatment strategy is warranted. This might include 1) conversion to and stabilization on the equivalent dose of an alternative benzodiazepine with a slower onset and a longer duration of effect (e.g., conversion from alprazolam to clonazepam); 2) conversion to and stabilization on the lower dose of the alternative benzodiazepine; 3) complete discontinuation of benzodiazepines and stabilization on an alternative GABAergic agent with a more favorable safety profile (e.g., carbamazepine or valproate); or 4) discontinuation of medication and implementation of behavioral treatment strategies (see Figure 16–2 for the suggested treatment strategies).

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FIGURE 16–2. Suggested sequenced treatment strategies for individuals with a primary psychiatric disorder who developed sedative-hypnotic use disorder.

FIGURE 16–3. Suggested sequenced treatment strategies for individuals with a primary substance use disorder who developed sedative-hypnotic use disorder.GABA = -aminobutyric acid.

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