Intravenous Zolpidem Injection in a Zolpidem Abuser

• Abstract
• References

Abstract

Zolpidem abuse has been frequently observed in recent years. This study presents a case of zolpidem abuse. Although numerous cases of zolpidem dependence have been reported, this is the first case to report zolpidem intravenous injection without any history of opiate use. Clinicians should monitor patients with a history of zolpidem abuse and be aware that there is a risk of zolpidem injection.

Zolpidem is a widely used hypnotic agent acting at the GABA_A receptor benzodiazepine site [1]. Zolpidem is effective for initiating sleep. Its therapeutic dose is up to 10 mg/d. An increasing amount of evidence supports the potential for zolpidem abuse [2] [3]. The Taiwanese government has listed zolpidem as a Class 4 controlled medication. However, clinicians continue to identify patients that abuse zolpidem. Herein, we report a case of intravenous zolpidem abuse. The patient is a 29-year-old single man diagnosed with depressive disorder and a history of hypnotic abuse. He visited the psychiatry department for the first time approximately 6 years ago presenting with depression and insomnia. He began abusing zolpidem over the past 2 years and reported taking 40 mg zolpidem per day, and frequently visited the psychiatry department to obtain more zolpidem. The patient also reported dangerous driving and behavior after taking zolpidem. In addition, he has maintained a low mood and negative thoughts during these 6 years, and was also being treated with 60 mg duloxetine per day. Poor occupational performance was also reported after zolpidem abuse began. Because of the patient’s high zolpidem tolerance and irregular psychiatric follow-up, we commenced zolpidem control and monitored the patient closely. We attempted to reduce the dosage of zolpidem to 30 mg daily and substituted flunitrazepam; however, the patient expressed concern with his insomnia after the zolpidem dosage was decreased and exhibited behavioral symptoms of anxiety. Because of his craving for zolpidem to treat his insomnia, he injected a mix of crushed 10 mg zolpidem and normal saline. A 2 cm carbuncle was observed on his left palm with several needle puncture holes 1 d after injection. Pain, swelling, and local heat were noted, and thrombophlebitis was suspected. Furthermore, confusion, difficulty in communicating, and emotional dysregulation were noted. His wound improved following management with drainage and cephalexin treatment. The patient was recently prescribed a daily dosage of 20 mg zolpidem and 30 mg mirtazapine and his insomnia improved. He is currently satisfied with the prescribed medication.

The number of articles on zolpidem intravenous injection is limited, and only 4 have mentioned parenteral zolpidem abuse [4–7]. The majority of these patients had a history of opiate abuse. However, our patient had no history of illegal substance abuse. Crushed zolpidem injection is dangerous. Zolpidem tablets contain microcrystalline cellulose, which is a potent embolic agent [4]. Microvascular embolization may have contributed to the ischemia of the hand or other parts of the body [4]. Clinicians should closely monitor patients who present with zolpidem abuse and be aware of the risk of zolpidem injection. Close follow-up and assessment are required when reducing the prescribed dose of zolpidem for patients who present with zolpidem abuse or dependence.

Conflict of Interest

The authors declare no conflict of interest.

• References

• 1 Wilkinson CJ. The abuse potential of zolpidem administered alone and with alcohol. Pharmacol Biochem Behav 1998; 60: 193-202
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• 2 Hajak G, Muller WE, Wittchen HU et al. Abuse and dependence potential for the non-benzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data. Addiction (Abingdon, England) 2003; 98: 1371-1378
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• 3 Victorri-Vigneau C, Dailly E, Veyrac G et al. Evidence of zolpidem abuse and dependence: results of the French Centre for Evaluation and Information on Pharmacodependence (CEIP) network survey. Br J Clin Pharmacol 2007; 64: 198-209
  CrossrefPubMedSearch in Google Scholar
• 4 Chang MY, Lin JL. Irreversible ischemic hand following intraarterial injection of zolpidem powder. J Toxicol Clin Toxicol 2003; 41: 1025-1028
  CrossrefPubMedSearch in Google Scholar
• 5 Kao CL, Huang SC, Yang YJ et al. A case of parenteral zolpidem dependence with opioid-like withdrawal symptoms. J Clin Psychiatry 2004; 65: 1287
  CrossrefPubMedSearch in Google Scholar
• 6 Brunelle E, Rotily M, Lancon C et al. Zolpidem: intravenous misuse in drug abusers. Addiction 2005; 100: 1377-1378
  CrossrefPubMedSearch in Google Scholar
• 7 Benyamina A, Dublanchet O, Karila L et al. Intravenous zolpidem abuse: a case for serotonin depletion. Am J Addict 2007; 16: 534
  CrossrefPubMedSearch in Google Scholar

Correspondence

• References

• 1 Wilkinson CJ. The abuse potential of zolpidem administered alone and with alcohol. Pharmacol Biochem Behav 1998; 60: 193-202
  CrossrefPubMedSearch in Google Scholar
• 2 Hajak G, Muller WE, Wittchen HU et al. Abuse and dependence potential for the non-benzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data. Addiction (Abingdon, England) 2003; 98: 1371-1378
  Search in Google Scholar
• 3 Victorri-Vigneau C, Dailly E, Veyrac G et al. Evidence of zolpidem abuse and dependence: results of the French Centre for Evaluation and Information on Pharmacodependence (CEIP) network survey. Br J Clin Pharmacol 2007; 64: 198-209
  CrossrefPubMedSearch in Google Scholar
• 4 Chang MY, Lin JL. Irreversible ischemic hand following intraarterial injection of zolpidem powder. J Toxicol Clin Toxicol 2003; 41: 1025-1028
  CrossrefPubMedSearch in Google Scholar
• 5 Kao CL, Huang SC, Yang YJ et al. A case of parenteral zolpidem dependence with opioid-like withdrawal symptoms. J Clin Psychiatry 2004; 65: 1287
  CrossrefPubMedSearch in Google Scholar
• 6 Brunelle E, Rotily M, Lancon C et al. Zolpidem: intravenous misuse in drug abusers. Addiction 2005; 100: 1377-1378
  CrossrefPubMedSearch in Google Scholar
• 7 Benyamina A, Dublanchet O, Karila L et al. Intravenous zolpidem abuse: a case for serotonin depletion. Am J Addict 2007; 16: 534
  CrossrefPubMedSearch in Google Scholar