Hypnotics consider

Educating the Patient and Family hi educating the patient and family about barbiturates and miscellaneous sedatives and hypnotics, several general points must be considered, as well as teaching about two common abuses of these drugp. 

Acylated derivatives of urea are referred to as ureides. Acylation of urea with a monoacid produces acyclic ureides, whereas diacylation with malonic acid (a diacid) yields the cyclic structure of barbiturates. The acyclic ureides carbromal and bromisoval, now outdated hypnotics, can be considered ring-opened analogues of the barbiturates to be examined in the next subsection. 

Whichever sedative-hypnotic agent is selected, the following guidelines can help ensure a safe and effective treatment. Use the minimal therapeutic dose at first to decrease possible hangover effects. Consider using the medication on an as-needed basis if the insomnia is intermittent, and after 2-4 weeks attempt a trial off medication to see if it is still required. Many individuals with chronic insomnia will relapse after a 14-28 day trial of treatment, but this time frame also affords an opportunity to implement sleep hygiene improvements. 

Several Hi histamine antagonists (e.g., diphenhydramine, promethazine, and hydroxyzine) have been used as sedative-hypnotics, since they produce some degree of sedation. While this sedation is usually considered a side effect of their antihistaminic activity, in some cases the sedation is sufficient to allow the drugs to be used in the treatment of anxiety and sleep disturbances. For these drugs, the anxiolytic properties are thought to be a direct consequence of their ability to produce sedation. 

Chloral hydrate (Noctec, Somnos) was developed in the late 1800s and is still used as a sedative-hypnotic agent. It is a hydrated aldehyde with a disagreeable smell and taste that is rapidly reduced in vivo to trichloroethanol, which is considered to be the active metabohte. It produces a high incidence of gastric irritation and allergic responses, occasionally causes cardiac arrhythmias, and is unreliable in patients with liver damage. 

In Chapter 1 of this book, psychopharmaceuticals were introduced as effective medicines that primarily have a symptomatic action but are problematic in several respects. Antipsvchotics can cause serious side effects and antidepressants often exert their therapeutic effects only after a delay of weeks and in many cases have unpleasant side effects. With anxiolytics, hypnotics and, in particular, psychostimulants, there are problems with habituation and the potential of dependency. It is therefore not surprising that psychopharmaceuticals do not enjoy a very high reputation among many doctors and the general public (see Box 8.1) and have been given names such as chemical strait-jackets for the older neuroleptics (Szasz, 1957) or chemical blinkers for the mind for tranquillizers. Elomaa (1993) even posed the question of whether the long-tom use of conventional antipsychotics should be considered a crime against humanity. 

Specific factors to consider are both psychiatric and physical contraindications. For example, bupropion is contraindicated in a depressed patient with a history of seizures due to the increased risk of recurrence while on this agent. Conversely, it may be an appropriate choice for a bipolar disorder with intermittent depressive episodes that is otherwise under good control with standard mood stabilizers. This consideration is based on the limited data suggesting that bupropion is less likely to induce a manic switch in comparison with standard heterocyclic antidepressants. Another example is the avoidance of benzodiazepines for the treatment of panic disorder in a patient with a history of alcohol or sedative-hypnotic abuse due to the increased risk of misuse or dependency. In this situation, a selective serotonin reuptake inhibitor (SSRI) may be more appropriate. 

Barbiturates and barbiturate-like drugs, such as chloral hydrate, although effective hypnotics, are considered far less safe than BZDs in terms of tolerance, interaction with alcohol, and lethality in overdose. Therefore, their use is not generally recommended. 

Benzodiazepines are used as hypnotics because they have the ability to increase total sleep time. They demonstrate minimal cardiovascular effects, but do have the ability to increase heart rate and decrease cardiac output. Most CNS depressants, including the benzodiazepines, exhibit the ability to relax skeletal muscles. Clozapine, a dibenzodiazepine, is used in the treatment of schizophrenia. It has both sedative and antipsychotic actions, and is the only FDA-approved medication indicated for treatment-resistant schizophrenia, and for reducing the risk of suicidal behavior in patients with schizophrenia. This drug can have potentially life-threatening side effects, but appears to have no abuse potential and will not be considered further. 

For the sake of convenience, metronome and nonmetronome inductions of the same condition will be treated under the same heading. The effects of each kind of induction will, however, be considered separately. The sample for all these time rate conditions consists of four hypnotic subjects and the simulator. 

Several other nonbenzodiazepine compounds can be prescribed for their sedative-hypnotic properties (see Table 6-1). These compounds are chemically dissimilar from one another, but share the ability to promote relaxation and sleep via depressing the CNS. Cyclic ethers and alcohols (including ethanol) can be included in this category, but their use specifically as sedative-hypnotics is fairly limited at present. The recreational use of ethanol in alcoholic beverages is an important topic in terms of abuse and long-term effects. However, since this area is much too extensive to be addressed here, only their effects as sedative-hypnotics is considered. 

Nonbarbiturate sedative-hypnotics. Nonbarbiturate sedative-hypnotics are drugs with chemical or physiological properties similar to barbiturates and are considered barbiturate-like substances. These drugs include ... 

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