Mental Health MDD plus HIV: Benzo Tolerance/Insomnia

[Dr. J]

I thought this post fit best here, but mods please feel free to move.

Former stimulant (recreation & prescribed) user, dx with MDD, Panic Attacks/Anxiety, Chronic and severe insomnia, plus HIV. No longer using anything recreationally. Currently prescribed:

1. Wellbutrin 300mg q AM.
2. HIV med: 1 pill q AM.
3. Klonopin: 4mg/day - #120 - take up to 3x during the day, plus 1mg PRN at bedtime (successfully tapered from 6mg xanax/day & 6mg mg Klonopin/day) - Doc feel 4mg Klonopin daily is a reasonable level to counter anxiety and she agrees that my successful but looonnng taper from previous dosing (thx primary doc) means any further dose reduction would cause symptoms to reemerge
4. Ambien CR: 12.5mg at bedtime + 1mg Klonopin
5. Flexiril: 10mg - just recently added by PCP to assist w/ insomnia since not habit forming or controlled

I am not looking or wanting to try to get recreation from my medication, but the flexiril did help some - found my sweet spit to be 30mg at bedtime. PCP understood, wrote new script for #90, take as directed (up to 30mg at bedtime).

TL;DR

The Wellbutrin is the only AD that has been even moderately effective, and to me, is noticeably stimulating/anxiety causing. My HIV medication is known for its insomnia causing side-effects and has far fewer side effects or medication contraindications as other one pill/day regimin.

I still struggle to fall asleep and just this morning, fell asleep about 11pm but was up for good at 3am.

I practice good sleep hygeine, use a meditation/calming app when I lay down and yet I still do not get a restful night of sleep which has started to impact work performance and recently promoted with big salary increase, so using FMLA time - keeping in mind I work from home 3-4 days per week - is not really a viable option. At my level now, I am essentially the only one who can do the job....so it has to get done, timely, or client rightfully starts to make noise.

Based on my prior major use of benzodiazepines, I don't think throwing another one in the mix would be advised. PCP wrote me a 5 day supply of Xanax 2mg (prior to the flexiril) to assist with faklling asleep during work trip. My pharmacist - perhaps rightfully so - lectured me and told me not to take my Klonopin while taking the Xanax. With my tolerance and docs direction, I still did, and was n bed by 10pm, was still waking up around 5am, but felt no hangover effects and beng in another city in a loud hotel, the extra meds helped, but I know not a long term solution nor do I want to go back down xanax rabbit hole.

Ive tried melatonin, Zquil, and Trazadone - no benefit and the Trazadone made it worse. Ive considered a possibly a low dose of Seroquel, but my past experience with it made me a zombie the next day and I gained weight.

****Given all this - is there possibly another medication which could be more effective? I thought about possibly switching over to Ativan, but I wouldnt even know the equivalent dosing to match and i feel much more stable on Klonopin.

Welcome to any comments/suggestions. I thought about Temazepam, 30mg at bedtime to replace the 1 extra mg of Klonopin, but since already takng Ambien, my pharmacist would have a shit fit, I'm sure - but both my psych and PCP have called and told her to fill it so she does, but not without some serious side-eye.

Thanks again for any thoughts/comments.

DRJ

 

[AlphaMethylPhenyl]

Well there's a reason why klonopin/ativan/xanax are minor tranquilizers, and things like seroquel are major tranquilizers. The latter are generally considered a step up, in terms of calming people. They are hard to tolerate, but get easier to take as time goes by. These days they have some that may be more tolerable. I believe that there are almost 20 major tranquilizers, too.

It's a give and take situation. We all at some point realize that nothing and no med is perfect. Everything will have side effects.