Patient-Initiated Deprescribing of Benzodiazepines

Benzodiazepines are a class of highly overprescribed sedative hypnotic drugs primarily used to treat anxiety and insomnia (see Table, below, for a list of benzodiazepines available in the U.S.). It has been estimated that approximately one in every 20 adult Americans fills a benzodiazepine prescription each year.[1] Use of these drugs is highest among those age 65 to 80, and nearly one third of users in this age group take the drugs on a long-term basis (120 days or more), a proportion that is higher than users in all younger age groups.[2]

Commonly Prescribed Benzodiazepines in the U.S.*

*All are Do Not Use except for alprazolam, which is designated Do Not Use Except For Panic Disorder, and clonazepam, which is approved only for certain types of seizures and panic disorder.

Benzodiazepines cause numerous adverse effects, including unsteady gait, dizziness, falls (which may lead to hip fractures and other injuries), memory problems, other cognitive impairments and daytime sedation.[3]

Because of their effects on receptors in the brain, long-term use of benzodiazepines can lead to addiction and psychological and physical dependence, resulting in withdrawal symptoms (including insomnia, restlessness and anxiety) upon discontinuation, particularly if the drugs are stopped suddenly.[4],[5] Yet, consistent with the high rates of long-term benzodiazepine use in older patients, many physicians do not view such use of benzodiazepines as a public health problem.[6]

For these reasons, Public Citizen’s Health Research Group designates all benzodiazepines as Do Not Use for insomnia, anxiety or any other use, with the exception of alprazolam (XANAX), which we list as Do Not Use Except For Panic Disorder, and clonazepam (KLONOPIN), which is approved by the FDA only for certain types of seizures and panic disorder.

Deprescribing benzodiazepines

In 2012, the American Board of Internal Medicine (ABIM) Foundation launched its Choosing Wisely campaign to help physicians and patients avoid overused tests and treatments that waste medical resources and increase the risk of harm.[7] The inappropriate prescribing of benzodiazepines to older adults was one treatment targeted by the ABIM’s campaign.[8]

Because of the evidence that too many doctors were not, on their own, discontinuing benzodiazepines for older adults, and consistent with the ABIM’s Choosing Wisely campaign, researchers in Canada conducted a randomized controlled trial to test whether an education program targeted at older patients would prompt them to engage with their doctors and pharmacists in a collaborative effort to discontinue these drugs.[9]

For the trial, known as the EMPOWER study, researchers recruited patients age 65 or older who had been using a benzodiazepine for at least three consecutive months, from 30 community pharmacies in the Montreal area.[10] After obtaining informed consent from all eligible patients who agreed to participate, the study researchers randomly divided the 30 participating pharmacies into two equal groups. Fifteen pharmacies with 148 subjects were assigned to the experimental group. Subjects in this group received an eight-page educational booklet that included a self-assessment tool about the risks of benzodiazepines, evidence of the harms of using these drugs, suggestions for equally or more effective therapies and recommendations for how to gradually taper off the drugs. These subjects also were asked to discuss the deprescribing recommendations with their doctors and pharmacists.

Fifteen pharmacies with 155 subjects were assigned to a control group. Subjects in this group received usual pharmacy care without the education on deprescribing benzodiazepines. (They were given the educational booklet after the trial was over.)

The researchers determined how many subjects in each group had successfully discontinued benzodiazepines within six months. Of the 303 subjects, 261 (86 percent) were available for 6-month follow-up, including 123 in the experimental group and 138 in the control group.

EMPOWER study results

Complete cessation of benzodiazepines was achieved in 40 (27 percent) of the 148 subjects in the experimental group, compared with only seven (5 percent) of the 155 subjects in the control group. After adjusting for multiple demographic and clinical characteristics of the two subject groups, the researchers determined that subjects who received education on deprescribing benzodiazepines had an eightfold greater likelihood of achieving discontinuation of these drugs than those in the control group. In addition, of the 123 subjects in the experimental group who were available for follow-up at six months, 120 (98%) acknowledged satisfaction with receiving benzodiazepine risk information.

For the 71 subjects in the experimental group who reported attempting benzodiazepine discontinuation, 38 (54 percent) were successful and 16 (22 percent) achieved a dose reduction. Among the 52 subjects who did not attempt to discontinue benzodiazepines, the following were the most commonly reported reasons for not doing so:

• discouragement by their physician or pharmacist (17 subjects [33%])
• fear of withdrawal symptoms (13 subjects [25%])
• lack of concern about taking benzodiazepines (12 subjects [23%])

Several subjects stated that their physician had discouraged tapering of benzodiazepines because of a perceived absence of adverse effects from the drugs.

The EMPOWER study researchers concluded that “the added value of directly educating the patient, in the absence of initial physician involvement, likely promotes patient buy-in for discontinuation [of benzodiazepines] at an early stage and allows the patient to act as a catalyst for initiating discussions about medication management, which is a more effective approach than the traditional paternalistic approach to patient care.” This conclusion could not be in closer agreement with our long-held view that a well-educated, empowered patient is critical for ensuring the safe and appropriate use of prescription medications – a philosophy underpinning Worst Pills, Best Pills News.

What You Can Do

We recommend that you not use benzodiazepines to alleviate insomnia or anxiety. If you are currently taking a benzodiazepine (other than alprazolam for panic attacks or clonazepam for panic attacks or seizures), talk to your doctor about developing a schedule to gradually taper your dose over several weeks to reduce the risk of severe withdrawal symptoms.

References

[1] Olfson M, King M, Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry. 2015;72(2):136-142.

[2] Ibid.

[3] Drug Profile. Worst Pills, Best Pills./monographs/view/83. Accessed September 7, 2018.

[4] Potts NL, Krishnan KR. Long-term use of benzodiazepines. Can Fam Physcian. 1992;38(1):149-153.

[5] Drug Profile. Worst Pills, Best Pills. /monographs/view/83. Accessed September 7, 2018.

[6] Cook JM, Marshall R, Masci C, Coyne JC. Physicians’ perspectives on prescribing benzodiazepines for older adults: a qualitative study. J Gen Intern Med. 2007;22(3):303-307.

[7] Cassel CK, Guest JA. Choosing wisely: Helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802.

[8] Choosing Wisely. American Geriatrics Society: Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. February 21, 2013. http://www.choosingwisely.org/clinician-lists/american-geriatrics-society-benzodiazepines-sedative-hypnotics-for-insomnia-in-older-adults/. Accessed September 13, 2018.

[9] Martin P, Tamblyn R, Ahmed S, Tannenbaum C. An educational intervention to reduce the use of potentially inappropriate medications among older adults (EMPOWER study): protocol for a cluster randomized trial. Trials. 2013 Mar 20;14:80.

[10] Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: The EMPOWER Cluster Randomized Trial. JAMA Intern Med. 2014;174(6):890–898.