Why Do I Need to Taper? Challenges and Evidence Behind Benzodiazepine Discontinuation

Over the past several years there have been rising concerns about the misuse of benzodiazepines. It is estimated that 30.6 million adults (12.6%) reported benzodiazepine use in the year 2015-2016 (Maust et al., 2019). Among them they report that 2.2% have misused a BZD prescription. Among adults and adolescents, benzodiazepines are the third most commonly misused illicit or prescription drug in the USA (Bachuber et al, 2016). Over the past few decades, benzodiazepine use has increased tremendously. A study done by Bachhuber et al. showed that the number of adults who filled a benzodiazepine prescription increased by 67%, from 8.1 million to 13.5 million between the years 1996 and 2013. The quantity obtained also increased from 1.1 kg to 3.6 kg lorazepam-equivalents per 100,000 adults (Bachuber et al., 2016)

To complicate matters, during the pandemic anxiety, sleep and mood disorders have skyrocketed. Data show an increase in use of benzodiazepines, making it imperative BCPPs be prepared to assist in monitoring an tapering as appropriate. In the USA, a study was done comparing the unique dispense of medications from January 2019 to May 2020 (Niles et al., 2021). The monthly number of unique patients dispensed as benzodiazepines (mean = 4,781,043 [SD = 166,850]; range = 4,478,448 to 5,011,279) was relatively stable until March 2020. Since March 2020 the number of unique patients dispensed benzodiazepines (5,128,721) was statistically and significantly higher than forecast estimates. In March 2020, an estimated additional 450,074 (95% CI:189,999 to 710,149) unique patients were dispensed benzodiazepines, compared to forecast estimates (Niles et al., 2021). Another study was done in Italy by analyzing hair samples to see drug use patterns during the COVID-19 pandemic. It revealed the percentage of samples positive for benzodiazepines ranged from 16.7% (5/30 cases) in the period before the lockdown to 53.3% (16/30 cases, p0.01) during the lockdown and remained high (43.3%, 13/30 cases, p0.01) even after the lockdown (Gili et al, 2021). The benzodiazepines reported in this study were not prescribed and their intake indicated illicit use. The study revealed changes in the overall trend of drug intake during the considered study period; 11/30 (37%) patients switched from single-drug use in the two pre-lockdown period controls to poly-drug use in the post-lockdown period. According to an Italian report during COVID-19, there has been a concerning increase in the prescription of hypnotics/sedatives with the potential for misuse, which has almost doubled and increased by about 17-19%, In another study in Ontario, data from January 1 to May 31, 2019, were compared with data from January 1 to May 31, 2020. There was a 43.7% increase in benzodiazepine dispensing in the first five months of the year compared to the year prior (Yu et al., 2021) The same study also reported that the number of benzodiazepine tablets dispensed monthly during the COVID-19 pandemic was statistically higher compared to the previous year (1037.4 ± 122.24, 721.6 ± 156.87, respectively, z=-2.402, p=0.016).

Prescribing guidelines do not recommend the long-term use of benzodiazepines since their effectiveness with chronic use is outweighed by risks including dependence, memory and cognitive impairment, hip fractures and traffic accidents. Discontinuation of benzodiazepines has proven to be of benefit, as it is followed by improvements in cognitive and psychomotor function, particularly in elderly patients. An interprofessional effort, focusing on the primary care setting, is required to address benzodiazepine misuse and to ensure appropriate pharmaceutical care. Pharmacists must be an integral part of this inter-professional effort, not least because they are uniquely positioned as the health professional with most frequent patient contact. There is already some supporting evidence that pharmacists’ involvement in interventions to reduce benzodiazepine use can have positive effects on patient outcomes (Gallagher, 2013).