Strategies for Successful Benzodiazepine Discontinuation

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Beth Hall, PharmD, BCPP
CPNP Recertification Editorial Board

This session can be purchased in CPNP University.

Benzodiazepines are used widely for the treatment of anxiety, sleep, depression (as adjuvant therapy), and pain (as muscle relaxants). Between 1996 and 2013, the number of adults filling a benzodiazepine prescription increased by 67% and the total quantity filled more than tripled.  Kristina Ward, PharmD, BCPS, BCPP, presented the most current information regarding the prevalence of benzodiazepine use and strategies for benzodiazepine discontinuation at the CPNP 2017 meeting in her presentation entitled, Stop the Benzodiazepines: Identifying High Risk Patient Populations and Successfully Tapering These Medications.  Dr. Ward is currently a Clinical Pharmacy Specialist in Mental Health with the VA Northern California Health Care System.

Risks Associated with Chronic Benzodiazepine Use

Dr. Ward began her presentation discussing the short and long terms risks of benzodiazepine use.1 While discussing the negative impact benzodiazepines have on cognitive function, Dr. Ward reviewed results of a meta – analysis which evaluated patients taking benzodiazepines for over a year. Impairment in cognition was seen across many cognitive domains.2

In regards to the use of benzodiazepines in high – risk patient populations, Dr. Ward discussed the adverse outcomes associated with benzodiazepine use in the elderly, dementia, PTSD and chronic respiratory disease.  In the elderly, benzodiazepines are associated with an increased risk of falls, hip fractures, sedation, and cognitive impairment.3 A 2015 literature review found benzodiazepine use in patients with Alzheimers’ disease to be associated with more rapid cognitive decline, higher deterioration rate, shorter time to death, and increased falls.4 Benzodiazepine use is not recommended in the treatment of PTSD because these medications do not reduce the core symptoms of PTSD and may increase the risk of developing PTSD when administered shortly after a trauma.5,6  Use of benzodiazepines in patients with COPD was evaluated in a population based observations study and found to be associated with a 45% increased risk of outpatient respiratory exacerbations and 92% increased risk of emergency room visits.7

Successful Discontinuation of Benzodiazepine Treatment

The remaining portion of Dr. Ward’s presentation reviewed non-pharmacologic and pharmacologic strategies to use for successful benzodiazepine discontinuation. The Brief Education Intervention and Direct-to-Consumer Education were discussed as options for practitioners to utilize.8,9 Finally, Dr. Ward presented various tapers and evidence supporting the use of each strategy.10

Take Home Messages

  • Benzodiazepines continue to be widely used for extended periods of time and in patients who may experience more harm than benefit from the treatment. 
  • When identifying patients who may be candidates for benzodiazepine discontinuation, begin with patients at higher risk for adverse outcomes. 
  • A variety of effective, evidence – based strategies exist to assist clinicians and patients with achieving successful benzodiazepine discontinuation.

References

  1. Bachhuber MA, et al., AJPH, 2016. 106(4): p. 686-8.
  2. Barker MJ, et al., CNS Drugs, 200. 18(1): p. 37-48.
  3. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):2227-46. DOI: 10.1111/jgs.13702. PubMed PMID: 26446832.
  4. Defrancesco M, et al., Int J Neuropsychopharmacol, 2015. 18(10): p. pyv005.
  5. Guina J, Rossetter SR, DeRHODES BJ, Nahhas RW, Welton RS. Benzodiazepines for PTSD: A Systematic Review and Meta-Analysis. J Psychiatr Pract. 2015;21(4):281-303. DOI: 10.1097/PRA.0000000000000091. PubMed PMID: 26164054.
  6. Shin HJ, Rosen CS, Greenbaum MA, Jain S. Longitudinal correlates of aggressive behavior in help-seeking U.S. veterans with PTSD. J Trauma Stress. 2012;25(6):649-56. DOI: 10.1002/jts.21761. PubMed PMID: 23225031.
  7. Vozoris NT. Do benzodiazepines contribute to respiratory problems?. Expert Rev Respir Med. 2014;8(6):661-3. DOI: 10.1586/17476348.2014.957186. PubMed PMID: 25193249.
  8. Screening for Drug Use in General Medicine Settings Resource Guide. National Institute on Drug Abuse, 2010.
  9. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. Jama Intern Med. 2014;174(6):890-8. DOI: 10.1001/jamainternmed.2014.949. PubMed PMID: 24733354.
  10. Denis C, Fatséas M, Lavie E, Auriacombe M. Pharmacological interventions for benzodiazepine mono-dependence management in outpatient settings. Cochrane Database Syst Rev. 2006;(3):CD005194. DOI: 10.1002/14651858.CD005194.pub2. PubMed PMID: 16856084.
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