Deprescribing benzodiazepines

Much national attention has been given to the opioid epidemic, yet there has been little focus on deprescribing benzodiazepines. Deprescribing is the planned and supervised process of dose reduction and cessation of medications that might be causing harm or provide no further benefit.¹ Between 1996 and 2013, the number of adults prescribed a benzodiazepine has increased by 67% from 8 million to 13.5 million, and the quantity obtained has more than tripled during this period.² The benzodiazepines alprazolam, clonazepam, and lorazepam are among the most commonly prescribed psychotropic drugs in the US.²

The FDA granted approval for several medications in the benzodiazepine class to be prescribed for use in treating anxiety disorders including clorazepate, diazepam, lorazepam, and oxazepam. Benzodiazepines are also commonly used to treat insomnia. The benzodiazepines with FDA approval for the treatment of insomnia include estazolam, flurazepam, quazepam, temazepam, and triazolam. The mechanism of action of benzodiazepines is through the modulation of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter that suppresses the central nervous system (CNS); the drugs have efficacy for short-term use (less than 1 month), but patients can develop a tolerance and dependence with long-term use.²

The benefits of benzodiazepines decrease over time and there are increased associated risks such as cognitive decline, accidental injuries, falls, and increased rates of hospital admissions and ED visits.² Patients can also have paradoxical anxiety while on benzodiazepines.³ Studies have shown that long-term use of benzodiazepines increases the risk of dementia.^4,5

Recent clinical practice guidelines recommend deprescribing benzodiazepines for older adults (age 65 years or older) for use in insomnia, and the American Geriatric Society (AGS) BEERs Criteria recommend avoidance of benzodiazepines in older adults because of the increased risk of adverse reactions such as falls and fractures.^1,6 The AGS does say that benzodiazepines may be appropriate for use in older adults in certain circumstances such as ethanol withdrawal, and periprocedural anesthesia.⁶ The FDA has cautioned providers about prescribing benzodiazepines in patients using opioids but does not recommend withholding medications used for opioid use disorder in patients taking benzodiazepines.^7,8 NPs can be instrumental in adequately treating anxiety and insomnia disorders with nonpharmacologic interventions (such as yoga and sleep hygiene) as well as with other medication classes that are not benzodiazepines.

How to start the discussion for deprescribing

Engaging the patient in a conversation about deprescribing a benzodiazepine is a critical first step and may be difficult.¹ Barriers to deprescribing include patient expectations that the medication is a requirement of treatment as well as the healthcare prescribing culture (in other words, prescribers are taught more on how to prescribe than how to deprescribe) coupled with organizational constraints (for example, short appointment times and difficulty in coordinating between specialties).⁹ However, evidence points to greater likelihood of a patient accepting medication cessation if the medication reduction is done gradually.¹⁰

Patient engagement must be established at the start of the deprescribing process and maintained throughout. The existence of a good therapeutic relationship will help ensure success.¹⁰ Before decreasing or stopping benzodiazepines in patients, assess why the patient is using the medication. Is it for anxiety, insomnia, panic attacks, and/or grief reactions? What is the patient's understanding of the effectiveness, instructions for use, and purpose of the medication? Perhaps not surprisingly, patients' impressions may differ from the prescribing information on the bottle. Motivational interviewing may be an effective way to begin the conversation.

Raising awareness is an important aspect of the deprescribing process. Studies show that providing education on the long-term use of medications and information regarding possible withdrawal symptoms during the process along with a plan to mitigate them can assist the patient in making an informed decision about embarking on the process of gradual reduction.¹¹ Simple tools such as the Eliminating Medications through Patient Ownership of End Results (EMPOWER) brochure, targeted toward the older adult population and available in the public domain, can be a valuable educational instrument.^12,13

NPs can then explain how the deprescribing process works and discuss a plan specific to that patient.¹⁴ A clear plan designed collaboratively by the prescriber and the patient, with the patient in control of the tapering schedule, is more likely to facilitate patient engagement in the tapering process.¹ Concerns and questions from the patient, the family, and/or caregivers must also be addressed. This helps to obtain acceptance from all involved as part of the patient's support system and to help pave the way for implementation of the deprescribing plan.¹⁴

Tapering

There need to be alternative treatments in place for patients undergoing a tapering process. A complete physical exam is appropriate before weaning. NPs also need to assess for a history of seizure disorders, history of weaning from benzodiazepines, history of substance use, a specific pattern of use, length of use, and type of medication used (short- versus long-acting). Patients should never abruptly stop taking benzodiazepines because of the risk of seizures. In patients with a history of seizure disorder, a referral to a neurologist may be appropriate before deprescribing.

In patients who have depression or anxiety disorders, start, continue, or increase the dose of a selective serotonin reuptake inhibitor (SSRI) or selective norepinephrine reuptake inhibitor (SNRI) until significant improvement in symptoms (less anxiety and depressed mood, improved appetite and sleep, no suicidal ideation, and so forth) is seen, which may take 8 to 12 weeks before weaning benzodiazepines. Patients may also benefit from psychotherapy while tapering off benzodiazepines.¹⁵

If patients use benzodiazepines for insomnia, discuss sleep hygiene (avoiding bright lights, a consistent sleep schedule, positioning clocks away from the bed, avoiding caffeine and electronics before bed), recommend cognitive behavioral therapy for insomnia, and use other sedating medications, such as doxepin, if warranted.^16,17

There are no US clinical guidelines that detail deprescribing benzodiazepines. The U.K. guidelines recommend reducing the daily dose by 10% to 20% every 2 weeks.¹⁸ These guidelines also recommend converting the benzodiazepine to the diazepam equivalent. For example, 0.5 mg of alprazolam is equivalent to 10 mg of diazepam.¹⁹ By converting short-acting agents to long-acting agents, patients experience fewer withdrawal symptoms and are better able to tolerate them. Withdrawal effects vary among patients and can include anxiety, physical symptoms (for example, perspiration, tachycardia, hot and cold flushes, or tremors), and perceptual symptoms (for example, increased sensitivity to light, taste and smell disturbances, or increased sensitivity to touch).²⁰

These symptoms tend to occur faster with shorter-acting agents (within 2 to 3 days) than longer-acting agents (within 5 to 10 days).²¹ Tapering may need to be slower if patients have significant withdrawal problems or are long-term users of benzodiazepines (more than 1 year). If the patient is experiencing withdrawal symptoms, maintain the current dose.²⁰ Overall, the taper schedule needs to be in collaboration with the patient.

Some patients may benefit from remaining on benzodiazepines if their anxiety or panic attacks are not well managed with SSRIs, SNRIs, or psychotherapy. NPs should prescribe the lowest dose needed for symptom relief. It is important to explain to patients the risks of chronic benzodiazepine use and to use the lowest dosage possible. Patients with panic attacks can learn to use coping mechanisms during an attack before using a benzodiazepine. Patients with depression (without anxiety) will not benefit from taking a benzodiazepine, so tapering for this disorder is important.

If tapering is difficult or if patients have significant withdrawal symptoms, a referral to a psychiatric care provider is appropriate. Patients on high doses (equivalent to greater or equal to 100 mg of diazepam) can benefit from tapering in an inpatient setting.²¹ It is important for NPs to check their state pharmacy database when tapering benzodiazepines to ensure patients are not already receiving a benzodiazepine, or other controlled substance CNS depressants, from another provider. If patients are abusing a benzodiazepine, then a referral for substance use disorder treatment would be appropriate.²²

Conclusion

Deprescribing benzodiazepines in patients with long-term use can decrease the negative outcomes from their use, such as tolerance, cognitive decline, and falls. There are other evidence-based treatments that can be used for anxiety and insomnia, such as SSRIs, SNRIs, and psychotherapy. Tapering of benzodiazepines needs to be done in collaboration with patients, and attention should be given to withdrawal-associated adverse reactions.