Deprescribing Benzodiazepines: Changing Attitudes

Linda Brookes, MSc

Disclosures

June 15, 2018

Identify the Patient and Taper the Dose

The first step in the algorithm is to identify patients who have been taking a benzodiazepine for insomnia — for more than 4 weeks in those aged 18-64 years, or for any length of time in those 65 years or older. "Many physicians are reluctant to start the discussion because they believe it will be a bit of a fight with patients who are afraid of stopping because they believe they won't function without these drugs," Dr Pottie admitted. But in his own experience, he has found that most patients are more than willing to consider stopping. "When you lay down a progressive, evidence-based, informed process that your patients can understand, and give them the option not to [take these medications], your patients see that they have options and they are empowered to take them or not." He added that when patients learn about the adverse effects, they tend to be most concerned about the drug's effect on memory. "Many people have felt that effect already and are very afraid of dementia," he said. "That is where motivation starts to come in."

The guideline recommends tapering and then stopping the drug. "Tapering has historically not received a lot of positive reinforcement," Dr Pottie noted. The guidelines suggest gradual dose reduction by 25% every 2 weeks and by 12.5% toward the end of the taper, before the drug is stopped altogether. If the dosage form does not allow this, the guidelines suggest a reduction by 50%, with drug-free days later.

"A lot of people like to taper and it is definitely the more comfortable route," Dr Pottie acknowledged. "Many people need that confidence, especially when they are nervous that they will 'explode' when they reduce the dose. When they see that they don't explode, then they can go down a bit further." Stopping immediately, without tapering, is also possible in some cases.

"I have actually stopped without tapering in several people, because they just wanted to do that," Dr Pottie recalled. "It's not like the 1980s, when people were on very high doses. We are dealing with more low to modest-sized doses so there are no major medical contraindications risks to stopping. Patients have to be able and willing to sleep less for maybe for a week or two, but if they are willing to do this, they are ready for deprescribing."

Alternative Medications Are Not Recommended

The guidelines do not recommend any alternative medications to treat insomnia or other drugs to facilitate tapering. Rather, they encourage nondrug approaches such as cognitive behavioral therapy. "We are not putting forward any drugs to replace the benzodiazepines, because there are no completely safe effective alternatives," Dr Pottie said. "We were pressured by some clinicians to name some of the new drugs in development, but we felt that we were not going to play that game." He acknowledged that some clinicians may feel that they have to have something else to offer to help people sleep, but the evidence steers toward sleep hygiene or cognitive behavior therapy.

"When you have tried everything and patients still can't sleep, you are in a bit of a clinical quagmire," he said. "Some physicians will reach for a newer unproven medication, some will use some even older drugs that are still on the market. You can get caught on the idea that medication is the way to help your patients when really, reassessment of the diagnoses and consideration of nonmedical interventions may be indicated."

Do We Need 'Deprescribing' Guidelines for Insomnia?

Dr Pottie and his colleagues debated whether the guidelines should include recommendations for managing insomnia, but they believed this was not appropriate for their deprescribing guidelines.[19] Dr Pottie personally questions whether these drugs should be prescribed at all, or very rarely, at most.

"We are not saying that this is a 'do not prescribe' guideline, but I do feel that it is a 'prescribe with caution' guideline," he said. "I think deprescribing guidelines should highlight that, in the short term, writing a prescription is very fast, but you are going to have to deal with this issue later on. So, I feel the guideline may reduce prescribing from the beginning. I am cautious to give these addictive medications as my first line now, and I find that more patients are ready to go with that and not go on medication."

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