Hypnotic Discontinuation Using a Blinded (Masked) Tapering Approach: A Case Series

Abstract

Chronic use of hypnotic medications such as benzodiazepines is associated with adverse consequences including increased risk of falls. Efforts to help patients discontinue these medications have had varying levels of success. We developed a blinded (masked) tapering protocol to help patients taper off hypnotics. In this blinded protocol, patients consented to a drug taper but agreed to forego knowledge about the specific tapering schedule or the actual dose each night until the end of the taper. Blinded tapering aims to reduce negative expectancies for withdrawal effects that may impair a patient’s successful discontinuation of hypnotics. In preparation for a randomized trial, we tested the feasibility of adding a blinded tapering component to current best evidence practice [supervised hypnotic taper combined with cognitive behavioral therapy for insomnia (CBTI)] in 5 adult patients recruited from an outpatient mental health practice in Oregon. A compounding pharmacy prepared the blinded capsules for each patient. During the gradual blinded taper, each participant completed CBTI. Measures collected included feasibility/process (e.g., recruitment barriers), hypnotic use, the Dysfunctional Beliefs and Attitudes about Sleep Scale, Insomnia Severity Index, Epworth Sleepiness Scale, and Patient Health Questionnaire-9 (depressive symptoms). The intervention was feasible, and participants reported high satisfaction with the protocol and willingness to follow the same treatment again. All five participants successfully discontinued their hypnotic medication use post-treatment. Dysfunctional beliefs/attitudes about sleep and insomnia severity improved. Blinded tapering is a promising new method for improving hypnotic discontinuation among patients treated with a combination of hypnotic tapering plus CBTI.

Sleep characteristics and use of multiple benzodiazepine receptor agonists in older adults

“…Telephone screening surveys were conducted for an ongoing BZA deprescribing clinical trial (NCT03687086) 4 to recruit adults aged ≥55 in California who were receiving care through the Department of Veterans Affairs or University of California, Los Angeles and were prescribed at least one of five targeted BZAs (alprazolam, clonazepam, lorazepam, temazepam, zolpidem) chosen for practicality for the dose reduction component of the trial. Screeners between February 2019 and October 2022 were analyzed.…”

“…The findings do not necessarily reflect the views of the NIA or Department of Veterans Affairs. Sara Ghadimi BS 1,2 Austin Grinberg PhD 1 Michael N. Mitchell PhD 1 Cathy Alessi MD 1,2 Alison A. Moore MD, MPH 3 Jennifer L. Martin PhD 1,2 Joseph M. Dzierzewski PhD 4 Monica Kelly PhD 1,2 M. Safwan Badr MD, MBA 5,6 Andrew Guzman PhD 1,2 Jason P. Smith PharmD 7…”

“…2,3 Widelycited research published in 2018 suggest the risk-benefit balance of aspirin use in CVD prevention in older adults is outweighed by bleeding and other side effects. 4 In the context of new data and guidelines, this study describes the prevalence and trends in aspirin use from 2015 to 2020 among adults ages 60-79 living in five Upper Midwestern states.…”

Reduction of Sleep Medications via a Combined Digital Insomnia and Pharmacist-Led Deprescribing Intervention: Protocol for a Feasibility Trial

“…A typical intervention will involve gradual dose reduction (GDR), or tapering, and is sometimes accompanied by psychological treatment, like CBT-I [45]. GDR and tapering approaches, including the use of telehealth [46,47], often involve dose reductions of 25%-50% every 1-3 weeks until cessation is achieved [44]. Cessation, however, has varying rates of success (27%-80%).…”

“…Adding psychological treatments (eg, CBT-I) helps to reduce rebound insomnia and improve cessation rates compared to routine care (odds ratios [OR] 3.38-5.96). However, the results of combining medication tapering and psychological interventions have been mixed [47][48][49]. Two key challenges to deprescribing sedative-hypnotics are rebound insomnia symptoms and the lack of personalized care (eg, educational brochures) [49].…”