Withdrawing Benzodiazepines in Primary Care

Abstract

The use of benzodiazepine anxiolytics and hypnotics continues to excite controversy. Views differ from expert to expert and from country to country as to the extent of the problem, or even whether long-term benzodiazepine use actually constitutes a problem. The adverse effects of these drugs have been extensively documented and their effectiveness is being increasingly questioned. Discontinuation is usually beneficial as it is followed by improved psychomotor and cognitive functioning, particularly in the elderly. The potential for dependence and addiction have also become more apparent. The licensing of SSRIs for anxiety disorders has widened the prescribers' therapeutic choices (although this group of medications also have their own adverse effects). Melatonin agonists show promise in some forms of insomnia. Accordingly, it is now even more imperative that long-term benzodiazepine users be reviewed with respect to possible discontinuation. Strategies for discontinuation start with primary-care practitioners, who are still the main prescribers.This review sets out the stratagems that have been evaluated, concentrating on those of a pharmacological nature. Simple interventions include basic monitoring of repeat prescriptions and assessment by the doctor. Even a letter from the primary-care practitioner pointing out the continuing usage of benzodiazepines and questioning their need can result in reduction or cessation of use. Pharmacists also have a role to play in monitoring the use of benzodiazepines, although mobilizing their assistance is not yet routine. Such stratagems can avoid the use of specialist back-up services such as psychiatrists, home care, and addiction and alcohol misuse treatment facilities.Pharmacological interventions for benzodiazepine dependence have been reviewed in detail in a recent Cochrane review, but only eight studies proved adequate for analysis. Carbamazepine was the only drug that appeared to have any useful adjunctive properties for assisting in the discontinuation of benzodiazepines but the available data are insufficient for recommendations to be made regarding its use. Antidepressants can help if the patient is depressed before withdrawal or develops a depressive syndrome during withdrawal. The clearest strategy was to taper the medication; abrupt cessation can only be justified if a very serious adverse effect supervenes during treatment. No clear evidence suggests the optimum rate of tapering, and schedules vary from 4 weeks to several years. Our recommendation is to aim for withdrawal in <6 months, otherwise the withdrawal process can become the morbid focus of the patient's existence. Substitution of diazepam for another benzodiazepine can be helpful, at least logistically, as diazepam is available in a liquid formulation.Psychological interventions range from simple support through counselling to expert cognitive-behavioural therapy (CBT). Group therapy may be helpful as it at least provides support from other patients. The value of counselling is not established and it ca...

Benzodiazepine use in Belgian nursing homes: a closer look into indications and dosages

“…However, a small intervention study in primary care showed that sending a letter from the physician to the BZD/Z user could have a positive impact on successful withdrawal [51,52]. Motivation and gradual tapering seems to be the best strategy for discontinuation [11,53].…”

“…Long-term use of benzodiazepines is discouraged in guidelines [5,7,8] because of the lack of effectiveness after 4 weeks [9,10], the increased risk of dependence and abuse, and withdrawal syndromes [11,12]. Moreover, it has been hypothesised that long-term use might have a detrimental effect on cognition and a potential acceleration of cognitive impairment [13][14][15].…”

Håndtering av seponeringsreaksjoner

“…Ved uttalte plager kan det i enkelte tilfeller vaere aktuelt å bruke et adjuvant legemiddel for en periode for å redusere symptomene. Klonidin ved opioidnedtrapping og karbamazepin og antidepressiver ved seponering av benzodiazepiner er eksempler (6). Oppfølging fra for eksempel fastlege med ikke-medikamentelle tiltak med vekt på støtte og motivasjon er effektive og lite ressurskrevende tiltak som øker sjansen for å lykkes med nedtrapping (7).…”

Uma revisão sistemática e metanálise sobre os eventos adversos decorrentes do uso de benzodiazepínicos pos idosos.

“…Já no Canadá e na Espanha, estes são utilizados por mais de 20% dos idosos e, na Austrália, prevalece o seu uso em cerca de 15% (CARRASCO-GARRIDO et al, 2007;HOGAN et al, 2003;WINDLE et al, 2007) Atualmente, apesar desta prática de utilização apresentar-se menos acentuada nos EUA e no Reino Unido, verifica-se uma escala ainda elevada em idosos (GALLACHER et al, 2012). Fator este em modificação, principalmente nos países da Europa, em virtude de programas governamentais de conscientização aos profissionais envolvidos no atendimento ao paciente para promoção de descontinuação acompanhada desta classe farmacológica, visando minimizar os efeitos de abstinência até a sua total extinção (GOULD et al, 2014;HARTHOLT et al, 2011;LADER et al, 2009;SALONOJA et al, 2012;VELERT VILA et al, 2012).…”

“…As incidências de eventos adversos relatados no grupo flunitrazepam foram vertigem (4), depressão (10), artralgia (5), diarreia (6), dor de cabeça (6); no grupo zopiclona, foram relatados vertigem (10), depressão (7), artralgia (7), diarreia (2), dor de cabeça (2) e; no grupo placebo inicial (n=102), vertigem (3), depressão (6), artralgia (6) Com relação às perdas e desistências, um paciente faleceu durante o estudo devido a infarto de miocárdio, apresentando histórico prévio e fumante. Dezoitos pacientes, durante a fase de randomização duplo-cega, desistiram do estudo devido à eventos adversos, sendo dois do grupo zolpidem, cinco do triazolam (dor de cabeça, letargia, dor no peito, diarreia e sonolência), 5 do temazepam (tontura, asma, vertigem, amebíase e acidente automobilístico) e 6 do grupo placebo (dor na virilha, bursite, fratura de quadril, infecção de ouvido, sonolência e náusea).…”