Tapering benzodiazepines

Benzodiazepines are commonly prescribed to treat a variety of conditions ranging from insomnia and anxiety, to seizure disorders and skeletal muscle spasticity.1 In 2017, there were 533 benzodiazepine prescriptions per 1,000 population across Canada, representing an average of one in two people receiving a prescription for a benzodiazepine.2 While effective in the short-term, a myriad of concerning long-term adverse effects have led to many guidelines recommending against the use of benzodiazepines long-term.3-6 This is especially true in the elderly population, where adverse effects such as increased falls risk, cognitive impairment, paradoxical agitation and oversedation have led Choosing Wisely Canada to generally recommend against their use in older adults.7,8 The development of tolerance over time also often leads to escalating doses of benzodiazepines, further increasing the risks of side effects and the development of dependence.9In practice, many patients receive benzodiazepines for long periods of time, despite only a very limited number of valid long-term indications.8 Given the prevalence of long-term use, pharmacists are often faced with the difficult challenge of helping patients navigate benzodiazepine tapering.Start conversations and educate patientsTapering benzodiazepines can be a difficult conversation with patients, and this may be one of the reasons for the prevalence of continuing benzodiazepines long-term. However, given the many significant adverse effects of benzodiazepines, pharmacists should avoid the path of least resistance, and initiate discussions and help guide patients through this often-difficult process.After a thorough clinical assessment in collaboration with the patient’s care team and prescribing physician, provide education to the patient in a nonjudgmental manner. Many patients are simply unaware of the many long-term risks of benzodiazepines, and have never considered tapering because they did not know long-term use could be a potential problem. Evidence shows that patient education leads to a significantly greater portion of elderly patients discontinuing benzodiazepines or reducing their total daily dose.10 Framing the many potential risks and their consequences in relation to the patient’s goals and lifestyle may be of benefit. For example, reviewing the increased risk of falls and fractures may be beneficial to a 67-year-old grandfather of two, who wishes to teach his grandchildren how to play soccer. Further, given many benzodiazepine drug interactions with commonly prescribed medications (e.g., first-generation antihistamines, antihypertensives, other sleep aids), informing patients of these interactions and the potential benefits of a taper may also be helpful. Patients are often unaware that benzodiazepines are the reason for their daytime drowsiness or lack of energy when combined with some of their other medications, and that a taper can lead to increased alertness, focus and energy throughout the day.Offer solutions A wise colleague once said “Never just present problems, offer solutions.” While you may have patients’ best interests in mind, what they may hear when you propose a benzodiazepine taper is that you want to take away their sleep aid, or their ‘emergency pill’ for when they get anxious. Always find out and understand why patients are taking benzodiazepines, and present alternatives, whether it’s a safer pharmacologic option, or nonpharmacologic strategies to help manage their condition. You could even suggest a sleep study; the patient may discover that they actually have obstructive sleep apnea and that their insomnia would be better managed with a CPAP machine than a benzodiazepine.Be aware of the logistics of taperingEvidence for benzodiazepine tapering is scarce and there are many different approaches. A good starting point is to follow the general rule of thumb of reducing the total dose by 10%–25% every one to two weeks.8,11 No strong evidence supports the use of one particular benzodiazepine for tapering, but the use of long-acting agents (e.g., diazepam or clonazepam) may be beneficial to minimize withdrawal symptoms throughout the day.8,11 Short-acting agents (e.g., alprazolam) should be avoided where possible because they generally require frequent dosing, and their fast onset and offset may cause additional instability and withdrawal symptoms.1 While diazepam’s ultra-long half life, and many dose availabilities offer many benefits, its use in the elderly and hepatically impaired individuals should be approached cautiously.1,8Multiple benzodiazepines should ideally be consolidated into one long-acting benzodiazepine to simplify the process. Although common in practice, there really is no rationale for a patient to be taking standing clonazepam twice daily, plus lorazepam “as needed.” Tapering should also generally be done using scheduled doses, with as needed (prn) doses avoided.8Towards the end of the taper, it is reasonable to slow the taper pace both in dose and frequency (e.g., reduce by 5% every 2–4 weeks).8 However, it is important to avoid extremely long tapers (> 6 months) to minimize patients from potentially developing further psychological dependence.11,12 A firm but reassuring approach is often helpful. Remind patients of the significant progress they’ve made, along with the many benefits of tapering. Provide alternate nonpharmacologic strategies (e.g., sleep hygiene, cognitive behavioural therapy for insomnia [CBT-I]) to help manage the patient’s concerns.12,13 Where possible, adhere to predetermined and agreed-upon tapering schedules in a firm but supportive way. If the patient experiences significant adverse effects or extremely distressing withdrawal symptoms, it is prudent to pause the taper, re-titrate the dose back to the previous step, and reassess in one to two weeks for resumption of tapering at a slower pace.SummaryBenzodiazepines are associated with significant long-term risks. Pharmacists play an important role in identifying opportunities for benzodiazepine tapers, and helping patients navigate this difficult process. Sunny Wang is a clinical pharmacist and Pharmacy Education Coordinator at the Centre for Addiction and Mental Health (CAMH) in Toronto. His clinical work is currently with the inpatient Crisis and Critical Care Unit, serving a diverse population of patients with acute psychiatric and substance use disorders. In addition to his role as Education Coordinator at CAMH, Sunny is involved as a Clinical Instructor at the Leslie Dan Faculty of Pharmacy and serves as an Expert Hub Member for the Addiction Medicine and Psychosocial Interventions Program with Project ECHO.ReferencesCanadian Pharmacists Association. Benzodiazepines CPhA monograph. Last revised May 1, 2015.Canadian Institute for Health Information. Pan-Canadian trends in the prescribing of opioids and benzodiazepines, 2012 to 2017. Ottawa, ON: CIHI; 2018.Canadian Pharmacists Association. Six things pharmacists and patients should question: Choosing Wisely Canada; 2020.College of Physicians & Surgeons of Manitoba. Standard of practice: prescribing benzodiazepines & Z-drugs (including zopiclone & other drugs). Winnipeg, MB: The College of Physicians & Surgeons of Manitoba; 2020.College of Physicians & Surgeons of Nova Scotia. Benzodiazepines and Z-drugs professional standards regarding benzodiazepines and Z-drugs. Bedford, NS: College of Physicians & Surgeons of Nova Scotia; 2022.The Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice, Part B – Benzodiazepines, summary of recommendations. East Melbourne, Australia: RACGP; 2019.Canadian Pharmacists Association. Geriatrics: eight things physicians and patients should question: Choosing Wisely Canada; 2022.College of Physicians & Surgeons of Alberta. Clinical toolkit benzodiazepines: use and taper. Edmonton, AB: CPSA; 2016.Longo LP, Johnson B. Addiction: Part I. Benzodiazepines – side effects, abuse risk and alternatives. Am Fam Physician 2000;61:2121-8.Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med 2014;174:890-8. doi:10.1001/jamainternmed.2014.949.Soyka M. Treatment of benzodiazepine dependence. N Engl J Med 2017;376:1147-57.National Center for PTSD. Effective treatments for PTSD: helping patients taper from benzodiazepines: Veteran’s Affairs; 2015.Deprescribing.org. Benzodiazepine & Z-drug deprescribing algorithm: Deprescribing.org; 2019. (accessed October 24, 2023).

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Tapering benzodiazepines

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Sunny Wang

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