Interventions to improve benzodiazepine tapering success in the elderly: a systematic review Cognitive-behavioural, pharmacological and psychosocial predictors of outcome during tapered discontinuation of benzodiazepine. Efficacy of CBT for benzodiazepine discontinuation in patients with panic disorder: Further evaluation. Self-efficacy and compliance with benzodiazepine taper in older adults with chronic insomnia. Controlled evaluation of brief intervention by general practitioners to reduce chronic use of benzodiazepines. Tapering off long-term benzodiazepine use with or without group cognitive-behavioural therapy: three-condition, randomised controlled trial. Discontinuation of benzodiazepine treatment: efficacy of cognitive-behavioral therapy for patients with panic disorder. Cross-validation, predictive validity, and time course of the Benzodiazepine Dependence Self-Report Questionnaire in a benzodiazepine discontinuation trial. Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. An educational intervention to reduce the use of potentially inappropriate medications among older adults (EMPOWER study): protocol for a cluster randomized trial Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Evaluation of an easy, cost-effective strategy for cutting benzodiazepine use in general practice. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. Treatment of out-patients with complicated benzodiazepine dependence: comparison of two approaches. Withdrawal from long-term benzodiazepine use: randomised trial in family practice. General Practitioners reduced benzodiazepine prescriptions in an intervention study: a multilevel application.
ABSTRACT Background : Long-term benzodiazepine use in the elderly population is a significant public health problem that leads to impaired cognitive functioning , medication dependence and increased risks for adverse drug reactions . The aim of this review was to examine r and omized controlled trials ( RCTs ) on the efficacy of different methods for tapering and discontinuing benzodiazepines . Method : We used four data bases ( Ovid , PubMed , Academic Search Complete , Web of Science ) to retrieve r and omized controlled trials published in peer- review ed journals that explored different methods for tapering benzodiazepine use in a primarily geriatric population . Results : Eleven papers met the inclusion criteria . Methods to assist in benzodiazepine tapering included patient education , cognitive behavioural therapy ( CBT ) , and pharmaceutical adjuvants ( SSRIs , melatonin , progesterone ) . Patient education was consistently effective in increasing benzodiazepine discontinuation success while CBT had mixed but promising results . The use of medications to help improve tapering success was inconclusive . Conclusions : Patient education is a successful , time- and cost-effective intervention that can significantly help with benzodiazepine discontinuation success .  CBT may also be an effective approach . However , cost can be an issue since public healthcare coverage in Canada does not cover psychotherapy . More research is needed in looking at pharmaceutical adjuvants and their role in assisting with benzodiazepine discontinuation Eighty-six participants wishing to stop benzodiazepine and who met DSM-IV ( Diagnostic and Statistical Manual of Mental Disorders , 4th ed . American Psychological Association , 1994 ) criteria for anxiety disorder or insomnia were assessed pre- and post-taper on clinical , pharmacological and psychosocial measures . An initial cohort of 41 participants received treatment as usual ( taper only ) plus physician counselling in the same clinic setting . A second cohort of 45 participants were r and omly allocated to group cognitive-behavioural therapy ( CBT ) plus taper , or group support ( GS ) plus taper . At 3 months follow-up , the outcomes in both the CBT and the GS subgroups were equivalent . Intention to treat analysis revealed a slight advantage to the CBT over the GS group and the CBT group showed higher self-efficacy post-taper . Over all 86 participants , a high-baseline level of psychological distress , anxiety and dosage predicted a poor outcome , but increase in self-efficacy contributed to a successful outcome particularly in those with initially poor baseline predictors . Although there was a decrease in positive affect during preliminary stages of tapered discontinuation compared to baseline , there was no significant overall increase in negative affect Despite its acute efficacy for the treatment of panic disorder , benzodiazepines ( BZs ) are associated with a withdrawal syndrome that closely mimics anxiety sensations , leading to difficulty with treatment discontinuation and often disorder relapse . An exposure-based cognitive-behavioral treatment for BZ discontinuation , Panic Control Treatment for BZ Discontinuation ( CBT ) targets the fear of these sensations and has demonstrated efficacy in preventing disorder relapse and facilitating successful BZ discontinuation among patients with panic disorder . In this r and omized controlled trial , CBT was compared to taper alone and a taper plus a relaxation condition to control for the effect of therapist contact and support among 47 patients with panic disorder seeking taper from BZs . Based on the primary outcome of successful discontinuation of BZ use , results indicate that adjunctive CBT provided additive benefits above both taper alone and taper plus relaxation , with consistently medium and large effect sizes over time that reached significance at the six month follow-up evaluation . The efficacy of CBT relative to either of the other taper conditions reflected very large and significant effect sizes at that time . These findings suggest that CBT provides specific efficacy for the successful discontinuation from BZs , even when controlling for therapist contact and relaxation training Better underst and ing of compliance with BZD taper is warranted . Compliance with a taper program and perceived self-efficacy ( SE ) in being able to comply with hypnotic reduction goals was monitored weekly in 52 older adults ( mean age : 63.0 years ) with chronic insomnia ( average duration : 21.9 years ) who underwent a 10-week physician-supervised medication tapering .  One group received cognitive- behavior therapy for insomnia during discontinuation , whereas the other did not . Compliant patients showed higher SE ratings at Weeks 6 , 8 , 9 , and 10 . Medication-free patients at the end of the treatment also reported higher mean SE ratings at those 4 weeks . Differences remained significant when withdrawal symptoms and sleep efficiency were controlled for . These results have important clinical implication s because SE may indicate key time points when patients are experiencing more difficulty during discontinuation BACKGROUND It is recommended that long-term users of benzodiazepines in general practice be withdrawn from their medication where possible . AIM A study was undertaken to assess the effectiveness of minimal intervention delivered by general practitioners in helping chronic users of benzodiazepines  to withdraw from their medication , and to determine the psychological sequelae on patients of such intervention . METHOD Patients taking benzodiazepines regularly for at least one year were recruited by their general practitioner and allocated either to a group receiving brief advice during one consultation supplemented by a self-help booklet or to a control group who received routine care . The patients completed the 12-item general health question naire and a benzodiazepine  withdrawal symptom question naire at the outset of the study and at three and six months after this . RESULTS Eighteen per cent of patients in the intervention group ( 9/50 ) had a reduction in benzodiazepine prescribing recorded in the notes compared with 5 % of the 55 patients in the control group ( P < 0.05 ) . In the intervention group , 63 % of patients had a score of two or more on the general health question naire at baseline compared with 52 % at six months . Of the 20 intervention patients reporting benzodiazepine reduction , 60 % had a score of two or more at baseline compared with 40 % at six months . Intervention patients had significantly more qualitative , but not quantitative , withdrawal symptoms at six months compared with baseline . Consultation rates were not increased in the intervention group . CONCLUSION The study indicates that some chronic users can successfully reduce their intake of benzodiazepines with simple advice from the general practitioner and a self-help booklet . This type of intervention does not lead to psychological distress or increased consultation BACKGROUND Benzodiazepine withdrawal programmes have never been experimentally compared with a nonintervention control condition . AIMS To evaluate the efficacy and feasibility of tapering off long-term benzodiazepine use in general practice , and to evaluate the value of additional group cognitive-behavioural therapy ( CBT ) . METHOD A 3-month r and omised , 3-month controlled trial was conducted in which 180 people attempting to discontinue long-term benzodiazepine use were assigned to tapering off plus group CBT , tapering off alone or usual care . RESULTS Tapering off led to a significantly higher proportion of successful discontinuations than usual care ( 62 % nu . 21 % ) . Adding group CBT did not increase the success rate ( 58 % v. 62 % ) . Neither successful discontinuation nor intervention type affected psychological functioning . Both tapering strategies showed good feasibilityin general practice . CONCLUSIONS Tapering off is a feasible and effective way of discontinuing long-term benzodiazepine use in general practice . The addition of group CBT is of limited value OBJECTIVE The primary disadvantage of high-potency benzodiazepine treatment for panic disorder is the difficulty of discontinuing the treatment . During treatment discontinuation , new symptoms may emerge and anxiety may return , preventing many patients from successfully discontinuing their treatment . In this controlled , r and omized trial the authors investigated the efficacy of a cognitive-behavioral program for patients with panic disorder who were attempting to discontinue treatment with high-potency benzodiazepines .  METHOD Out patients treated for panic disorder with alprazolam or clonazepam for a minimum of 6 months and expressing a desire to stop taking the medication ( N = 33 ) were r and omly assigned to one of two taper conditions : a slow taper condition alone or a slow taper condition in conjunction with 10 weeks of group cognitive-behavioral therapy . RESULTS The rate of successful discontinuation of benzodiazepine treatment was significantly higher for the patients receiving the cognitive-behavioral program ( 13 of 17 ; 76 % ) than for the patients receiving the slow taper program alone ( four of 16 ; 25 % ) . There was no difference in the likelihood of discontinuation success between the patients treated with alprazolam and those who received clonazepam . At the 3-month follow-up evaluation , 77 % of the patients in the cognitive-behavioral program who successfully discontinued benzodiazepine treatment remained benzodiazepine free . CONCLUSIONS These findings support the efficacy of cognitive-behavioral interventions in aiding benzodiazepine discontinuation for patients with panic disorder The Benzodiazepine Dependence Self-Report Question naire ( Bendep-SRQ ) measures the severity of  benzodiazepine ( BZ ) dependence on four domains : awareness of problematic use , preoccupation with the availability of BZ , lack of compliance with the therapeutic regimen , and withdrawal . Although promising results of the Bendep-SRQ have been obtained in cross-sectional studies , no attention has been paid to its clinical relevance during BZ withdrawal , i.e. , predictive validity and time course . We performed cross-validation and evaluated the predictive validity and time course on 180 long-term BZ users who were taking part in a general practice BZ discontinuation trial . Three of the four domains had good scalability . Some concerns arose about the preoccupation scale , which emphasizes the need for cross-validation in clinical ly relevant population s. All scales showed excellent reliability ( subject discriminability , item discriminability ) , while construct and discriminant validity were adequate . All four scales contributed significantly to the prediction of whether complete abstinence would be achieved directly after taking part in the discontinuation program . This prediction was independent of the other prognostic variables , except for those in the domain problematic use . The scales problematic use and preoccupation showed good sensitivity to changes during follow-up . The insensitivity of the scale , lack of compliance can be explained by low baseline scores in our population , while the insensitivity of the withdrawal scale was probably the result of the study design . In conclusion , our study indicated the clinical relevance of the Bendep-SRQ before and during a BZ discontinuation trial . We recommend the use of the Bendep-SRQ in discontinuation therapy and research into the field of BZ addiction OBJECTIVE This study evaluated the effectiveness of a supervised benzodiazepine taper , singly and combined with cognitive behavior therapy , for benzodiazepine discontinuation in older adults with chronic insomnia . METHOD Seventy-six older adult out patients ( 38 women , 38 men ; mean age of 62.5 years ) with chronic insomnia and prolonged use ( mean duration of 19.3 years ) of benzodiazepine medication for sleep were r and omly assigned for a 10-week intervention consisting of a supervised benzodiazepine withdrawal program ( N=25 ) , cognitive behavior therapy for insomnia ( N=24 ) , or supervised withdrawal plus cognitive behavior therapy ( N=27 ) . Follow-up assessment s were conducted at 3 and 12 months . The main outcome measures were  benzodiazepine use , sleep parameters , and anxiety and depressive symptoms . RESULTS All three interventions produced significant reductions in both the quantity ( 90 % reduction ) and frequency ( 80 % reduction ) of benzodiazepine use , and 63 % of the patients were drug-free within an average of 7 weeks . More patients who received medication taper plus cognitive behavior therapy ( 85 % ) were benzodiazepine-free after the initial intervention , compared to those who received medication taper alone ( 48 % ) and cognitive behavior therapy alone ( 54 % ) . The patients in the two groups that received cognitive behavior therapy perceived greater subjective sleep improvements than those who received medication taper alone . Polysomnographic data showed an increase in the amount of time spent in stages 3 and 4 sleep and REM sleep and a decrease in total sleep time across all three conditions from baseline to posttreatment . Initial benzodiazepine reductions were well maintained up to the 12-month follow-up , and sleep improvements became more noticeable over this period . No significant withdrawal symptoms or adverse events were associated with benzodiazepine tapering . CONCLUSIONS A structured , time-limited intervention is effective in assisting chronic users of benzodiazepine medication to discontinue or reduce their use of medication . The addition of cognitive behavior therapy alleviates insomnia , but sleep improvements may become noticeable only after several months of benzodiazepine abstinence Background Currently , far too many older adults consume inappropriate prescriptions , which increase the risk of adverse drug reactions and unnecessary hospitalizations . A health education program directly informing patients of prescription risks may promote inappropriate prescription discontinuation in chronic benzodiazepine users . Methods / Design This is a cluster r and omized controlled trial using a two-arm parallel- design . A total of 250 older chronic benzodiazepine users recruited from community pharmacies in the greater Montreal area will be studied with informed consent . A participating pharmacy with recruited participants represents a cluster , the unit of r and omization . For every four pharmacies recruited , a simple 2:2 r and omization is used to allocate clusters into intervention and control arms . Participants will be followed for 1 year . Within the intervention clusters , participants will receive a novel educational intervention detailing risks and safe alternatives to their current potentially inappropriate medication , while the control group will be wait-listed for the intervention for 6 months and receive usual care during that time period . The primary outcome is the rate of change in benzodiazepine use at 6 months . Secondary outcomes are changes in risk perception , self-efficacy for discontinuing benzodiazepines , and activation of patients initiating discussion s with their physician or pharmacist about safer prescribing practice s. An intention-to-treat analysis will be followed . The rate of change of benzodiazepine use will be compared between intervention and control groups at the individual level at the 6-month follow-up . Risk differences between the control and experimental groups will be calculated , and the robust variance estimator will be used to estimate the associated 95 % confidence interval ( CI ) . As a sensitivity analysis ( and /or if any confounders are unbalanced between the groups ) , we will estimate the risk difference for the intervention via a marginal model estimated via generalized estimating equations with an exchangeable correlation structure . Discussion Targeting consumers directly as catalysts for engaging physicians and pharmacists in collaborative discontinuation of benzodiazepine drugs is a novel approach to reduce inappropriate prescriptions . By directly empowering chronic users with knowledge about risks , we hope to imitate the success of individually targeted anti-smoking campaigns . Trial registration Clinical Trials.gov identifier : BACKGROUND Benzodiazepines are extensively used in primary care , but their long-term use is associated with adverse health outcomes and dependence . AIMS To analyse the efficacy of two structured interventions in primary care to enable patients to discontinue long-term benzodiazepine use . METHOD A multicentre three-arm cluster r and omised controlled trial was conducted , with r and omisation at general practitioner level ( trial registration IS RCT N13024375 ) . A total of 532 patients taking benzodiazepines for at least 6 months participated . After all patients were included , general practitioners were r and omly allocated ( 1:1:1 ) to usual care , a structured intervention with follow-up visits ( SIF ) or a structured intervention with written instructions ( SIW ) . The primary end-point was the last month self-declared benzodiazepine discontinuation confirmed by prescription cl aims at 12 months . RESULTS At 12 months , 76 of 168 ( 45 % ) patients in the SIW group and 86 of 191 ( 45 % ) in the SIF group had discontinued benzodiazepine use compared with 26 of 173 ( 15 % ) in the control group . After adjusting by cluster , the relative risks for benzodiazepine discontinuation were 3.01 ( 95 % CI 2.03 - 4.46 , P<0.0001 ) in the SIW and 3.00 ( 95 % CI 2.04 - 4.40 , P<0.0001 ) in the SIF group . The most frequently reported withdrawal symptoms were insomnia , anxiety and irritability . CONCLUSIONS Both interventions led to significant reductions in long-term benzodiazepine use in patients without severe comorbidity . A structured intervention with a written individualised stepped-dose reduction is less time-consuming and as effective in primary care as a more complex intervention involving follow-up visits INTRODUCTION The purpose of this guideline is to establish clinical practice recommendations for the pharmacologic treatment of chronic insomnia in adults , when such treatment is clinical ly indicated . Unlike previous meta-analyses , which focused on broad classes of drugs , this guideline focuses on individual drugs commonly used to treat insomnia . It includes drugs that are FDA -approved for the treatment of insomnia , as well as several drugs commonly used to treat insomnia without an FDA indication for this condition . This guideline should be used in conjunction with other AASM guidelines on the evaluation and treatment of chronic insomnia in adults . METHODS The American Academy of Sleep Medicine commissioned a task force of four experts in sleep medicine . A systematic review was conducted to identify r and omized controlled trials , and the Grading of Recommendations Assessment , Development , and Evaluation ( GRADE ) process was used to assess the evidence . The task force developed recommendations and assigned strengths based on the quality of evidence , the balance of benefits and harms , and patient values and preferences . Literature review s are provided for those pharmacologic agents for which sufficient evidence was available to establish recommendations . The AASM Board of Directors approved the final recommendations . RECOMMENDATIONS The following recommendations are intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment of chronic insomnia in adults , when such treatment is indicated . Under GRADE , a STRONG recommendation is one that clinicians should , under most circumstances , follow . A WEAK recommendation reflects a lower degree of certainty in the outcome and appropriateness of the patient-care strategy for all patients , but should not be construed as an indication of ineffectiveness . GRADE recommendation strengths do not refer to the magnitude of treatment effects in a particular patient , but rather , to the strength of evidence in published data . Downgrading the quality of evidence for these treatments is predictable in GRADE , due to the funding source for most pharmacological clinical trials and the attendant risk of publication bias ; the relatively small number of eligible trials for each individual agent ; and the observed heterogeneity in the data . The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient , available diagnostic tools , accessible treatment options , and re sources . We suggest that clinicians use suvorexant as a treatment for sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use zaleplon as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use zolpidem as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use triazolam as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use temazepam as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use ramelteon as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use doxepin as a treatment for sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use trazodone as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use tiagabine as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  diphenhydramine  as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  melatonin  as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use tryptophan as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  valerian  as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) AIM This study set out to assess the effect of a letter from the general practitioner , suggesting a reduction in the use of benzodiazepines , and whether the impact of the letter could be increased by the addition of information on how to tackle drug reduction . METHOD Two hundred and nine long-term users of benzodiazepines in general practice were divided into three groups : two intervention groups and a control group . The first intervention group received a letter from their general practitioner asking that benzodiazepine use be gradually reduced and perhaps , in time , stopped . The second intervention group received the same letter plus four information sheets at monthly intervals , design ed to assist drug reduction : The mean age of the 209 people was 69 years ( age range 34 - 102 years ) . RESULTS After six months , both intervention groups had reduced their consumption to approximately two thirds of the original intake of benzodiazepines and there was a statistically significant difference between the intervention groups and the control group . Eighteen per cent of those receiving the interventions received no prescriptions at all during the six month monitoring period . CONCLUSION The results indicate that a simple intervention can have a considerable effect on the use of hypnotic and anxiolytic drugs , even with a sample of elderly users IMPORTANCE The American Board of Internal Medicine Foundation Choosing Wisely Campaign recommends against the use of benzodiazepine drugs for adults 65 years and older . The effect of direct patient education to catalyze collaborative care for reducing inappropriate prescriptions remains unknown . OBJECTIVE To compare the effect of a direct-to-consumer educational intervention against usual care on benzodiazepine therapy discontinuation in community-dwelling older adults . DESIGN , SETTING , AND PARTICIPANTS Cluster r and omized trial ( EMPOWER [ Eliminating Medications Through Patient Ownership of End Results ] study [ 2010 - 2012 , 6-month follow-up ] ) . Community pharmacies were r and omly allocated to the intervention or control arm in nonstratified , blocked groups of 4 . Participants ( 303 long-term users of benzodiazepine medication aged 65 - 95 years , recruited from 30 community pharmacies ) were screened and enrolled prior to r and omization : 15 pharmacies r and omized to the educational intervention included 148 participants and 15 pharmacies r and omized to the " wait list " control included 155 participants . Participants , physicians , pharmacists , and evaluators were blinded to outcome assessment . INTERVENTIONS The active arm received a deprescribing patient empowerment intervention describing the risks of benzodiazepine use and a stepwise tapering protocol . The control arm received usual care . MAIN OUTCOMES AND MEASURES Benzodiazepine therapy discontinuation at 6 months after r and omization , ascertained by pharmacy medication renewal profiles . RESULTS A total of 261 participants ( 86 % ) completed the 6-month follow-up . Of the recipients in the intervention group , 62 % initiated conversation about benzodiazepine therapy cessation with a physician and /or pharmacist . At 6 months , 27 % of the intervention group had discontinued benzodiazepine use compared with 5 % of the control group ( risk difference , 23 % [ 95 % CI , 14%-32 % ] ; intracluster correlation , 0.008 ; number needed to treat , 4 ) . Dose reduction occurred in an additional 11 % ( 95 % CI , 6%-16 % ) . In multivariate subanalyses , age greater than 80 years , sex , duration of use , indication for use , dose , previous attempt to taper , and concomitant polypharmacy ( 10 drugs or more per day ) did not have a significant interaction effect with benzodiazepine therapy discontinuation . CONCLUSIONS AND RELEVANCE Direct-to-consumer education effectively elicits shared decision making around the overuse of medications that increase the risk of harm in older adults . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01148186 AIMS To evaluate whether gradual benzodiazepine taper combined with cognitive-behavioural treatment is more effective than st and ard treatment for patients with dependence in out-patient clinics . DESIGN A r and omized , controlled clinical trial , using st and ard question naires and serum and urine tests . SETTING S Four public-sector out-patient clinics for alcohol and drug abusers in Helsinki . PARTICIPANTS Seventy-six patients with benzodiazepine dependence ( DSM-III-R ) . Patients taking high doses of the drug or with alcohol use disorders were included to obtain a subject group representative of usual clinical practice . INTERVENTION Subjects received gradual benzodiazepine taper combined with cognitive-behavioural therapy ( experimental group ) or st and ard withdrawal treatment not scheduled by the research ers ( control group ) . MEASUREMENTS The outcome was measured in terms of attaining a state of abstinence or by a decrease in the dosage during the study period of up to 12 months ' duration . FINDINGS No statistically significant differences in the outcomes were observed between the groups . A total of 13 % of the experimental group and 27 % of the control group were able to discontinue drug use . In addition 67 % of the experimental group and 57 % of the control group were able to decrease the dose . CONCLUSIONS The search continues for improved methods of helping patients with complicated benzodiazepine dependence BACKGROUND The long-term use of benzodiazepines is highly prevalent in developed societies and is not devoid of risks . Withdrawing patients from these drugs is often difficult . Tapering off benzodiazepines has been shown to be a good strategy for discontinuing their long-term use . AIM To establish the efficacy of an intervention programme for reducing the chronic use of benzodiazepines . DESIGN OF STUDY R and omised , two-arm , parallel , non-blinded controlled trial . SETTING Three urban healthcare centres covering a population of 50,000 inhabitants ( Mallorca , Spain ) . METHOD Adult patients ( n = 139 ) taking benzodiazepines daily for more than a year and visited by their family physician were r and omised into an intervention group ( n = 73 ) that received st and ardised advice and a tapering off schedule with biweekly follow-up visits , or into a control group ( n = 66 ) , that was managed following routine clinical practice . Both were followed for a year . RESULTS Patients achieved withdrawal or reduced their dose by at least 50 % after 6 and 12 months . Abstinence and withdrawal symptoms were also measured . Both groups were homogeneous for personal , clinical and psychological characteristics and for benzodiazepine use . Only two patients from each group were lost to follow-up . After 12 months , 33 ( 45.2 % ) patients in the intervention group and six ( 9.1 % ) in the control group had discontinued benzodiazepine use ; relative risk = 4.97 ( 95 % confidence interval [ CI ] = 2.2 to 11.1 ) , absolute risk reduction = 0.36 ( 95 % CI = 0.22 to 0.50 ) . For every three interventions , one patient achieved withdrawal . Sixteen ( 21.9 % ) subjects from the intervention group and 11 ( 16.7 % ) controls reduced their initial dose by more than 50 % . CONCLUSION St and ardised advice given by the family physician , together with a tapering off schedule , is effective for withdrawing patients from long-term benzodiazepine use and is feasible in primary care OBJECTIVE This study investigated the effects of general practitioner , patient , and prescription characteristics on the reduction of long-term benzodiazepine prescribing by sending a letter to chronic users . The data were analyzed with a method respecting the hierarchical data structure . STUDY DESIGN AND SETTING Data were obtained from 8,170 chronic users nested in 147 general practice s. One thous and two hundred fifty-six chronic users in 19 general practice s received a letter with the advice to reduce or stop the use of benzodiazepines after the general practitioners had attended a course on benzodiazepine use . In a three-level r and om intercept multilevel regression model , long-term prescribing of benzodiazepines was the dependent variable . RESULTS The reduction in benzodiazepine prescribing was significantly larger in the intervention than in the control group : 16 % after 6 months and 14 % after 12 months , respectively . The age of the patient , gender , and the interaction between age and gender were significant . The combination of the duration ( long acting or short acting ) with the type of benzodiazepine ( anxiolytic or hypnotic ) was an important pharmacological baseline covariate . CONCLUSIONS The reduction of benzodiazepine prescribing was mainly explained by the letter intervention and individual patient characteristics . Multilevel analysis was a worthwhile method for application in this study with its unbalanced design
This guideline does not apply to those with other sleep disorders or untreated anxiety , depression , or other physical or mental health conditions that might be causing or aggravating insomnia .
Benzodiazepine receptor agonists are associated with harms , and therapeutic effects might be short term .
Tapering BZRAs improves cessation rates compared with usual care without serious harms .
Patients might be more amenable to deprescribing conversations if they underst and the rationale ( potential for harm ) , are involved in developing the tapering plan , and are offered behavioural advice .
OBJECTIVE To develop an evidence -based guideline to help clinicians make decisions about when and how to safely taper and stop benzodiazepine receptor agonists ( BZRAs ) ; to focus on the highest level of evidence available and seek input from primary care professionals in the guideline development , review , and endorsement processes .