Shailendra Prasad, MBBS, MPH, MD

Practice Changer
Express your concern about long-term use of benzodiazepines in a letter—a simple intervention that patients often respond to.¹

Strength of recommendation
A: Based on a well-done meta-analysis with few clinical trials.

Illustrative Case
A 65-year-old patient has been taking lorazepam for insomnia for more than a year. You are concerned about her ongoing use and want to wean her from the medication. What strategies can you use to decrease, or eliminate, her use of the drug?

Benzodiazepines are commonly used medications, with an estimated 12-month prevalence of use of 8.6% in the United States.² While short-term use of these antianxiety medications can be effective, long-term use (> 3 months) is associated with significant risk.

Abuse linked to chronic use
Prescription drug abuse has recently become the nation’s leading cause of accidental death, overtaking motor vehicle accidents.³ And tranquilizers, including benzodiazepines, are the second most abused prescription medication, after pain relievers.⁴ In addition to dependence and withdrawal, chronic use of benzodiazepines is associated with daytime somnolence, blunted reflexes, memory loss, cognitive impairment, and an increased risk for falls and fractures—particularly in older patients.⁵
Reducing long-term use of benzodiazepines in a primary care setting is important but challenging. Until recently, most of the successful strategies reported were resource intensive and required multiple office visits.⁶

STUDY SUMMARY
Brief interventions effective
This study was a meta-analysis of randomized controlled trials in which “minimal interventions” were compared with usual care for their effectiveness in reducing or eliminating benzodiazepine use in primary care patients. A minimal intervention was defined as a letter, self-help information, or short consultation with a primary care provider. In each case, the message to the patient included (a) an expression of concern about the patient’s long-term use of the medication, (b) information about the potential adverse effects of the medication, and (c) advice on how to gradually reduce or stop use.

Three studies met the inclusion criteria for randomization, blinding, and analysis by intention-to-treat.^7-9 All three (n = 615) had a six-month follow-up period, a higher proportion of women (> 60%), and participants with a mean age > 60. Each study compared a letter with usual care; two of the three had a third arm that included both a letter and a short consultation.

Pooled results showed twice the reduction in benzodiazepine use in the intervention groups compared with the control groups (risk ratio [RR] = 2.04). The RR for cessation of benzodiazepine use was 2.3. The number needed to treat for a reduction or cessation of use was 12. The studies reported benzodiazepine reduction rates of 20% to 35% in the intervention groups versus 6% to 15% in the usual care groups.^7-9 There appeared to be no additional benefit to adding the brief consultation compared with the letter alone.

WHAT’S NEW
Easy-to-implement strategy
While many methods to reduce benzodiazepine use have been studied, most involved levels of skill and resources that are not feasible for widespread use. This study found that a letter, stating the risks of continued use of the medication and providing a weaning schedule and tips for handling withdrawal, can be effective in reducing chronic use in a small but significant part of the population.

CAVEATS
Withdrawal effects unaddressed
The study did not adequately address the adverse effects of withdrawal from benzodiazepines, with one of the studies reporting significantly worse qualitative (but not quantitative) withdrawal symptoms at six months.7 This is of particular concern, as withdrawal symptoms are associated with the potential for relapse and concomitant abuse of other drugs and alcohol. We recommend that primary care clinicians screen for substance abuse prior to the intervention and arrange for adequate follow-up.

All three studies in the meta-analysis lasted six months; no longer-term outcomes were reported. In addition, the study did not yield enough information to identify patients who would be most likely to respond to this brief intervention.

CHALLENGES TO

IMPLEMENTATION
Which patients to target?
Identifying patients who are appropriate candidates for this brief intervention and providing adequate monitoring for adverse effects of withdrawal are the main challenges of this practice changer. Nonetheless, chronic benzodiazepine use is of considerable concern, and we believe that this is a useful, and manageable, intervention.

REFERENCES
1. Mugunthan K, McGuire T, Glasziou P. Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis. Br J Gen Pract. 2011;61:e573-e578.
2. Tyrer PJ. Benzodiazepines on trial. Br Med J. 1984;288:1101-1102.
3. CDC. Deaths: Leading causes for 2008. June 6, 2012. www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_06.pdf. Accessed October 10, 2012.
4. National Institute on Drug Abuse. Topics in brief: Prescription drug abuse. www.drugabuse.gov/publications/topics-in-brief/prescription-drug-abuse. Accessed October 11, 2012.
5. Morin CM, Bastien C, Guay B, et al. Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. Am J Psychiatry. 2004;161:332-342.
6. Oude Voshaar RC, Couvee JE, van Balkorn AJ, et al. Strategies for discontinuing long-term benzodiazepine use: a meta-analysis. Br J Psychiatr. 2006;189: 213-220.
7. Bashir K, King M, Ashworth M. Controlled evaluation of brief intervention by general practitioners to reduce chronic use of benzodiazepines. Br J Gen Pract. 1994;44:408-412.
8. Cormack MA, Sweeney KG, Hughes-Jones H, et al. Evaluation of an easy, cost-effective strategy to cut benzodiazepine use in general practice. Br J Gen Pract. 1994;44:5-8
9. Heather NA, Bowie A, Ashton H, et al. Randomized controlled trial of two brief interventions against long-term benzodiazepine use: outcome of intervention. Addict Res Theory. 2004;12:141-145.

ACKNOWLEDGEMENT
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
Copyright © 2012. The Family Physicians Inquiries Network. All rights reserved.
Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice. 2012;61(11):671-672.

Practice Changer
Express your concern about long-term use of benzodiazepines in a letter—a simple intervention that patients often respond to.¹

Strength of recommendation
A: Based on a well-done meta-analysis with few clinical trials.

Illustrative Case
A 65-year-old patient has been taking lorazepam for insomnia for more than a year. You are concerned about her ongoing use and want to wean her from the medication. What strategies can you use to decrease, or eliminate, her use of the drug?

Benzodiazepines are commonly used medications, with an estimated 12-month prevalence of use of 8.6% in the United States.² While short-term use of these antianxiety medications can be effective, long-term use (> 3 months) is associated with significant risk.

Abuse linked to chronic use
Prescription drug abuse has recently become the nation’s leading cause of accidental death, overtaking motor vehicle accidents.³ And tranquilizers, including benzodiazepines, are the second most abused prescription medication, after pain relievers.⁴ In addition to dependence and withdrawal, chronic use of benzodiazepines is associated with daytime somnolence, blunted reflexes, memory loss, cognitive impairment, and an increased risk for falls and fractures—particularly in older patients.⁵
Reducing long-term use of benzodiazepines in a primary care setting is important but challenging. Until recently, most of the successful strategies reported were resource intensive and required multiple office visits.⁶

STUDY SUMMARY
Brief interventions effective
This study was a meta-analysis of randomized controlled trials in which “minimal interventions” were compared with usual care for their effectiveness in reducing or eliminating benzodiazepine use in primary care patients. A minimal intervention was defined as a letter, self-help information, or short consultation with a primary care provider. In each case, the message to the patient included (a) an expression of concern about the patient’s long-term use of the medication, (b) information about the potential adverse effects of the medication, and (c) advice on how to gradually reduce or stop use.

Three studies met the inclusion criteria for randomization, blinding, and analysis by intention-to-treat.^7-9 All three (n = 615) had a six-month follow-up period, a higher proportion of women (> 60%), and participants with a mean age > 60. Each study compared a letter with usual care; two of the three had a third arm that included both a letter and a short consultation.

Pooled results showed twice the reduction in benzodiazepine use in the intervention groups compared with the control groups (risk ratio [RR] = 2.04). The RR for cessation of benzodiazepine use was 2.3. The number needed to treat for a reduction or cessation of use was 12. The studies reported benzodiazepine reduction rates of 20% to 35% in the intervention groups versus 6% to 15% in the usual care groups.^7-9 There appeared to be no additional benefit to adding the brief consultation compared with the letter alone.

WHAT’S NEW
Easy-to-implement strategy
While many methods to reduce benzodiazepine use have been studied, most involved levels of skill and resources that are not feasible for widespread use. This study found that a letter, stating the risks of continued use of the medication and providing a weaning schedule and tips for handling withdrawal, can be effective in reducing chronic use in a small but significant part of the population.

CAVEATS
Withdrawal effects unaddressed
The study did not adequately address the adverse effects of withdrawal from benzodiazepines, with one of the studies reporting significantly worse qualitative (but not quantitative) withdrawal symptoms at six months.7 This is of particular concern, as withdrawal symptoms are associated with the potential for relapse and concomitant abuse of other drugs and alcohol. We recommend that primary care clinicians screen for substance abuse prior to the intervention and arrange for adequate follow-up.

All three studies in the meta-analysis lasted six months; no longer-term outcomes were reported. In addition, the study did not yield enough information to identify patients who would be most likely to respond to this brief intervention.

CHALLENGES TO

IMPLEMENTATION
Which patients to target?
Identifying patients who are appropriate candidates for this brief intervention and providing adequate monitoring for adverse effects of withdrawal are the main challenges of this practice changer. Nonetheless, chronic benzodiazepine use is of considerable concern, and we believe that this is a useful, and manageable, intervention.

REFERENCES
1. Mugunthan K, McGuire T, Glasziou P. Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis. Br J Gen Pract. 2011;61:e573-e578.
2. Tyrer PJ. Benzodiazepines on trial. Br Med J. 1984;288:1101-1102.
3. CDC. Deaths: Leading causes for 2008. June 6, 2012. www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_06.pdf. Accessed October 10, 2012.
4. National Institute on Drug Abuse. Topics in brief: Prescription drug abuse. www.drugabuse.gov/publications/topics-in-brief/prescription-drug-abuse. Accessed October 11, 2012.
5. Morin CM, Bastien C, Guay B, et al. Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. Am J Psychiatry. 2004;161:332-342.
6. Oude Voshaar RC, Couvee JE, van Balkorn AJ, et al. Strategies for discontinuing long-term benzodiazepine use: a meta-analysis. Br J Psychiatr. 2006;189: 213-220.
7. Bashir K, King M, Ashworth M. Controlled evaluation of brief intervention by general practitioners to reduce chronic use of benzodiazepines. Br J Gen Pract. 1994;44:408-412.
8. Cormack MA, Sweeney KG, Hughes-Jones H, et al. Evaluation of an easy, cost-effective strategy to cut benzodiazepine use in general practice. Br J Gen Pract. 1994;44:5-8
9. Heather NA, Bowie A, Ashton H, et al. Randomized controlled trial of two brief interventions against long-term benzodiazepine use: outcome of intervention. Addict Res Theory. 2004;12:141-145.

ACKNOWLEDGEMENT
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
Copyright © 2012. The Family Physicians Inquiries Network. All rights reserved.
Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice. 2012;61(11):671-672.

Practice Changer
Express your concern about long-term use of benzodiazepines in a letter—a simple intervention that patients often respond to.¹

Strength of recommendation
A: Based on a well-done meta-analysis with few clinical trials.

Illustrative Case
A 65-year-old patient has been taking lorazepam for insomnia for more than a year. You are concerned about her ongoing use and want to wean her from the medication. What strategies can you use to decrease, or eliminate, her use of the drug?

Benzodiazepines are commonly used medications, with an estimated 12-month prevalence of use of 8.6% in the United States.² While short-term use of these antianxiety medications can be effective, long-term use (> 3 months) is associated with significant risk.

Abuse linked to chronic use
Prescription drug abuse has recently become the nation’s leading cause of accidental death, overtaking motor vehicle accidents.³ And tranquilizers, including benzodiazepines, are the second most abused prescription medication, after pain relievers.⁴ In addition to dependence and withdrawal, chronic use of benzodiazepines is associated with daytime somnolence, blunted reflexes, memory loss, cognitive impairment, and an increased risk for falls and fractures—particularly in older patients.⁵
Reducing long-term use of benzodiazepines in a primary care setting is important but challenging. Until recently, most of the successful strategies reported were resource intensive and required multiple office visits.⁶

STUDY SUMMARY
Brief interventions effective
This study was a meta-analysis of randomized controlled trials in which “minimal interventions” were compared with usual care for their effectiveness in reducing or eliminating benzodiazepine use in primary care patients. A minimal intervention was defined as a letter, self-help information, or short consultation with a primary care provider. In each case, the message to the patient included (a) an expression of concern about the patient’s long-term use of the medication, (b) information about the potential adverse effects of the medication, and (c) advice on how to gradually reduce or stop use.

Three studies met the inclusion criteria for randomization, blinding, and analysis by intention-to-treat.^7-9 All three (n = 615) had a six-month follow-up period, a higher proportion of women (> 60%), and participants with a mean age > 60. Each study compared a letter with usual care; two of the three had a third arm that included both a letter and a short consultation.

Pooled results showed twice the reduction in benzodiazepine use in the intervention groups compared with the control groups (risk ratio [RR] = 2.04). The RR for cessation of benzodiazepine use was 2.3. The number needed to treat for a reduction or cessation of use was 12. The studies reported benzodiazepine reduction rates of 20% to 35% in the intervention groups versus 6% to 15% in the usual care groups.^7-9 There appeared to be no additional benefit to adding the brief consultation compared with the letter alone.

WHAT’S NEW
Easy-to-implement strategy
While many methods to reduce benzodiazepine use have been studied, most involved levels of skill and resources that are not feasible for widespread use. This study found that a letter, stating the risks of continued use of the medication and providing a weaning schedule and tips for handling withdrawal, can be effective in reducing chronic use in a small but significant part of the population.

CAVEATS
Withdrawal effects unaddressed
The study did not adequately address the adverse effects of withdrawal from benzodiazepines, with one of the studies reporting significantly worse qualitative (but not quantitative) withdrawal symptoms at six months.7 This is of particular concern, as withdrawal symptoms are associated with the potential for relapse and concomitant abuse of other drugs and alcohol. We recommend that primary care clinicians screen for substance abuse prior to the intervention and arrange for adequate follow-up.

All three studies in the meta-analysis lasted six months; no longer-term outcomes were reported. In addition, the study did not yield enough information to identify patients who would be most likely to respond to this brief intervention.

CHALLENGES TO

IMPLEMENTATION
Which patients to target?
Identifying patients who are appropriate candidates for this brief intervention and providing adequate monitoring for adverse effects of withdrawal are the main challenges of this practice changer. Nonetheless, chronic benzodiazepine use is of considerable concern, and we believe that this is a useful, and manageable, intervention.

REFERENCES
1. Mugunthan K, McGuire T, Glasziou P. Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis. Br J Gen Pract. 2011;61:e573-e578.
2. Tyrer PJ. Benzodiazepines on trial. Br Med J. 1984;288:1101-1102.
3. CDC. Deaths: Leading causes for 2008. June 6, 2012. www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_06.pdf. Accessed October 10, 2012.
4. National Institute on Drug Abuse. Topics in brief: Prescription drug abuse. www.drugabuse.gov/publications/topics-in-brief/prescription-drug-abuse. Accessed October 11, 2012.
5. Morin CM, Bastien C, Guay B, et al. Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. Am J Psychiatry. 2004;161:332-342.
6. Oude Voshaar RC, Couvee JE, van Balkorn AJ, et al. Strategies for discontinuing long-term benzodiazepine use: a meta-analysis. Br J Psychiatr. 2006;189: 213-220.
7. Bashir K, King M, Ashworth M. Controlled evaluation of brief intervention by general practitioners to reduce chronic use of benzodiazepines. Br J Gen Pract. 1994;44:408-412.
8. Cormack MA, Sweeney KG, Hughes-Jones H, et al. Evaluation of an easy, cost-effective strategy to cut benzodiazepine use in general practice. Br J Gen Pract. 1994;44:5-8
9. Heather NA, Bowie A, Ashton H, et al. Randomized controlled trial of two brief interventions against long-term benzodiazepine use: outcome of intervention. Addict Res Theory. 2004;12:141-145.

ACKNOWLEDGEMENT
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
Copyright © 2012. The Family Physicians Inquiries Network. All rights reserved.
Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice. 2012;61(11):671-672.