Patient overusing antianxiety meds? Say so (in a letter)

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 of the benzodiazepine 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 (defined as regular use for >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 of 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 are often 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 using it.

Three studies met the inclusion criteria for randomization, blinding, and analysis by intention-to-treat.^7-9 All 3 (n=615) had a 6-month follow-up period, a higher proportion of women (>60%), and participants with a mean age >60 years. Few patients were lost to follow-up; withdrawal rates were low and similar in all 3 studies. Each study compared a letter with usual care; 2 of the 3 had a third arm that included both a letter and a short consultation.

Pooled results from the studies showed twice the reduction in benzodiazepine use in the intervention groups compared with the control groups (risk ratio [RR]=2.04; 95% confidence interval [CI], 1.5-2.8; P< .001). The RR for cessation of benzodiazepine use was 2.3 (95% CI, 1.3-4.2; P= .003). 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 vs 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?: This strategy is easy to implement

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: Effects of withdrawal went 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 6 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 physicians screen for substance abuse prior to the intervention and arrange for adequate follow-up.

All 3 studies in the meta-analysis lasted 6 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: Determining 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.

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.

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 of the benzodiazepine 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 (defined as regular use for >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 of 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 are often 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 using it.

Three studies met the inclusion criteria for randomization, blinding, and analysis by intention-to-treat.^7-9 All 3 (n=615) had a 6-month follow-up period, a higher proportion of women (>60%), and participants with a mean age >60 years. Few patients were lost to follow-up; withdrawal rates were low and similar in all 3 studies. Each study compared a letter with usual care; 2 of the 3 had a third arm that included both a letter and a short consultation.

Pooled results from the studies showed twice the reduction in benzodiazepine use in the intervention groups compared with the control groups (risk ratio [RR]=2.04; 95% confidence interval [CI], 1.5-2.8; P< .001). The RR for cessation of benzodiazepine use was 2.3 (95% CI, 1.3-4.2; P= .003). 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 vs 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?: This strategy is easy to implement

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: Effects of withdrawal went 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 6 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 physicians screen for substance abuse prior to the intervention and arrange for adequate follow-up.

All 3 studies in the meta-analysis lasted 6 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: Determining 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.

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.

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 of the benzodiazepine 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 (defined as regular use for >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 of 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 are often 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 using it.

Three studies met the inclusion criteria for randomization, blinding, and analysis by intention-to-treat.^7-9 All 3 (n=615) had a 6-month follow-up period, a higher proportion of women (>60%), and participants with a mean age >60 years. Few patients were lost to follow-up; withdrawal rates were low and similar in all 3 studies. Each study compared a letter with usual care; 2 of the 3 had a third arm that included both a letter and a short consultation.

Pooled results from the studies showed twice the reduction in benzodiazepine use in the intervention groups compared with the control groups (risk ratio [RR]=2.04; 95% confidence interval [CI], 1.5-2.8; P< .001). The RR for cessation of benzodiazepine use was 2.3 (95% CI, 1.3-4.2; P= .003). 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 vs 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?: This strategy is easy to implement

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: Effects of withdrawal went 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 6 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 physicians screen for substance abuse prior to the intervention and arrange for adequate follow-up.

All 3 studies in the meta-analysis lasted 6 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: Determining 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.

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.