Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review

BMC Pharmacology and Toxicology, Jul 2015

Background Long-term sedative use is prevalent and associated with significant morbidity, including adverse events such as falls, cognitive impairment, and sedation. The development of dependence can pose significant challenges when discontinuation is attempted as withdrawal symptoms often develop. We conducted a scoping review to map and characterize the literature and determine opportunities for future research regarding deprescribing strategies for long-term benzodiazepine and Z-drug (zopiclone, zolpidem, and zaleplon) use in community-dwelling adults. Methods We searched PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, CINAHL, TRIP, and JBI Ovid databases and conducted a grey literature search. Articles discussing methods for deprescribing benzodiazepines or Z-drugs in community-dwelling adults were selected. Results Following removal of duplicates, 2797 articles were reviewed for eligibility. Of these, 367 were retrieved for full-text assessment and 139 were subsequently included for review. Seventy-four (53 %) articles were original research, predominantly randomized controlled trials (n = 52 [37 %]), whereas 58 (42 %) were narrative reviews and seven (5 %) were guidelines. Amongst original studies, pharmacologic strategies were the most commonly studied intervention (n = 42 [57 %]). Additional deprescribing strategies included psychological therapies (n = 10 [14 %]), mixed interventions (n = 12 [16 %]), and others (n = 10 [14 %]). Behaviour change interventions were commonly combined and included enablement (n = 56 [76 %]), education (n = 36 [47 %]), and training (n = 29 [39 %]). Gradual dose reduction was frequently a component of studies, reviews, and guidelines, but methods varied widely. Conclusions Approaches proposed for deprescribing benzodiazepines and Z-drugs are numerous and heterogeneous. Current research in this area using methods such as randomized trials and meta-analyses may too narrowly encompass potential strategies available to target this phenomenon. Realist synthesis methods would be well suited to understand the mechanisms by which deprescribing interventions work and why they fail.

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Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review

Pollmann et al. BMC Pharmacology and Toxicology Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review André S. Pollmann 1 Andrea L. Murphy 3 Joel C. Bergman 3 David M. Gardner 2 0 259, 5849 University Avenue , Room C-125, PO Box 15000, Halifax, NS B3H 4R2 , Canada 1 Faculty of Medicine, Dalhousie University , Mail Box 2 Department of Psychiatry and College of Pharmacy, Dalhousie University , QEII HSC, AJLB 7517, 5909 Veterans' Memorial Lane, Halifax, NS B3H 2E2 , Canada 3 College of Pharmacy and Department of Psychiatry, Dalhousie University , 5968 College St, PO Box 15000, Halifax, NS B3H 4R2 , Canada Background: Long-term sedative use is prevalent and associated with significant morbidity, including adverse events such as falls, cognitive impairment, and sedation. The development of dependence can pose significant challenges when discontinuation is attempted as withdrawal symptoms often develop. We conducted a scoping review to map and characterize the literature and determine opportunities for future research regarding deprescribing strategies for long-term benzodiazepine and Z-drug (zopiclone, zolpidem, and zaleplon) use in community-dwelling adults. Methods: We searched PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, CINAHL, TRIP, and JBI Ovid databases and conducted a grey literature search. Articles discussing methods for deprescribing benzodiazepines or Z-drugs in community-dwelling adults were selected. Results: Following removal of duplicates, 2797 articles were reviewed for eligibility. Of these, 367 were retrieved for full-text assessment and 139 were subsequently included for review. Seventy-four (53 %) articles were original research, predominantly randomized controlled trials (n = 52 [37 %]), whereas 58 (42 %) were narrative reviews and seven (5 %) were guidelines. Amongst original studies, pharmacologic strategies were the most commonly studied intervention (n = 42 [57 %]). Additional deprescribing strategies included psychological therapies (n = 10 [14 %]), mixed interventions (n = 12 [16 %]), and others (n = 10 [14 %]). Behaviour change interventions were commonly combined and included enablement (n = 56 [76 %]), education (n = 36 [47 %]), and training (n = 29 [39 %]). Gradual dose reduction was frequently a component of studies, reviews, and guidelines, but methods varied widely. Conclusions: Approaches proposed for deprescribing benzodiazepines and Z-drugs are numerous and heterogeneous. Current research in this area using methods such as randomized trials and meta-analyses may too narrowly encompass potential strategies available to target this phenomenon. Realist synthesis methods would be well suited to understand the mechanisms by which deprescribing interventions work and why they fail. Benzodiazepines; Z-drugs; Deprescribing; Clinical pharmacology; Behaviour change wheel; Scoping review - Background Benzodiazepines and similar sedative hypnotics, including zopiclone, zaleplon, and zolpidem (“Z-drugs”), are extensively prescribed medications in the community setting [1–7]. The annual incidence of long-term benzodiazepine use across North America and Europe is estimated to be between 0.4 % to 6 %, with higher rates of chronic use in patients older than 65 years [5, 8–10]. The prevalence of benzodiazepine use in adults aged 18 to 64 years has remained relatively stable over the past decade, suggesting potential issues with long-term use beyond what is normally indicated [3, 5, 11]. Recent data from Canada suggest important changes in prescribing practices. New prescriptions for benzodiazepines are declining, especially in older adults, while Z-drug use has steadily increased [5]. These trends mirror similar findings from other international studies [8, 12–18]. While indicated only for short-term management of anxiety and insomnia, reasons for acute benzodiazepine and Z-drug therapy transforming into chronic use are complex. Several prescriber related factors are believed to influence this process. These factors may include the prescriber’s attitudes toward these medications and toward the ‘deserving’ patient, deficits in specialized knowledge about sedative prescribing, the clinical work environment, conflicting patient health priorities, and the prescribing practices of others involved in the patient’s care [19, 20]. The perceived or real inaccessibility to alternative treatment modalities may further encourage the renewal of benzodiazepine and Z-drug prescriptions in favor of initiating other interventions that are perceived as less effective [21]. Patient factors including disagreement with appropriateness of cessation, fears of symptom return, withdrawal experiences, and the impression of unsuitability of alternatives also act to promote continued use [22, 23]. Considering the highly varied contributing factors that lead to long-term benzodiazepine and Z-drug use, deprescribing strategies need to be flexible and (...truncated)


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André Pollmann, Andrea Murphy, Joel Bergman, David Gardner. Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review, BMC Pharmacology and Toxicology, 2015, pp. 19, 16, DOI: 10.1186/s40360-015-0019-8