Systemic model of chronic benzodiazepine use among mature adults

Long-term effects of benzodiazepine discontinuation among older adults: potential improvements on depressive symptoms

OBJECTIVES

To examine how change in benzodiazepine (BZD) use is linked to changes in depressive symptoms intensity, worry intensity, and sleep quality over 16 months.

METHOD

Data come from a larger randomised controlled trial (RCT) named the 'Programme d'Aide du Succès au SEvrage (PASSE-60+)' study (NCT02281175). Seventy-three participants age 60 years and older took part in a 4-month discontinuation programme and were assessed four times over 16 months. Change in BZD use was defined as the difference in reported mg/day between two assessments. Control variables were RCT discontinuation group; BZD use at T1; and either depressive symptoms, worry intensity, or sleep quality at T1. Hierarchical multiple regressions were used to analyse data.

RESULTS

In the short term, right after the discontinuation programme, sleep quality worsened with lower BZD use. This link was no longer significant at the 3- and 12-month follow-up. In the long term, depressive symptoms lowered with lower BZD use. No change was found in worry intensity in relation to BZD use at all measurement times.

CONCLUSION

Discontinuation may improve depressive symptoms. Our study also questions the long-term effectiveness of BZD use, since long-term discontinuation was not linked with change in worry intensity and sleep quality.

Benzodiazepine Utilization in Ischemic Stroke Survivors: Analyzing Initial Excess Supply and Longitudinal Trends

BACKGROUND

Benzodiazepines are commonly prescribed for post-acute ischemic stroke for anxiety, insomnia, and agitation. While guidelines discourage use in those aged ≥65 years, little is known about prescription patterns at the national level.

METHODS

We analyzed a 20% sample of US Medicare claims from April 1, 2013, to September 30, 2021. We selected beneficiaries aged ≥65 years discharged alive following an acute ischemic stroke who had traditional Medicare coverage and 6 months' prior enrollment in Parts A (hospital insurance), B (Medical insurance), and D (drug coverage). We excluded those with prior benzodiazepine prescriptions, self-discharges, or discharge to skilled nursing facilities. We examined demographics, comorbidities, first prescription days' supply, cumulative incidences of benzodiazepine first prescription fills within 90 days after discharge, and geographic and yearly trends.

RESULTS

We included 126 050 beneficiaries with a mean age of 78 years (SD, 8); 54% were female and 82% were White. Within 90 days, 6127 (4.9%) initiated a benzodiazepine. Among new prescriptions, lorazepam (40%) and alprazolam (33%) were the most prescribed. Most (76%) of first fills had a day's supply over 7 days and 55% between 15 and 30 days. Female initiation rates were higher (5.5% [95% CI, 5.3-5.7]) than male initiation rates (3.8% [95% CI, 3.6%-3.9%]). Rates were highest in the southeast (5.1% [95% CI, 4.8%-5.3%]) and lowest in the midwest (4.0% [95% CI, 3.8%-4.3%]), with a modest nationwide initiation decline from 2013 to 2021 (cumulative incidence difference, 1.6%).

CONCLUSIONS

Despite a gradual decline in benzodiazepine initiation from 2013 to 2021, we noted excessive supplies in prescriptions post-acute ischemic stroke discharge, underscoring the need for improved policies.

Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review

Background

Clinical practice guidelines and guidance documents routinely offer prescribing clinicians' recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion.

Methods

A Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing.

Findings

113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being "International" (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents.

Interpretation

Documents were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to "short-term" use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or 'as needed') selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering.

Funding

The authors received no funding for this work.

Role of the prescriber in supporting patients to discontinue benzodiazepines: a qualitative study

BACKGROUND

Given the prevalence of long-term benzodiazepine (BZD) prescribing, increased monitoring through the implementation of prescription monitoring programmes (PMPs) may be the necessary impetus to promote BZD deprescribing. Despite evidence promoting the importance of patient-centred care, GPs have not been sufficiently supported to implement these principles through current deprescribing practice.

AIM

To investigate patients' perception of their prescriber's influence on ceasing BZD use, including their willingness to take their advice, and to understand how a patient's stage of change influences the barriers and facilitators they perceive to discontinuing BZDs.

DESIGN AND SETTING

An online survey and qualitative interviews with 22 long-term users of BZD (≥6 months), aged 18-69 years, recruited from the general population in Victoria, Australia.

METHOD

Two groups of users of BZD participated, one in the process of reducing their BZD and one not reducing, and were categorised according to their stage of change. Data underwent thematic analysis to identify barriers and facilitators to reducing BZDs both at the patient level and the prescriber level.

RESULTS

BZD patients' perceptions of the prescriber influence were characterised by prescribing behaviours, treatment approach, and attitude. Barriers and facilitators to reducing their BZD were mapped against their stage of change. Irrespective of their stage of change, participants reported they would be willing to try reducing their BZD if they trusted their prescriber.

CONCLUSION

This study illustrates that, with a few key strategies at each step of the deprescribing conversation, GPs are well positioned to tackle the issue of long-term BZD use in a manner that is patient centred.

The Perspectives of Australian Naturopaths about Providing Health Services for People with Sleep Disorders

Objective: The purpose of the study was to determine and describe the clinical approach Australian naturopaths take in providing care for people with sleep disorders, as it well known that Australians commonly seek care from naturopathic practitioners and no data on naturopathic practices for people with sleep disorders is currently documented.Participants: Naturopaths registered with the Australian PRACI (Practitioner Research and Collaboration Initiative) involved in the clinical management of people with sleep disorders.Methods: Consenting participants were invited to participate in semi-structured phone interviews conducted with the aid of a project-specific interview guide until data saturation was evident. Interview recordings were transcribed verbatim and analyzed thematically.Results: A total of 20 naturopaths across 5 different Australian states were interviewed, 4 themes were identifiable. Thematic interpretation suggests that (1) sleep health consults were common and involved detailed history taking by providers, (2) herbal remedies supported by lifestyle and sleep hygiene behaviors were the most common treatments recommended, and (3) interprofessional communication to medical doctors was seldom reciprocated. Government-funded research and establishing statutory registration of naturopaths were identified as key steps in profiling the professions role and to develop/evaluate integrated patient-centered sleep health care models.Conclusion: Naturopaths engage in the treatment of sleep disorders yet face barriers in executing an integration of such approaches within the current health care system. Research is required to explore how to overcome these barriers and develop integrated patient-centered models of care within tertiary sleep clinics and/or primary care physicians.

[Use and abuse of benzodiazepines in primary healthcare: professional practices in Brazil and Cuba]

The current study aimed to grasp the healthcare aspects present at the basis of the indiscriminate use of benzodiazepines. Based on a partnership between a Brazilian university and a Cuban university, the study aimed to understand the practices related to the use of these drugs in primary care and the meanings healthcare workers assign to them. The research was part of a multiple case study in the cities of São Paulo and Diadema (Brasil), and Santiago de Cuba (Cuba). The fieldwork data collection strategy was based on individual interviews and focus groups. Data were analyzed thematically and yielded five themes: (i) no man's land: lack of management of benzodiazepine use by primary care workers; (ii) inadequate indications: the benzodiazepine prescribed for unjustifiable situations; (iii) salvation and perdition: the medicine as attenuating the difficulty of acting in mental health by primary care professionals; (iv) limited empowerment to work in mental health; and (v) fragmented care: dissociation of the psychosocial care network. Limited grasp of mental health issues by primary care workers, fragmented care, work overload with what are considered other priorities, deficiencies in the availability of therapeutic resources, and limited investment in specific training contribute to the inadequate use of benzodiazepines. Independently of the health contexts, the challenges are similar for the health systems and can only be confronted if they become a priority for the organizations' management and the health workers as a whole.

Long-term use of benzodiazepines and Z drugs: a qualitative study of patients' and healthcare professionals' perceptions and possible levers for change

BACKGROUND

Although long-term use of benzodiazepines (BZDs) and Z drugs is associated with various side effects, they remain popular among the older population. Possible reasons for this phenomenon could be ineffective ways of transmitting information on the health risks associated with long-term use, and communication gaps between patients and healthcare professionals.

AIM

The aim was to investigate the views of patients, physicians, nurses, and pharmacists regarding long-term BZD and Z drug use.

DESIGN & SETTING

The qualitative study design used focus group interviews with physicians, pharmacists, and nurses in Hamburg. Patient interviews were conducted in Lippstadt, Germany.

METHOD

The interviews were audiotaped with each participant's permission, transcribed, and thematically analysed using a software program for qualitative research (MAXQDA).

RESULTS

The data from the four focus groups consisting of 28 participants were analysed. Patients indicated lack of knowledge about risks and side effects, difficult access to alternatives, and fears of ceasing drug use without professional support. Although the physicians were reported to be cautious about prescribing BZDs and Z drugs, the psychosocial problems of older patients are often considered to be complex and treatment knowledge, experience, and resources are frequently unsatisfactory. Nurses described that when BZDs were prescribed, they did not feel it was their responsibility to evaluate their effects. Pharmacists were reported to be strongly ambivalent in informing patients about the risks, which may contradict the prescription advice provided by the physician.

CONCLUSION

Patients, physicians, nurses, and pharmacists reported differences in the perception of long-term BZD and Z drug use. Nevertheless, all of the participants described lack of information and expressed the need for greater communication exchange.

Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients

Benzodiazepines (BZDs; including the related Z-drugs) are frequently targets for deprescribing; long-term use in older people is harmful and often not beneficial. BZDs can result in significant harms, including falls, fractures, cognitive impairment, car crashes and a significant financial and legal burden to society. Deprescribing BZDs is problematic due to a complex interaction of drug, patient, physician and systematic barriers, including concern about a potentially distressing but rarely fatal withdrawal syndrome. Multiple studies have trialled interventions to deprescribe BZDs in older people and are discussed in this narrative review. Reported success rates of deprescribing BZD interventions range between 27 and 80%, and this variability can be attributed to heterogeneity of methodological approaches and limited generalisability to cognitively impaired patients. Interventions targeting the patient and/or carer include raising awareness (direct-to-consumer education, minimal interventions, and 'one-off' geriatrician counselling) and resourcing the patient (gradual dose reduction [GDR] with or without cognitive behavioural therapy, teaching relaxation techniques, and sleep hygiene). These are effective if the patient is motivated to cease and is not significantly cognitively impaired. Interventions targeted to physicians include prescribing interventions by audit, algorithm or medication review, and providing supervised GDR in combination with medication substitution. Pharmacists have less frequently been the targets for studies, but have key roles in several multifaceted interventions. Interventions are evaluated according to the Behaviour Change Wheel. Research supports trialling a stepwise approach in the cognitively intact older person, but having a low threshold to use less-consultative methods in patients with dementia. Several resources are available to support deprescribing of BZDs in clinical practice, including online protocols.

Representation of People's Decisions in Health Information Systems.* A Complementary Approach for Understanding Health Care Systems and Population Health

OBJECTIVES

In this study, we aimed: 1) to conceptualize the theoretical challenges facing health information systems (HIS) to represent patients' decisions about health and medical treatments in everyday life; 2) to suggest approaches for modeling these processes.

METHODS

The conceptualization of the theoretical and methodological challenges was discussed in 2015 during a series of interdisciplinary meetings attended by health informatics staff, epidemiologists and health professionals working in quality management and primary and secondary prevention of chronic diseases of the Hospital Italiano de Buenos Aires, together with sociologists, anthropologists and e-health stakeholders.

RESULTS

HIS are facing the need and challenge to represent social human processes based on constructivist and complexity theories, which are the current frameworks of human sciences for understanding human learning and socio-cultural changes. Computer systems based on these theories can model processes of social construction of concrete and subjective entities and the interrelationships between them. These theories could be implemented, among other ways, through the mapping of health assets, analysis of social impact through community trials and modeling of complexity with system simulation tools.

CONCLUSIONS

This analysis suggested the need to complement the traditional linear causal explanations of disease onset (and treatments) that are the bases for models of analysis of HIS with constructivist and complexity frameworks. Both may enlighten the complex interrelationships among patients, health services and the health system. The aim of this strategy is to clarify people's decision making processes to improve the efficiency, quality and equity of the health services and the health system.