Reducing Benzodiazepine Use

By Jamie Santa Cruz

Benzodiazepines, known to impair cognitive function, physical coordination, and balance, must be prescribed with caution.

Despite warnings against the use of benzodiazepines in older adults, particularly as a first-line treatment or for long-term treatment,1 a new study in JAMA Psychiatry shows that benzodiazepines continue to be widely used by Americans. Most worrisome is the fact that the highest use occurs among older adults, who are at the greatest risk of experiencing side effects.2

Using data from the 2008 LifeLink Rx Longitudinal Prescription database, the study researchers sought to determine the percentage of adults who filled one or more prescriptions for benzodiazepines during 2008. They found that approximately 5.2% of adults in the United States had used benzodiazepines during that year, with the percentage increasing steadily with age: among 18- to 35-year-olds, fewer than 3% filled at least one prescription, but that percentage jumped to more than 7% among those aged 51to 64 and to 8.7% in those aged 65 to 80.

Furthermore, the propensity toward long-term use also increased steadily with age: Only about 15% of users in the 18- to 35-year-old age category were long-term users, compared with more than 31% of those aged 65 to 80.

"When we observe that nearly 10% of US adults over the age of 65 received a benzodiazepine, that's really quite high," says Michael Schoenbaum, PhD, senior advisor for mental health services, epidemiology, and economics at the National Institute of Mental Health and one of the study's authors. "We were surprised to see rates that high—and concerned." Individual health care delivery systems and regulatory agencies have taken steps to improve the prescribing patterns of benzodiazepines, he says, but at the level of the US population, rates of use have remained persistently high in recent decades. "Progress is pretty slow and hard to detect," Schoenbaum says.

Gauging the Risks
As for the specific risks, they are substantial for older adults. Benzodiazepines are known to impair cognitive function, physical coordination, and balance.3-5 Consequently, their use is strongly correlated with falls,6-8 which frequently lead to hip fractures, surgery, head injury, and loss of independence. Benzodiazepine use has also been shown to increase the risk of Alzheimer's disease and dementia by almost 50%,9,10 and other studies have shown higher rates of certain forms of cancer.11,12 Unsurprisingly, then, several studies have also tied benzodiazepine use to a substantial risk of increased mortality, even when use is limited to only a few doses per year.12,13

"The safety risks associated with benzodiazepine use in the elderly are considerable and include potentially life-threatening events," says Mark Olfson, MD, MPH, a professor of psychiatry at Columbia University Medical Center and the lead study author of a paper in JAMA Psychiatry on the subject. "As a result, there is a pressing public health need to increase access to safer alternative nonpharmacological interventions for insomnia and anxiety in older adults."

Even for patients who don't experience extreme side effects, there are substantial drawbacks to the drugs. In particular, the clinical benefits of benzodiazepines decline with long-term use, yet the drugs are simultaneously habituating. With long-term use, then, patients continue taking the medications primarily because if they stop, they experience symptoms of withdrawal. Those symptoms of withdrawal often take the form of the symptoms for which they began taking the medication in the first place, namely insomnia and anxiety.

"What happens is kind of a perverse thing," Schoenbaum says. "People [have] the impression that the medication is still helping them, but really, in long-term use, the main benefit of people taking these medicines is that it just staves off withdrawal symptoms."

The concerns about safety are so significant that the French authors of an editorial accompanying Olfson and Schoenbaum's study have argued bluntly that benzodiazepines would likely not be approved if they were under review today. "Other medications with potentially more benefits and less absolute risks have been taken off the market," they wrote in the editorial. "If benzodiazepines were new antidiabetic drugs with even one-hundredth of their burden of harms, they would be immediately removed."14

Factors Contributing to High Usage Rates
Despite the risks, says Cara Tannenbaum, MD, MSc, a professor of medicine and pharmacy at the Université de Montréal, there are several factors that encourage continued use of benzodiazepines. The first, she says, is that anxiety and sleep problems, which are the main indicators for benzodiazepines, tend to be of great concern to older adults. Anxiety typically increases with age, as individuals face the loss of loved ones, the loss of independence, and declining health. As for sleep, many older adults experience frustration with their inability to sleep as long and as deeply as they used to. In reality, Tannenbaum says, older adults need less sleep than their younger counterparts (only about 5 to 7 hours), but there's a false belief in most cases that they should be able to sleep 10 to 12 hours per night.

Meanwhile, benzodiazepines offer a quick and easy solution. Taking a pill is far simpler for both patients and physicians than other more effective therapies that carry less risk, Tannenbaum says. Physicians aren't entirely to blame for the tendency to turn to pills; the medical system tends to encourage the trend, according to Tannenbaum. "If a health care organization wants you to see a new patient every 15 minutes, then you simply will not have the time to sit down and talk to them about these therapies. It's just easier to prescribe the pills," she says.

A final factor, Tannenbaum says, is that although multiple systems and regulatory agencies focus on approving medications, few agencies and few resources are devoted to looking into the harms of approved drugs and considering whether or not problematic drugs should be removed from the list.

As for whether clinicians are fully aware of the harms, Olfson suggests they may not be. "I think there is a general tendency for physicians to underestimate the risks," he says. "This is partly because there is natural tendency to attribute falls and fractures when they do occur to general aspects of aging such as decreased motor coordination, rather than to modifiable factors such as prescribed medications."

At the same time, however, lack of physician awareness probably does not explain why physicians are so prone to dispensing benzodiazepines, considering that warnings about benzodiazepines have become increasingly strong in recent years.

"In the abstract, surely most practicing prescribers are aware of the cautions," Schoenbaum says. "The real issue is, what influence does that have at a practical level on their prescribing behavior?" Patient attachment to benzodiazepines, he says, may well influence physicians in their prescribing. The appeal to both patients and prescribers is that benzodiazepines work fairly quickly, unlike alternatives such as selective serotonin reuptake inhibitors (SSRIs), which frequently take up to a few weeks before they have an effect. "If you give [a patient] a benzodiazepine and [he feels] the effects within hours, both the clinicians and the patients like that," Schoenbaum says.

Implications for Clinical Practice
Though benzodiazepines may offer an easy solution for providers to prescribe, the main message Schoenbaum seeks to communicate to clinicians is that they should be highly cautious and reluctant to prescribe benzodiazepines as a first-line treatment for any condition, especially in older adults. Ideally, nonpharmacological therapies should be attempted first, but when medication is necessary for anxiety or other complaints for which benzodiazepines are indicated, physicians should look to drugs other than benzodiazepines, such as SSRIs.

The second key message for clinicians is that when they do prescribe benzodiazepines, they have a responsibility to keep the course of treatment short—even if that means being more proactive than usual. "We know that once people are established users, it's incredibly difficult to get them off," Schoenbaum says. If a physician feels that a benzodiazepine is an indicated treatment, it is not sufficient to write the prescription and then simply tell the patient not to take it for more than two weeks. "The practice needs to be more proactive. That could mean insisting on a follow-up visit. It could mean having a member of the staff make telephone contact. But be alert that people don't transition to long term."

In terms of strategies for helping patients avoid benzodiazepines or helping them taper off the medications if they are already regular users, Tannenbaum emphasizes the importance of patient education and cognitive behavioral therapy. Clinicians should help patients understand the myths surrounding sleep and aging and the risks associated with benzodiazepines. Her institution offers a brochure to help communicate these issues to patients (available at http://www.criugm.qc.ca/fichier/pdf/BENZOeng.pdf). She also recommends Sleepwell Nova Scotia as another resource for helping patients address insomnia symptoms with cognitive behavioral therapy (http://sleepwellns.ca/).

Mindfulness-based therapy is another useful first-line therapy, Tannenbaum says. Different forms are available, but the essence of mindfulness-based therapy is the use of stress-reduction and relaxation techniques. Patients are taught to be in the moment, to take deep breaths, to appreciate what they can control and what they can't, and to search out personal relaxation strategies such as meditation, music, or yoga that are impactful for them.

In some cases, Tannenbaum says, physicians may be able to coach patients through these alternative therapies on their own, because some patients are able to take ownership of the situation with a simple five- or 10-minute in-office conversation. However, she adds, for the large percentage of patients who aren't particularly motivated or who are outright resistant to tapering off, a referral to another provider for more extensive therapy will likely be necessary.

Either way, she suggests, the effort is worth it. "The dangers [with benzodiazepines] are very serious. Given that everyone is concerned about healthy aging, this is a completely reversible risk factor, and I think that we should be much more aggressive about informing people of these risks."

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

References

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