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

Implementation of an intervention aimed at deprescribing benzodiazepines in a large US healthcare system using patient education materials: a pre/post-observational study with a control group

OBJECTIVES

Long-term benzodiazepine use is common despite known risks. In the original Eliminating Medications Through Patient Ownership of End Results (EMPOWER) Study set in Canada, patient education led to increased rates of benzodiazepine cessation. We aimed to determine the effectiveness of implementing an adapted EMPOWER quality improvement (QI) initiative in a US-based healthcare system.

DESIGN

We used a pre-post design with a non-randomised control group.

SETTING

A network of primary care clinics.

PARTICIPANTS

Patients with ≥60 days' supply of benzodiazepines in 6 months and ≥1 risk factor (≥65 years of age, a concurrent high-risk medication prescribed or a diazepam equivalent daily dose ≥10) were eligible.

INTERVENTION

In March 2022, we engaged 22 primary care physicians (PCPs), and 308 of their patients were mailed an educational brochure, physician letter and flyer detailing benzodiazepine risks; the control group included 4 PCPs and 291 of their patients.

PRIMARY AND SECONDARY MEASURES

The primary measure was benzodiazepine cessation by 9 months. We used logistic regression and a generalised estimating equations approach to control for clustering by PCP, adjusting for demographics, frailty, number of risk factors, and diagnoses of arthritis, depression, diabetes, falls, and pain.

RESULTS

Patients in the intervention and control groups were comparable across most covariates; however, a greater proportion of intervention patients had pain-related diagnoses and depression. By 9 months, 26% of intervention patients (81 of 308) had discontinued benzodiazepines, compared with 17% (49 of 291) of control patients. Intervention patients had 1.73 greater odds of benzodiazepine discontinuation compared with controls (95% CI: 1.09, 2.75, p=0.02). The unadjusted number needed to treat was 10.5 (95% CI: 6.30, 34.92) and the absolute risk reduction was 0.095 (95% CI: 0.03 to 0.16).

CONCLUSIONS

Results from this non-randomised QI initiative indicate that patient education programmes using the EMPOWER brochures have the potential to promote cessation of benzodiazepines in primary care.

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.

Prescriber Acceptability of a Direct-to-Patient Intervention for Benzodiazepine Receptor Agonist Deprescribing and Behavioural Management of Insomnia in Older Adults

Behavioural treatments are recommended first-line for insomnia, but long-term benzodiazepine receptor agonist (BZRA) use remains common and engaging patients in a deprescribing consultation is challenging. Few deprescribing interventions directly target patients. Prescribers' support of patient-targeted interventions may facilitate their uptake. Recently assessed in the Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study, Sleepwell (mysleepwell.ca) was developed as a direct-to-patient behaviour change intervention promoting BZRA deprescribing and non-pharmacological insomnia management. BZRA prescribers of YAWNS NB participants were invited to complete an online survey assessing the acceptability of Sleepwell as a direct-to-patient intervention. The survey was developed using the seven construct components of the theoretical framework of acceptability (TFA) framework. Respondents (40/250, 17.2%) indicated high acceptability, with positive responses per TFA construct averaging 32.3/40 (80.7%). Perceived as an ethical, credible, and useful tool, Sleepwell also promoted prescriber-patient BZRA deprescribing engagements (11/19, 58%). Prescribers were accepting of Sleepwell and supported its application as a direct-to-patient intervention.

Benzodiazepine Discontinuation and Mortality Among Patients Receiving Long-Term Benzodiazepine Therapy

Importance

There is interest in reducing long-term benzodiazepine prescribing given harms associated with use, but the cumulative risks or benefits of discontinuation are unknown.

Objective

To identify the association of benzodiazepine discontinuation with mortality and other adverse events among patients prescribed stable long-term benzodiazepine therapy, stratified by baseline opioid exposure.

Design, Setting, and Participants

This comparative effectiveness study with a trial emulation approach included data from a US commercial insurance database between January 1, 2013, and December 31, 2017. Eligible participants were adults with stable long-term benzodiazepine prescription treatment. Data were analyzed between December 2022 and November 2023.

Exposure

Benzodiazepine discontinuation, defined as no benzodiazepine prescription coverage for 31 consecutive days identified during a 6-month grace period after baseline.

Main Outcome and Measures

Mortality during 12 months of follow-up; secondary outcomes included nonfatal overdose, suicide attempt or self-inflicted injury, suicidal ideation, and emergency department use, identified in medical claims. Inverse probability weighting was used to adjust for baseline confounders that potentially affected treatment assignment and censoring due to death or disenrollment. Primary analysis used an intention-to-treat approach; a secondary per-protocol analysis estimated associations after accounting for nonadherence. Analyses were stratified by opioid use.

Results

The study included 213 011 (136 609 female [64.1%]; mean [SD] age, 62.2 [14.9] years; 2953 Asian [1.4%], 18 926 Black [8.9%], 22 734 Hispanic [10.7%], and 168 398 White [60.2%]) and 140 565 (91 811 female [65.3%]; mean [SD] age, 61.1 [13.2] years; 1319 Asian [0.9%], 15 945 Black [11.3%], 11 989 Hispanic [8.5%], and 111 312 White [79.2%]) patients with stable long-term benzodiazepine use without and with opioid exposure, respectively. Among the nonopioid exposed, the adjusted cumulative incidence of death after 1 year was 5.5% (95% CI, 5.4%-5.8%) for discontinuers, an absolute risk difference of 2.1 percentage points (95% CI, 1.9-2.3 percentage points) higher than for nondiscontinuers. The mortality risk was 1.6 (95% CI, 1.6-1.7) times that of nondiscontinuers. Among those with opioid exposure, the adjusted cumulative incidence of death was 6.3% (95% CI, 6.0%-6.6%) for discontinuers, an absolute risk difference of 2.4 percentage points (95% CI, 2.2-2.7 percentage points) higher than for nondiscontinuers and a mortality risk 1.6 (95% CI, 1.5-1.7) times that of nondiscontinuers. Cumulative incidence of secondary outcomes was also higher among discontinuers.

Conclusions and Relevance

This study identifies small absolute increases in risk of harms among patients with stable long-term prescription benzodiazepine treatment who appear to discontinue relative to continuing treatment, including those with and without recent prescription opioid exposure. Policy broadly promoting benzodiazepine discontinuation may have unintended risks.

Pharmacists' contribution to benzodiazepine deprescribing in older outpatients: a systematic review and meta-analysis

BACKGROUND

Consolidated and reliable evidence regarding the effectiveness of pharmacist interventions for deprescribing benzodiazepines in older outpatients is lacking.

AIM

This study evaluated and summarized the impact of pharmacist interventions on benzodiazepine deprescribing among older outpatients.

METHOD

A literature search was conducted until August 2022 in PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials databases. The review included randomized controlled trials that assessed the impact of pharmacist interventions on deprescribing benzodiazepine in older outpatients. Two independent investigators conducted the study selection, data extraction, and risk of bias assessment. Meta-analyses were conducted using random-effect models in the RStudio software.

RESULTS

A total of 893 records were identified. Five studies, including 3,879 patients, met the inclusion criteria and were included in the systematic review. All five studies used health education as an intervention strategy, and three also conducted medication reviews. There was no evidence of the pharmacist's authority to modify prescriptions during benzodiazepine deprescribing. One study was classified as having a low risk of bias, whereas the other had some concerns or a high risk of bias. Three studies were included in the meta-analysis and a significant impact of pharmacist interventions on benzodiazepines deprescribing rates in older outpatients was observed (RR = 2.75 [95%CI 1.29; 5.89]; p = 0.04; I2 = 69%; low certainty of evidence).

CONCLUSION

Pharmacists may contribute to deprescribing benzodiazepines in older outpatients. Further studies are needed to increase the reliability of these findings. PROSPERO registration number: CRD42022358563.

Therapeutic dilemmas with benzodiazepines and Z-drugs: insomnia and anxiety disorders versus increased fall risk: a clinical review

PURPOSE

The aim of this clinical review was to summarise the existing knowledge on fall risk associated with benzodiazepines (BZDs) and Z-drugs in older people with focus on appropriate prescribing, including deprescribing.

METHODS

We conducted a literature search in June 2021 in PubMed and Embase with citation and reference checking. Personal reference libraries and international websites were also used. Keywords for the searches included "benzodiazepines", "Z-drugs", "falls", "deprescribing", "fall-risk-increasing-drugs", "inappropriate prescribing", "older people" and matching synonyms. We discuss use of BZDs and Z-drugs, potential fall-related adverse reactions, alternatives for and deprescribing of BZDs and Z-drugs in older persons.

RESULTS

BZDs and Z-drugs differ in fall-related adverse effect profile. They contribute to fall risk through orthostatic hypotension, dizziness and/or imbalance, sedation, muscular weakness, ataxia, etc. Fall incidents contribute significantly to mortality and morbidity. Therefore, there is a need for appropriate prescribing and use of BZDs and Z-drugs in older people. In practice, this means pertaining to a strict indication, strongly consider to non-pharmacological alternatives, limit use to the lowest dose and the shortest duration possible. Judicious deprescribing should be considered and encouraged as well. Practical resources, tools and algorithms are available to guide and assist clinicians in deprescribing BZDs and Z-drugs.

CONCLUSIONS

Prescribing BZDs and Z-drugs should be done in a well-considered way in fall-prone older people. A good overview and insight in the fall-related adverse effects of these drugs, as well as the availability of different strategies to increase the appropriate use, including deprescribing initiatives, can assist clinicians in clinical decision-making.

The impact of a pharmacist intervention on post-discharge hypnotic drug discontinuation in geriatric inpatients: a before-after study

BACKGROUND

Chronic use of hypnotic agents is prevalent in older adults, who as a result are at increased risk for certain adverse events, such as day-time drowsiness and falls. Multiple strategies to discontinue hypnotics have been tested in geriatric patients, but evidence remains scarce. Hence, we aimed to investigate a multicomponent intervention to reduce hypnotic drug use in geriatric inpatients.

METHODS

A before-after study was performed on the acute geriatric wards of a teaching hospital. The before group (= control group) received usual care, while intervention patients (= intervention group) were exposed to a pharmacist-led deprescribing intervention, comprising education of health care personnel, access to standardized discontinuation regimens, patient education and support of transitional care. The primary outcome was hypnotic drug discontinuation at one month after discharge. Secondary outcomes among others were sleep quality and hypnotic use at one and two weeks after enrolment and at discharge. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) upon inclusion, two weeks after enrolment and one month after discharge. Determinants for the primary outcome were identified using regression analysis.

RESULTS

A total of 173 patients were enrolled, with 70.5% of patients taking benzodiazepines. Average age was 85 years (interquartile range 81-88.5) and 28.3% were male. A higher discontinuation rate at one month after discharge was observed in favour of the intervention (37.7% vs. 21.9%, p = 0.02281). No difference in sleep quality was found between both groups (p = 0.719). The average sleep quality was 8.74 (95% confidence interval (CI): 7.98-9.49) and 8.57 (95% CI: 7.75-9.39) in the control and intervention groups respectively. Determinants for discontinuation at one month were: the intervention (odds ratio (OR) 2.36, 95% CI: 1.14-4.99), fall on admission (OR 2.05; 95% CI: 0.95-4.43), use of a z-drug (OR 0.54, 95% CI: 0.23-1.22), PSQI score on admission (OR 1.08, 95% CI: 0.97-1.19) and discontinuation prior to discharge (OR 4.71, 95% CI: 2.26-10.17).

CONCLUSIONS

A pharmacist-led intervention in geriatric inpatients was associated with a reduction of hypnotic drug use one month after discharge, without any loss in sleep quality.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05521971 (retrospectively registered on 29^th of August 2022).

Chronic use of benzodiazepines: The problem that persists

Though clinical guidelines and policies discourage the chronic prescribing of benzodiazepines, rates of prescribing have continued to rise in the United States to the tune of an estimated 65.9 million office visits per year. Quietly, we have become a nation on benzodiazepines. There are numerous reasons for this discrepancy between official recommendations on the one hand, and actual clinical practice on the other. Drawing from the literature, we argue that while patients and providers both shoulder some of the responsibility, they also cannot be solely blamed. Rather, policies and guidelines regarding benzodiazepines have become out of touch with the clinical reality that benzodiazepines are now deeply entrenched in modern medicine. We propose that guidelines regarding benzodiazepines need to reconsider how to apply concepts such as harm reduction and other lessons learned in the opioid epidemic in order to help physicians manage this oft-deferred, but increasingly pressing problem affecting millions of Americans.

Alliance for Sleep Clinical Practice Guideline on Switching or Deprescribing Hypnotic Medications for Insomnia

Determining the most effective insomnia medication for patients may require therapeutic trials of different medications. In addition, medication side effects, interactions with co-administered medications, and declining therapeutic efficacy can necessitate switching between different insomnia medications or deprescribing altogether. Currently, little guidance exists regarding the safest and most effective way to transition from one medication to another. Thus, we developed evidence-based guidelines to inform clinicians regarding best practices when deprescribing or transitioning between insomnia medications. Five U.S.-based sleep experts reviewed the literature involving insomnia medication deprescribing, tapering, and switching and rated the quality of evidence. They used this evidence to generate recommendations through discussion and consensus. When switching or discontinuing insomnia medications, we recommend benzodiazepine hypnotic drugs be tapered while additional CBT-I is provided. For Z-drugs zolpidem and eszopiclone (and not zaleplon), especially when prescribed at supratherapeutic doses, tapering is recommended with a 1–2-day delay in administration of the next insomnia therapy when applicable. There is no need to taper DORAs, doxepin, and ramelteon. Lastly, off-label antidepressants and antipsychotics used to treat insomnia should be gradually reduced when discontinuing. In general, offering individuals a rationale for deprescribing or switching and involving them in the decision-making process can facilitate the change and enhance treatment success.

Deprescribing Strategies for Opioids and Benzodiazepines with Emphasis on Concurrent Use: A Scoping Review

While the Food and Drug Administration's black-box warnings caution against concurrent opioid and benzodiazepine (OPI-BZD) use, there is little guidance on how to deprescribe these medications. This scoping review analyzes the available opioid and/or benzodiazepine deprescribing strategies from the PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library databases (01/1995-08/2020) and the gray literature. We identified 39 original research studies (opioids: n = 5, benzodiazepines: n = 31, concurrent use: n = 3) and 26 guidelines (opioids: n = 16, benzodiazepines: n = 11, concurrent use: n = 0). Among the three studies deprescribing concurrent use (success rates of 21-100%), two evaluated a 3-week rehabilitation program, and one assessed a 24-week primary care intervention for veterans. Initial opioid dose deprescribing rates ranged from (1) 10-20%/weekday followed by 2.5-10%/weekday over three weeks to (2) 10-25%/1-4 weeks. Initial benzodiazepine dose deprescribing rates ranged from (1) patient-specific reductions over three weeks to (2) 50% dose reduction for 2-4 weeks, followed by 2-8 weeks of dose maintenance and then a 25% reduction biweekly. Among the 26 guidelines identified, 22 highlighted the risks of co-prescribing OPI-BZD, and 4 provided conflicting recommendations on the OPI-BZD deprescribing sequence. Thirty-five states' websites provided resources for opioid deprescription and three states' websites had benzodiazepine deprescribing recommendations. Further studies are needed to better guide OPI-BZD deprescription.

Feasibility and effectiveness of deprescribing benzodiazepines and Z-drugs: systematic review and meta-analysis

BACKGROUND AND AIMS

A total of 2.4 million adults in England were dispensed a benzodiazepine or Z-drug (BZRA) in 2017/18, and more than 250 000 patients in the UK take BZRAs beyond the recommended duration. Deprescribing is a clinician-guided process of withdrawing inappropriate drugs. This review aimed to evaluate the evidence base supporting the feasibility and clinical effectiveness of all forms of deprescribing initiatives used to discontinue long-term (≥ 4 weeks) BZRAs.

METHOD

Systematic review of randomized controlled trials evaluating BZRAs deprescribing among adults in community, primary or outpatient settings. MEDLINE, Embase and PsycINFO were searched from inception to February 2021. Primary outcomes were successful discontinuation in the short (< 4 weeks) or long term (≥ 4 weeks) and the occurrence of withdrawal symptoms, behavioural or psychological symptoms. Studies were categorized as pharmacological or non-pharmacological supported interventions. Study quality was assessed using the Cochrane risk-of-bias tool. Where appropriate, risk ratios (RRs), mean differences and 95% confidence intervals (CIs) were calculated, and Mantel-Haenszel methods using the random-effect meta-analysis was undertaken to calculate summary effect estimates.

RESULTS

Ten studies were included (n = 1431 participants). Heterogeneity in study design and effect was observed. Benzodiazepines were successfully deprescribed when gradually tapered with non-pharmacological support compared with gradual tapering alone in the short term (n = 124; RR = 2.02; 95% CI = 1.41, 2.89) and long term (n = 123; RR = 2.45; 95% CI = 1.56, 3.85). Benzodiazepine deprescribing was more successful when supported by non-pharmacological methods versus routine care (n = 189; RR = 3.26; 95% CI = 2.36, 4.51). Quality of evidence reporting effectiveness was very low to low.

CONCLUSIONS

It may be feasible to deprescribe benzodiazepines depending on the process and support mechanisms employed.

Applying the intervention Complexity Assessment Tool to brief interventions targeting long-term benzodiazepine receptor agonist use in primary care: Lessons learned

Background

Benzodiazepine receptor agonists (BZRAs) are often prescribed for long-term use. However, guidelines recommend limiting prescriptions to short-term use (< 4 weeks) to reduce the risk of adverse effects and dependence. A recent systematic review reported that brief interventions targeting long-term BZRA use in primary care (e.g., short consultations, written letters to patients) were effective in helping patients to discontinue BZRA medication. However, the complexity of these interventions has not been examined in detail. This study aimed to apply the intervention Complexity Assessment Tool for Systematic Reviews (iCAT_SR) to brief interventions targeting long-term BZRA use. 

Methods

Two reviewers independently assessed the interventions using the six core iCAT_SR dimensions: organisational level/ category targeted, behaviour targeted, number of intervention components, degree of tailoring, skill level required by those delivering and receiving the intervention. The four optional iCAT_SR dimensions were applied where possible. A scoring system was using to calculate a complexity score for each intervention. Pearson’s correlations were used to assess the relationship between intervention complexity and effect size, as well as the relationship between intervention complexity and number of component behaviour change techniques (BCTs). Inter-rater reliability was calculated using Cohen’s Kappa coefficient.

Results

Four of the six core iCAT_SR dimensions were applied to the interventions with high inter-rater reliability (Cohen’s Kappa = 0.916). Application of the four optional dimensions was prevented by a lack of detail in study reports. Intervention complexity scores ranged from 8 to 11 (median: 11). There was no relationship detected between intervention complexity and either intervention effect size or number of component BCTs.

Conclusions

This study adds to the literature on worked examples of the practical application of the iCAT_SR. The findings highlight how more detailed reporting of interventions is needed in order to optimise the application of iCAT_SR and its potential to differentiate between interventions across the full range of complexity dimensions. Further work is needed to establish the validity of applying a scoring system to iCAT_SR assessments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01775-y.

Insights into patient characteristics and documentation of the use of sedative-hypnotic/anxiolytics in primary care: a retrospective chart review study

Background

Despite the known safety risks of long-term use of sedative-hypnotic/anxiolytic medications, there has been limited guidance for the safe and effective use of their chronic use in a primary care clinic setting. Understanding the characteristics of patients who receive sedative-hypnotic/anxiolytic medication and the clinical documentation process in primary care is the first step towards understanding the nature of the problem and will help inform future strategies for clinical research and practice.

Objectives

Characterize patients who received a sedative-hypnotic/anxiolytic prescription in primary care, and (2) gain an understanding of the clinical documentation of sedative-hypnotic/anxiolytic indication and monitoring in electronic medical records (EMR).

Methods

A random selection of patients who received a prescription for a benzodiazepine or Z-drug hypnotic between January 2014 and August 2016 from four primary care clinics in Winnipeg were included. Data was collected retrospectively using the EMR (Accuro®). Patient variables recorded included sex, age, comorbidities, medications, smoking status, and alcohol status. Treatment variables included drug type, indication, pattern of use, dose, adverse events, psychosocial intervention, tapering attempts, social support, life stressor, and monitoring parameters for sedative-hypnotic use. Demographic and clinical characteristics were described using descriptive statistics.

Results

Records from a sample of 200 primary care patients prescribed sedative-hypnotic/anxiolytics were analyzed (mean age 55.8 years old, 61.5% ≥ 65 years old, 61.0% female). Long-term chronic use (≥ 1 year) of a sedative-hypnotic/anxiolytic agent was observed in 29.5% of the sample. Zopiclone (30.7%) and lorazepam (28.7%) were the most common agents prescribed. Only 9.5% of patients had documentation of a past tapering attempt of their sedative-hypnotic/anxiolytic. The most common indications for sedative-hypnotic/anxiolytic use recorded were anxiety (33.0%) and sleep (18.0%), but indication was undetermined for 57.0% of patients. Depression (33.5%) and falls (18.5%) were reported by patients after the initiation of these agents.

Conclusions

A higher proportion of females and users 65 years and older received a prescription for a sedative-hypnotic/anxiolytic, consistent with previous studies on sedative-hypnotic use. We found inconsistencies in the documentation surrounding sedative-hypnotic/anxiolytic use. The indication for their use was unclear in a large number of patients. These findings will help us understand the state of the problem in primary care and inform future strategies for clinical research.

A Need for Benzodiazepine Deprescribing in the COVID-19 Pandemic: A Cohort Study

The COVID-19 pandemic has had a negative impact on patients’ mental health. The aim of this study was to explore whether the pandemic influenced the use and prescription of benzodiazepines and increased the need for community pharmacist involvement in counselling on deprescribing. Electronic prescription-related data from one pharmacy in Croatia were retrospectively collected for the COVID-19 period (April 2020 to March 2021) and compared with pre-COVID-19 (April 2019 to March 2020) data. Data were collected for patients diagnosed with anxiety disorders who filled out more than one prescription for benzodiazepines, and included age, sex, number of medicines, benzodiazepines, and comorbidities. A total of 1290 benzodiazepine users were identified; of these, 32.87% started using benzodiazepines during the COVID-19 period, while 35.2% continued with benzodiazepine use. More than half of all benzodiazepine users were identified as potential deprescribing candidates (dispensed more than three prescriptions). Women, older patients, multimorbid individuals, and patients with polypharmacy were more likely to use benzodiazepines for a prolonged period. The results show a negative trend of benzodiazepine usage among community-dwelling patients during the pandemic. Community pharmacists can identify potential candidates for deprescribing and initiate a process that ensures more rational use of benzodiazepines and increases the safety of treatment.

Use of a long-acting substitute in detoxification from benzodiazepines: safety (accumulation) problems and proposed mitigation procedure

Objective

In the majority of approaches, detoxification of patients with benzodiazepine (BZD) addiction is preceded by conversion to long-acting BZDs. Resulting BZD accumulation, however, is neither monitored nor prevented. An unrecognized shift of the key low-concentration phase beyond the nominal treatment period may underlie delayed unassisted crises and treatment failures. This open, single-arm, semi-naturalistic study examines the anti-accumulation paradigm to minimize the high-concentration treatment phase and to regain time for medical assistance during the low-concentration phase.

Methods

In 133 of 165 patients with BZD dependency, after conversion to diazepam by titration up to the satiation state, the loading dose and satiating concentration were recorded. The subsequent anti-accumulation procedure consisted of aggressive daily dose reductions under laboratory feedback (serum BZD concentration, radioimmunoassay) until accumulation stopped. The final overaccumulation ratio (OA) and maintenance-dose/loading-dose ratio (MTN) were estimated. The post-conversion peak-concentration/loading-dose ratio was illustratively compared with the concentration/dose ratio in 32 long-term diazepam users demonstrating the natural plateau.

Results

Despite gender- and age-related differences in loading and maintenance doses and in satiating and peak concentrations (higher in younger and male patients), their quotients remained similar. The MTN ratio had an average value of 0.29 and a median value of 0.25, with OA ratios of 1.54 and 1.39, respectively. The concentration/dose ratio was approximately 3 times lower than that in regular diazepam users. With effective elimination starting (on average) from the 6th day, the treatment, including post-elimination recovery, lasted on average 52 days.

Conclusions

The MTN values show how harmfully popular tapering schedules intensify and extend the high-concentration stage during alleged detoxification, leading to unrecognized delays in elimination, and delayed withdrawal crises. The common errors are discussed. An individual MTN, estimated from laboratory feedback (the anti-accumulation paradigm), expeditiously moves patients to the onset of actual detoxification. This action regains time to maintain medical assistance until treatment is properly completed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-022-03388-x.

Pharmacologic Treatment of Sleep Disorders in Pregnancy

Pregnancy is a unique physiologic state whose characteristics often predispose women to new-onset sleep disturbances or exacerbations of preexisting sleep disorders. Pregnancy-related factors that can disrupt sleep include heartburn, nocturnal oxytocin secretion, nocturia, and fetal movement. Sleep disorders in pregnancy include insomnia (primary and secondary), restless legs syndrome, and narcolepsy.

Concordance in psychopharmacological treatment before and after first mental health consultation

PURPOSE

To analyse concordance between treatment prescribed before and after the first mental health consultation. We understand concordance in two different senses: first, as a similar amount of equivalent doses and drug type; second, as a similar treatment for each patient.

METHOD

This is an analytical, descriptive, retrospective study on psychopharmacological treatment before and after first mental health consultation of 1236 patients. Drugs were classified into four groups and the equivalent dose respect to reference medication was considered in each group in order to make a comparison between primary and mental health.

RESULTS

Moderate concordance was found in prescribed treatments before and after first mental health consultation (except antidepressants). The average number of benzodiazepines decreased, as did average doses prescribed at mental health consultation respect to previously prescribed treatment; average doses of antidepressants, however, increased. From the patient's perspective, dose increase was more frequent than decrease. Nevertheless, a high percentage of polymedicated patients were found, although this percentage decreased after the first mental health consultation.

CONCLUSION

There exists a moderate concordance between the pharmacological treatment prescribed before and after the first mental health consultation. However, the use of benzodiazepines diminished significantly after the first consultation, mainly due to a decrease in the percentage of polymedicated patients.

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

BACKGROUND

Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy.

OBJECTIVES

We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice.

DATA SOURCES

Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches).

REVIEW METHODS

The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus.

RESULTS

Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust.

LIMITATIONS

Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available.

CONCLUSIONS

Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models.

FUTURE WORK

The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

Supporting safe and gradual reduction of long‐term benzodiazepine receptor agonist use: Development of the SAFEGUARDING‐BZRAs toolkit using a codesign approach

Introduction

Long‐term benzodiazepine receptor agonist (BZRA) use persists in healthcare settings worldwide and poses risks of patient harm.

Objective

This study aimed to develop an intervention to support discontinuation of long‐term BZRA use among willing individuals.

Methods

The intervention development process aligned with the UK Medical Research Council's complex intervention framework. This involved a previous systematic review of brief interventions targeting long‐term BZRA use in primary care and qualitative interviews based on the Theoretical Domains Framework that explored barriers and facilitators to discontinuing long‐term BZRA use. A codesign approach was used involving an active partnership between experts by experience, researchers and clinicians. Intervention content was specified in terms of behaviour change techniques (BCTs).

Results

The SAFEGUARDING‐BZRAs (Supporting sAFE and GradUAl ReDuctIon of loNG‐term BenZodiazepine Receptor Agonist uSe) toolkit comprises 24 BCTs and includes recommendations targeted at primary care‐based clinicians for operationalizing each BCT to support individuals with BZRA discontinuation.

Conclusion

The SAFEGUARDING‐BZRAs toolkit has been developed using a systematic and theory‐based approach that addresses identified limitations of previous research. Further research is needed to assess its usability and acceptability by service users and clinicians, as well as its potential to effectively support safe and gradual reduction of long‐term BZRA use.

Patient or Public Contribution

The qualitative interview phase included patients as participants. The codesign process included ‘experts by experience’ with either current or previous experience of long‐term BZRA use as collaborators.

Discontinuation of chronic benzodiazepine use in primary care: a nonrandomized intervention

BACKGROUND

Chronic benzodiazepine use is a challenge in primary care practice. Protocols to support safe discontinuation are still needed, especially in countries with high utilization rates.

OBJECTIVES

To evaluate the feasibility, effectiveness, and safety of a benzodiazepine discontinuation protocol in primary care setting.

METHODS

Nonrandomized, single-arm interventional study, at primary care units. Family physicians (FPs) recruited patients (18-85 years-old) with benzodiazepine dependence and chronic daily use ≥3 months. Patients with daily dosages ≥30 mg diazepam-equivalent, taking zolpidem, with a history of other substance abuse or major psychiatric disease were excluded. After the switch to diazepam, the dosage was gradually tapered according to a standardized protocol. Primary endpoint was the percentage of patients who stopped benzodiazepine at the intervention last visit. Dosage reduction, withdrawal symptoms, patients' and FPs' satisfaction with the protocol were evaluated.

RESULTS

From 66 enrolled patients (74% female; 66.7% aged >64 years; median time of benzodiazepine use was 120 months), 2 withdrew due to medical reasons and 3 presented protocol deviations. Overall, 59.4% of participants successfully stopped benzodiazepine (60.7% when excluding protocol deviations). Men had higher probability of success (relative risk = 0.51, P = 0.001). A total of 31 patients reported at least 1 withdrawal symptom, most frequently insomnia and anxiety. Most of participating FP considered the clinical protocol useful and feasible in daily practice. Among patients completing the protocol, 77% were satisfied. For the patients who reduced dosage, 85% kept without benzodiazepines after 12 months.

CONCLUSION

The discontinuation protocol with standardized dosage reduction was feasible at primary care and showed long-term effectiveness.

Efficacy and safety of Z-substances in the management of insomnia in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing

BACKGROUND

Z-drugs are usually prescribed as first line pharmacological therapy for insomnia. However, the benefits and risks of Z-drugs may differ for older adults. This systematic review investigated the available evidence on the efficacy and safety of Z-drugs in the management of insomnia in older adults.

METHODS

The Cochrane database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE were searched for systematic reviews, meta-analyses, controlled interventional and observational studies using a pre-formulated search term. The target population was older adults (≥65 years old) with insomnia. Studies were included if they reported efficacy and/or safety outcomes of the use of Z-drugs for the management of insomnia compared to placebo, usual or no treatment, or other pharmacological agents.

RESULTS

Eighteen studies were included (8 interventional and 10 observational studies). In short-term interventional studies, Z-drugs were similarly or better efficacious in improving both sleep and daytime parameters than placebo or other pharmacological treatments, while showing good results on measures of safety. However, in longer-term observational studies, Z-drugs significantly increased the risk for falls and fractures in comparison to no treatment or melatonin agonists.

CONCLUSIONS

Analyzing the evidence from short-term interventional studies, Z-drugs appear effective and safe for treatment of insomnia in older adults, but they may have unfavorable side effects when used for longer periods of time. We, therefore, recommend discontinuing Z-drugs, principally because of the high risk for falls and fractures. Nonetheless, quality and quantity of evidence are low. Due to the scarcity of data, especially concerning drug dependence after longer periods of treatment and due to the significantly increased risk for falls and fractures, further studies are needed to evaluate the benefit-risk profile of Z-drugs use in older patients, particularly for long-term use.

Interventions to change clinicians' behavior related to suicide-prevention care in the emergency department: a scoping review

OBJECTIVE

The objective of this scoping review was to explore, characterize, and map the literature on interventions and intervention components implemented to change emergency department clinicians' behavior related to suicide prevention using the Behaviour Change Wheel as a guiding theoretical framework.

INTRODUCTION

An emergency department is a critical place for suicide prevention, yet patients are often discharged without proper suicide risk assessments and/or referrals. In response, we must support emergency department clinicians' behavior change to follow evidence-based suicide prevention strategies. However, reviews to date have yet to systematically and theoretically examine interventions' functional characteristics and how they can influence emergency department clinicians' behaviors related to suicide-prevention care.

INCLUSION CRITERIA

This review considered interventions that targeted emergency department clinicians' behavior change related to suicide prevention. Behavior change referred to observable practice changes as well as proxy measures of behavior change, including changes in knowledge and attitude.

METHODS

This review followed JBI methodology for scoping reviews. Searches included PubMed, PsycINFO, CINAHL, Embase, and gray literature, including targeted Google searches for relevant organizations/websites, ProQuest Dissertations and Theses Global, and Scopus conference papers (using a specific filter). This review did not apply any date limits, but our search was limited to the English language. Data extraction was undertaken using a charting table developed specifically for the review objective. Narrative descriptions of interventions were coded using the Behavior Change Wheel's intervention functions. Reported outcome measures were categorized. Findings are tabulated and synthesized narratively.

RESULTS

Forty-one studies were included from the database searches, representing a mixture of experimental (n = 2), quasi-experimental (n = 24), non-experimental (n = 12), qualitative (n = 1), and mixed methods (n = 2) approaches. An additional 29 citations were included from gray literature searches. One was a pilot mixed methods study, and the rest were interventions. In summary, this review included a total of 70 citations, describing 66 different interventions. Identified interventions comprised a wide range of Behaviour Change Wheel intervention functions to change clinicians' behavior: education (n = 48), training (n = 40), enablement (n = 36), persuasion (n = 21), environmental restructuring (n = 18), modeling (n = 7), and incentivisation (n = 2). Based on the Behaviour Change Wheel analysis, many interventions targeted more than one determinant of behavior change, often employing education and training to improve clinicians' knowledge and skills simultaneously. Among the 42 studies that reported outcome measures, effectiveness was measured at clinician (n = 38), patient (n = 4), and/or organization levels (n = 6). Few studies reported implementation outcomes, such as measures of reach (n = 4), adoption (n = 5), or fidelity (n = 1). There were no evaluation data reported on the interventions identified through Google searches.

CONCLUSIONS

Interventions included in this review were diverse and leveraged a range of mechanisms to change emergency department clinicians' behavior. However, most interventions relied solely on education and/or training to improve clinicians' knowledge and/or skills. Future research should consider diverse intervention functions to target both individual- and/or organization-level barriers for a given context. Secondly, the ultimate goal for changing emergency department clinicians' behavior is to improve patient health outcomes related to suicide-related thoughts and behaviors, but current research has most commonly evaluated clinicians' behavior in isolation of patient outcomes. Future studies should consider reporting patient-level outcomes alongside clinician-level outcomes.

'I just thought that it was such an impossible thing': A qualitative study of barriers and facilitators to discontinuing long-term use of benzodiazepine receptor agonists using the Theoretical Domains Framework

Introduction

Existing interventions to reduce long‐term benzodiazepine receptor agonist (BZRA) use lack theoretical underpinning and detailed descriptions. This creates difficulties in understanding how interventions work and how to replicate them in practice. The Theoretical Domains Framework (TDF) can be used to identify behaviour change determinants to target during intervention development.

Objective

To explore barriers and facilitators to discontinuing BZRA use from the perspective of both current and previous long‐term BZRA users.

Design/Setting and Participants

Semistructured TDF‐based interviews were conducted with community‐based individuals with current or previous experience of long‐term BZRA use. Data were recorded, transcribed and analysed using the framework method.

Results

Twenty‐eight individuals were interviewed. Despite commonalities in perceived barriers/facilitators to discontinuing BZRA use within individual TDF domains, individual participants had different experiences of identified determinants of BZRA discontinuation. For example, both similarities and differences existed within and between each participant group in terms of knowledge of the appropriate duration of BZRA use (‘Knowledge’ domain) and experience of withdrawal symptoms (‘Reinforcement’ domain). Compared to previous users, current users typically anticipated more barriers to discontinuing BZRA use and fewer positive consequences of discontinuation.

Conclusion

This study reports on barriers and facilitators to discontinuing BZRA use from the perspectives of current and previous long‐term users. The findings highlight the challenging nature of BZRA discontinuation and a multitude of barriers that impact participants’ behaviour regarding BZRA use. Future work will involve developing a theory‐based intervention to support BZRA discontinuation in primary care.

Patient Contribution

The study included patients as participants.

Deprescribing paracetamol in pain conditions: A scoping review

OBJECTIVE

To examine evidence on deprescribing paracetamol in pain conditions and inform future strategies for paracetamol deprescription.

DESIGN

Scoping review.

PARTICIPANTS

Adults with pain conditions, taking paracetamol.

RESULTS

After two independent teams of reviewers screening for titles, abstracts, and then full texts, 16 original articles were included. Deprescribing strategies were grouped into 5 categories: (1) Pharmacological, (2) Psychological, (3) Physiological, (4) Policy, and (5) Combination. We found strategies were predominately consumer-focused, conducted in community settings and involved individuals experiencing musculoskeletal pain (such as low back pain and osteoarthritis). A total of twelve studies investigated interventions targeting dose reduction and four studies examined interventions focusing on discontinuation of paracetamol. The most common strategies used to deprescribe paracetamol in pain conditions were physiological strategies, followed by psychological strategies. All included studies demonstrated some level of effectiveness to deprescribe paracetamol in a pain conditions through dose reduction or discontinuation, although the effectiveness of deprescribing strategies were highly variable, ranging from the majority of participants discontinuing their paracetamol use, to less than 10% reducing their paracetamol use upon the latest follow-up.

CONCLUSIONS

There are clear opportunities for prospective trials to be designed more purposely and primarily focused to influence reduction and cessation of paracetamol for specific pain conditions where deprescription is appropriate.

General practitioners' compliance with benzodiazepine discontinuation guidelines in patients treated with long-term lorazepam: A case-vignette cross-sectional survey

AIM

To study determinants associated with GPs' compliance with benzodiazepine discontinuation guidelines through a case-vignette of a patient with multimorbidity treated with long-term lorazepam for insomnia.

METHODS

This cross-sectional survey was performed in a sample of French GPs. The questionnaire included items on their characteristics and questions related to the management of a case-vignette with long-term lorazepam use consulting for a prescription renewal. GPs who proposed a dedicated consultation to discuss discontinuation or progressive discontinuation were considered as "following guidelines", while they were considered as "out-of-guidelines" if they proposed immediate discontinuation or decided not to discontinue lorazepam. A backward selection process was used to select factors to be included in the final logistic regression model. The probabilities of out-of-guidelines practice and their 95% confidence interval (95% CI) were then plotted using a heatmap graph.

RESULTS

Of 1,177 GPs, the majority (92.2%) were aware of the necessity to discontinue lorazepam and reported practice consistent with good practice guidelines. Women GPs aged under 50 years had the lowest estimated probability of out-of-guidelines practice. Conversely, men aged over 58 years with high consideration of patient preferences and low concern about the benefit-risk ratio of lorazepam had the highest probability of out-of-guidelines practice (27.3% [18.7%; 34.7%]).

CONCLUSION

GPs largely reported practice compliant with benzodiazepine discontinuation guidelines, although some GPs, mainly older men who overemphasise patient preferences, were more likely to adopt out-of-guidelines practice.

Delayed crises following benzodiazepine withdrawal: deficient adaptive mechanisms or simple pharmacokinetics? Detoxification assisted by serum-benzodiazepine elimination tracking

Objective

Rapid relapses after successful withdrawal occur even in apparently motivated benzodiazepine (BZD)-dependent patients. Regardless of known personality or biological (re-adaptation) issues, the aim of this open-label, single-arm, seminaturalistic study was to search for any detoxification errors contributing to failures.

Methods

The data came from 350 inpatients. Based on serum-BZD evolution criteria, the procedure was divided into four stages: substitution, accumulation, elimination and post-elimination observation. After switching the patients to a long-acting substitute (diazepam), to prevent data falsification due to unwanted overaccumulation, the doses were expeditiously reduced under laboratory feedback until accumulation stopped. With the start of effective elimination, the tapering rate slowed and was individually adjusted to the patient’s current clinical state. The tracking of both serum-BZD concentration and the corresponding intensity of withdrawal symptoms was continued throughout the entire elimination phase, also following successful drug withdrawal. Detoxification was concluded only after the patient's post-elimination stabilization.

Results

Regardless of various initial serum-BZD concentration levels and the customized dose-reduction rate, and despite the novel lab-driven actions preventing initial overaccumulation, elimination was systematically proven to be protracted and varied within the 2- to 95-day range after the final dose. Within this period, withdrawal syndrome culminated several times, with varying combinations of symptoms. The last crisis occurrence (typically 2–3 weeks after withdrawal) correlated with the final serum-BZD elimination. The factors that prolonged elimination and delayed the final crisis were patient age, duration of addiction, adjunct valproate medication and elimination stage start parameters growing with former overaccumulation.

Conclusions

The low-concentration detoxification stage is critical for patients’ confrontations with recurring withdrawal symptoms. Underestimated elimination time following drug withdrawal and premature conclusions of detoxification expose patients to unassisted withdrawal crises. Concentration tracking defines proper limits for medical assistance, preventing early relapses.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-021-03205-x.

Interventions to reduce benzodiazepine and sedative-hypnotic drug use in acute care hospitals: A scoping review

BACKGROUND

Benzodiazepines and sedative-hypnotic drugs (BZD/SHD) are commonly utilized in the acute care setting for insomnia and anxiety and are associated with cognitive impairment, falls, and fractures. Interventions to reduce use of BZD/SHD in hospitals are not well characterized.

OBJECTIVE

The objective was to conduct a scoping review to identify and characterize interventions to reduce the use of BZD/SHD by adults in the acute care setting.

METHODS

English language studies and abstracts that described an intervention to reduce BZD/SHD in adult hospital patients were included. Six databases (PubMed, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science) were searched up to July 2018 and updated to February 3, 2021. The grey literature (Opengrey, Grey Matters, Google Advanced) was searched up to July 2018. Titles and abstracts were screened and full-text articles were reviewed and charted by three independent reviewers. Stakeholders were consulted to inform the scoping review and collect perspectives on the findings.

RESULTS

There were 13,046 records identified and 43 studies included. The most common study designs were uncontrolled before and after (23/43, 53.5%) and randomized controlled trials (7/43, 16.3%). The majority of studies tested a single intervention (32/43, 74.4%) such as education, deprescribing, relaxation training and sleep protocols. Patients were frequently the target of relaxation training and behavior change interventions; while sleep protocols, multifaceted interventions, education and deprescribing were usually directed at healthcare providers, either alone or in combination with patients. Most studies reported positive results in decreasing BZD/SHD use (27/43, 62.8%).

CONCLUSIONS

The scoping review found a variety of interventions to decrease the utilization of BZD/SHD in hospitals. Multifaceted interventions aimed at patients and healthcare providers that include a combination of education, sleep protocols, and deprescribing may support reductions in BZD/SHD use. Stakeholders also recommended policy and system changes such as computer alerts due to feasibility and workload.

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: A systematic review of randomized trials and non-randomized intervention studies

BACKGROUND

Polipharmacy has been identified as a contributing factor to the high hospital readmission rates of heart failure (HF) patients. Nevertheless, there limited evidence on pharmacist-led intervention on the reduction of inappropriate medication use in patients.

OBJECTIVE

To summarize the available evidence resulting from interventions, led by pharmacists (alone or as part of a professional team), aimed at reducing inappropriate medications in patients with heart failure.

METHODS

A systematic review was conducted using MEDLINE through PubMed, Embase, the Cochrane Library and Scopus until June 2020. We reviewed both randomized controlled trials and non-randomized intervention studies.The quality of evidence was assessed in accordance with the modified Cochrane Collaboration tool to assess risk of bias for randomized controlled trials. The search and extraction process followed PRISMA guidelines.

RESULTS

Of the 4367 records screening, 9 studies were included in the analysis. In 4 (44.4%) studies, the intervention was carried out by a pharmacist working together with a physician; in 4 (44.4%) the intervention was carried out by a pharmacist alone, and in 1 study, the pharmacist collaborated with a nurse. Only 5 (55.5%) studies described the utilization of guidelines or recommendations to carry out the deprescription, and 3 of these showed improved clinical outcomes in the interventional group compared to the control group. The other studies (4, 44.4%) did not follow a specific guideline or recommendation to evaluate the appropriateness of medication, and none of them showed statistically significant differences in clinical outcomes between interventional and control groups.

CONCLUSION

Only those studies where pharmacists evaluated the appropriateness of treatment to specific HF guidelines showed significant differences in patients' clinical outcomes. The development and validation of a specific tool to evaluate medication appropriateness in patients with HF, could contribute to the improvement of patient health.

Reducing prescribing of benzodiazepines in older adults: a comparison of four physician-focused interventions by a medical regulatory authority

BACKGROUND

The inappropriate and/or high prescribing of benzodiazepine and 'Z' drugs (BDZ +) is a major health concern. The purpose of this study was to determine whether physician or pharmacist led interventions or a simple letter or a personalized prescribing report from a medical regulatory authority (MRA) was the most effective intervention for reducing BDZ + prescribing by physicians to patients 65 years of age or older.

METHODS

This was a four-armed, one year, blinded, randomized, parallel-group, investigational trial in Alberta, Canada. Participants were fully licensed physicians (n = 272) who had prescribed 4 times the defined daily dose (4 + DDD) or more of any BDZ + to an older patient at least once in the 3rd quarter of 2016. All physician-participants were sent a personalized prescribing profile by the MRA. They were then randomized into four groups that received either nothing more, an additional personal warning letter from the MRA, a personal phone call from an MRA pharmacist or a personal phone call from an MRA physician. The main outcomes were prescribing behavior change of physicians at one year in terms of: change in mean number of older patients receiving 4 + DDD BDZ + and mean dose BDZ + prescribed per physician. To adjust for multiple statistical testing, we used MANCOVA to test both main outcome measures simultaneously by group whilst controlling for any baseline differences.

RESULTS

All groups experienced a significant fall in the total number of older patients receiving 4 + DDD of BDZ + by about 50% (range 43-54%) per physician at one year, and a fall in the mean dose of BDZ + prescribed of about 13% (range 10-16%). However, there was no significant difference between each group.

CONCLUSIONS

A personalized prescribing report alone sent from the MRA appears to be an effective intervention for reducing very high levels of BDZ + prescribing in older patients. Additional interventions by a pharmacist or physician did not result in additional benefit. The intervention needs to be tested further on a more general population of physicians, prescribing less extreme doses of BDZ + and that looks at more clinical and healthcare utilization outcomes.

Impact of changes in controlled drugs legislation on benzodiazepine receptor agonist prescribing in Ireland: a repeated cross-sectional study

Purpose

To examine the impact of new controlled drugs legislation introduced in May 2017 on benzodiazepine receptor agonist (BZRA) prescribing in Ireland.

Methods

A repeated cross-sectional analysis was conducted using publically available monthly pharmacy claims data from the General Medical Services (GMS) database. The study population comprised all GMS-eligible individuals aged ≥ 16 years from January 2016 to September 2019. Monthly prevalence rates of individuals receiving BZRA prescriptions per 10,000 eligible population were calculated and trends examined over time. Segmented linear regression of prevalence rates was used to examine changes before and after introduction of the legislation stratified by gender and age groups. Regression coefficients (β) and 95% confidence intervals (CIs) for monthly change were calculated.

Results

Pre-legislation (January 2016 to April 2017), there was a significant monthly decline in benzodiazepine prevalence rate (β = − 1.18; 95% CI − 1.84, − 0.51; p < 0.001) but no significant change in Z-drug prescribing. Post-legislation (May 2017 to September 2019), increases in prevalence rates were observed for benzodiazepines (β = 1.04; 95% CI 0.17, 1.92; p = 0.021) and Z-drugs (β = 1.04; 95% CI 0.26, 1.83; p = 0.010). Post-legislation trends showed increases in BZRA prevalence rates among the youngest subgroup (16–44 years), with variable changes in the middle-aged subgroup (45–64 years) and no changes in the oldest subgroup (≥ 65 years).

Conclusions

This study indicates that introduction of new legislation had limited impact on BZRA prescribing on the main public health scheme in Ireland. Interventions targeting specific population subgroups may be required to achieve sustained reductions in prescribing.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-020-03063-z.

Metabolic diversity as a reason for unsuccessful detoxification from benzodiazepines: the rationale for serum BZD concentration monitoring

PURPOSE

Many harms secondary to benzodiazepine (BZD) dependence force users towards detoxification treatment. However, even strongly motivated patients tolerate the process badly or experience early relapse. The detoxification procedure has not yet been standardized. The objective of this paper is to examine the hypothesis that faulty detoxification routines may have caused some failures.

METHODS

The detoxification approaches found in the literature were compared stage by stage. The review was used to identify possible common, across-the-board systematic errors.

RESULTS

The presented literature review confirms that the widespread divergence in the BZD metabolism rate is effectively neglected during detoxification routines. Without laboratory measurements, these differences, additionally interfered with by auxiliary drugs, undermine not only the scheduled but even the symptom-driven procedures. An initial substitution with a long-acting BZD, although recommended, may lead to over-accumulation. This excess, varying between patients and incompatible with the current tapering stage, may lead to repeated overestimation of the patient's adjustments to reduced doses. Consequently, the patient's good clinical presentation at withdrawal, resulting in a conclusion of detoxification, may actually reflect a persistently high serum BZD concentration. The low-concentration stage, if shifted past the end of treatment, exposes patients to unexpected, unassisted withdrawal crises. With laboratory feedback, these crises, unlike the symptoms related to deficient re-adaptation mechanisms, could be prevented. Moreover, by minimizing the high-concentration phase, time can be saved for properly assisted low-concentration challenges.

CONCLUSION

A customized detoxification procedure driven not only by the intensity of withdrawal symptoms but also by serum BZD monitoring may prevent some failures. As the standard regimen, it would make detoxification from BZDs more reliable and effective.

Trends in benzodiazepine receptor agonists use and associated factors in the Belgian general older population: analysis of the Belgian health interview survey data

BACKGROUND

Benzodiazepine receptor agonists (BZRA), which include benzodiazepines and z-drugs, are commonly prescribed for insomnia and anxiety in older adults, and used often long term. Yet, the risk-benefit ratio of BZRA use in older adults may be unfavorable and many recommendations suggest avoidance or a maximal treatment duration of 4 weeks. The aim of this study was to describe trends of BZRA use in older adults and associated factors.

METHODS

Using data from the Belgian Health Interview Survey in 2004 (n = 3594), 2008 (n = 2917), and 2013 (n = 2048), prevalence standardized for age, sex, and region were calculated to assess trends of BZRA use in people ⩾65 years. Analysis of associated factors to BZRA use was performed using a sub-sample of 2013 data for which variables assessing sleeping disorder and anxiety disorder were not missing (n = 1286). Variables from seven main topics were explored using multivariate logistic regression: socio-demographic factors, geriatric factors, comorbidities, subjective health and mental health indicators, social health indicators, medication use and healthcare services use.

RESULTS

Overall, standardized prevalence of BZRA use decreased significantly between 2004 and 2013 [22% to 18%, prevalence difference (95% confidence interval, CI): -4.0% (-6.8; -1.3)]. Factors associated with BZRA use in multivariable analysis included female gender [adjusted odds ratio (aOR) (95%CI) : 1.62 (1.14; 2.29)], poor mental health [aOR (95%CI): 1.73 (1.13-2.63)] a fall in the past 12 months [aOR (95%CI): 1.52 (1.02; 2.26), reporting a sleeping disorder [aOR (95%CI): 1.92 (1.35; 2.72)], polypharmacy [aOR (95%CI): 2.51 (1.75; 3.60)], and trazodone use [aOR (95%CI): 4.05 (1.64; 10.21)].

CONCLUSION

Despite an encouraging decline observed from 2004 to 2013, BZRA use remained highly prevalent in Belgian older adults. Promotion of alternatives to BZRA in treatment of sleeping problems need to be continued. Among BZRA older users, women, the oldest (⩾85 years) and high-risk subgroups should be targeted in deprescribing interventions.

TOP-ID: a Delphi technique-guided development of a prescription and deprescription tool for adults with intellectual disabilities

OBJECTIVES

Adults with an intellectual disability (AWID) are often polymedicated because of somatic and psychiatric health problems. Besides, they may display challenging behaviours, leading to off-label prescription of psychotropic drugs, without efficacy and with numerous adverse effects. In this context, a prescription/deprescription tool (Tool for Optimising Prescription in Intellectual Disability/TOP-ID) was developed to improve the care of AWID. This paper describes how TOP-ID was designed.

DESIGN

Four-step consensus-based process involving a review of the literature, eight semistructured interviews and a two-round Delphi process.

SETTING

Seventeen general practices and university and general hospitals from Belgium, France and Switzerland.

PARTICIPANTS

Eighteen French-speaking physicians from different domains of expertise participated in the Delphi process.

PRIMARY AND SECONDARY OUTCOME MEASURES

For the Delphi iteration process, consensus was defined as at least a 65% agreement between the experts.

RESULTS

Two rounds were needed for the Delphi process. Eighty-one items of the tool were submitted to 18 out of 35 recruited French-speaking experts during the first round. Sixty-nine per cent of the items reached a rate of agreement of 65% or more in that round. Thirteen questions were reformulated and resubmitted for the second Delphi iteration round. All of the statements reached a rate of agreement of 65% or more in the second round.

CONCLUSION

TOP-ID is the first prescription-deprescription tool developed specifically for AWIDs in French. It is intended to help prescribers document patient care in order to reduce prescription errors and to improve safety. The next steps of the project include the development of an electronic version of TOP-ID and a utility study.

Unravelling the Biological Activities of the Byttneria pilosa Leaves Using Experimental and Computational Approaches

Byttneria pilosa is locally known as Harijora, and used by the native hill-tract people of Bangladesh for the treatment of rheumatalgia, snake bite, syphilis, fractured bones, elephantiasis and an antidote for poisoning. The present study was carried out to determine the possible anti-inflammatory, analgesic, neuropharmacological and anti-diarrhoeal activity of the methanol extract of B. pilosa leaves (MEBPL) through in vitro, in vivo and in silico approaches. In the anti-inflammatory study, evaluated by membrane stabilizing and protein denaturation methods, MEBPL showed a significant and dose dependent inhibition. The analgesic effect of MEBPL tested by inducing acetic acid and formalin revealed significant inhibition of pain in both tests. During the anxiolytic evaluation, the extract exhibited a significant and dose-dependent reduction of anxiety-like behaviour in mice. Similarly, mice treated with MEBPL demonstrated dose-dependent reduction in locomotion effect in the open field test and increased sedative effect in the thiopental sodium induced sleeping test. MEBPL also showed good anti-diarrheal activity in both castor oil induced diarrheal and intestinal motility tests. Besides, a previously isolated compound (beta-sitosterol) exhibited good binding affinity in docking and drug-likeliness properties in ADME/T studies. Overall, B. pilosa is a biologically active plant and could be a potential source of drug leads, which warrants further advanced study.

Brief interventions targeting long-term benzodiazepine and Z-drug use in primary care: a systematic review and meta-analysis

AIMS

To assess the effectiveness of brief interventions in primary care aimed at reducing or discontinuing long-term benzodiazepine/Z-drug (BZRA) use.

METHOD

Systematic review of randomized controlled trials of brief interventions in primary care settings aimed at reducing or discontinuing long-term BZRA use in adults taking BZRAs for ≥ 3 months. Four electronic databases were searched: PubMed, EMBASE, PsycINFO and CENTRAL. The primary outcome was BZRA use, classified as discontinuation or reduction by ≥ 25%. The Theoretical Domains Framework (TDF) was used to retrospectively code behavioural determinants targeted by the interventions. The Behaviour Change Technique (BCT) Taxonomy was used to identify the interventions' active components. Study-specific estimates were pooled, where appropriate, to yield summary risk ratios (RRs) and 95% confidence intervals (CIs). Pearson's correlations were used to determine the relationship between intervention effect size and the results of both the TDF and BCT coding.

RESULTS

Eight studies were included (n = 2071 patients). Compared with usual care, intervention patients were more likely to have discontinued BZRA use at 6 months (eight studies, RR = 2.73, 95% CI = 1.84-4.06) and 12 months post-intervention (two studies, RR = 3.41, 95% CI = 2.22-5.25). TDF domains 'knowledge', 'memory, attention and decision processes', 'environmental context and resources' and 'social influences' were identified as having been included in every intervention. Commonly identified BCTs included 'information about health consequences', 'credible source' and 'adding objects to the environment'. There was no detectable relationship between effect size and the results of either the TDF or BCT coding.

CONCLUSION

Brief interventions delivered in primary care are more effective than usual care in reducing and discontinuing long-term benzodiazepine/Z-drug use.

Role of nurses in supporting proactive deprescribing

Deprescribing is the term used to describe the discontinuation of medicines. It can be either 'reactive', for example in response to an adverse event or therapeutic failure, or 'proactive', when the prescriber and patient decide to discontinue the medicine because its future benefits no longer outweigh its potential for harm. At present, there is a limited amount of proactive deprescribing activity in primary and secondary care. This article provides the rationale for increasing proactive deprescribing activity, lists the medicines this relates to, identifies the barriers and enablers to its implementation, and describes the potential role of the nurse in this process.

Benzodiazepine use in Sao Paulo, Brazil

OBJECTIVES

To report the prevalence and factors associated with the use of benzodiazepines in the general population and those with a mental health condition in the metropolitan area of São Paulo, Brazil.

METHODS

5,037 individuals from the Sao Paulo Megacity Mental Health Survey data were interviewed using the Composite International Diagnostic Interview, designed to generate DSM-IV diagnoses. Additionally, participants were asked if they had taken any medication in the previous 12 months for the treatment of any mental health condition.

RESULTS

The prevalence of benzodiazepine use ranged from 3.6% in the general population to 7.8% among subjects with a mental health condition. Benzodiazepine use was more prevalent in subjects that had been diagnosed with a mood disorder as opposed to an anxiety disorder (14.7% vs. 8.1%, respectively). Subjects that had been diagnosed with a panic disorder (33.7%) or bipolar I/II (23.3%) reported the highest use. Individuals aged ≥50 years (11.1%), those with two or more disorders (11.2%), those with moderate or severe disorders (10%), and those that used psychiatric services (29.8%) also reported higher use.

CONCLUSION

These findings give an overview of the use of benzodiazepines in the general population, which will be useful in the public health domain. Benzodiazepine use was higher in those with a mental health condition, with people that had a mood disorder being the most vulnerable. Furthermore, females and the elderly had high benzodiazepine use, so careful management in these groups is required.

Passing the acid test? Evaluating the impact of national education initiatives to reduce proton pump inhibitor use in Australia

BACKGROUND

Proton pump inhibitor (PPI) use is widespread. There have been increasing concerns about overuse of high-dose PPIs for durations longer than clinically necessary.

OBJECTIVE

To evaluate the impact of national education initiatives on reducing PPI use in Australia.

DESIGN

Population-based, controlled interrupted time series analysis of PPI dispensing claims data for Australian adults from July 2012 to June 2018; we used statin dispensing as a control.

INTERVENTIONS

A year-long educational initiative led by NPS MedicineWise (previously the National Prescribing Service) from April 2015. Simultaneously, Choosing Wisely released recommendations in April 2015 and May 2016. Both promoted review of prolonged PPI use and encouraged stepping down or ceasing treatment, where appropriate.

MEASUREMENTS

We examined monthly changes in PPI (and statin) dispensing (stratified by high, standard and low tablet strength), rates of switching from higher to lower strength PPIs and rates of PPI (and statin) discontinuation.

RESULTS

We observed 12 040 021 PPI dispensings to 579 594 people. We observed a sustained -1.7% (95% CI: -2.7 to -0.7%) decline in monthly dispensing of standard strength PPIs following the initiatives until the end of the study period. There were no significant changes in high or low strength PPI (or statin) dispensings, switching to lower strength PPIs, or PPI (and statin) treatment discontinuation.

CONCLUSION

Our findings suggest that these educational initiatives alone were insufficient in curbing overuse of PPIs on a national level. Concerted efforts with policy levers such as imposing tighter restrictions on subsidised use of PPIs may be more effective. Noting low strength esomeprazole is not publicly subsidised in Australia, availability of these preparations may also facilitate more appropriate practice.

Effect of reimbursement restriction policy on the use of benzodiazepines in the Netherlands: an interrupted time series analysis

OBJECTIVES

Use of benzodiazepines has health risks. Reimbursement was restricted in the Netherlands from January 2009 onwards with the goal to reduce chronic use and healthcare expenditures. The aim of this study is to assess the initial and long-term effects of this policy on benzodiazepine use.

DESIGN

Interrupted time series analysis, segmented regression models, Kaplan-Meier survival analysis and Cox proportional hazards analysis.

SETTING

A 10% random sample of benzodiazepine dispensings by outpatient pharmacies between January 2002 and August 2015 were obtained from the PHARMO database. This database covered a catchment area representing about 3.6 million residents in 2015.

PARTICIPANTS

2 500 800 benzodiazepine prescriptions from 128 603 patients were included.

INTERVENTION

Reimbursement restriction policy from January 2009 onwards.

OUTCOME MEASURES

Changes in: the volume of dispensed prescriptions and doses, the incidence, prevalence of incidental, regular and chronic use and discontinuation rates of benzodiazepines.

RESULTS

The volume of dispensed prescriptions and doses decreased by 12.5% (95% CI 9.0% to 15.9%) and 15.1% (95% CI 11.4% to 17.3%) respectively in January 2009 compared with December 2008. A clear initial effect on the overall incidence (-14.7%; 95% CI -19.8% to 9.6%) and the prevalence of incidental (-17.8%; 95% CI -23.9% to 11.7%), regular (-20.0%; 95% CI -26.1% to 13.9%) and chronic (-16.0%; 95% CI -23.1% to 8.9%) use was observed. A statistically significant reduction in the monthly trend per 1000 medication users was observed for the overall incidence (-0.017; 95% CI -0.031 to 0.003) and the prevalence of incidental (-3.624; 95% CI -4.996 to 2.252) but not for regular (-0.304; 95% CI -1.204 to 0.596) and chronic (0.136; 95% CI -0.858 to 1.130) use. Patients who started treatment before policy had a slightly higher probability of discontinuation (HR=1.013; 95% CI 1.004 to 1.022).

CONCLUSIONS

The reimbursement policy had a significant initial effect on the volume, incidence and prevalence of benzodiazepine use. In addition, there is a statistically significant reduction in the monthly trend of overall incidence and of the prevalence of incidental use. No statistically significant reduction in the monthly trend of chronic use, the main purpose of the reimbursement restriction, could be demonstrated.

Reduction of Benzodiazepine Use in Patients Prescribed Medical Cannabis

Background: Benzodiazepines are a class of medication with sedative properties, commonly used for anxiety and other neurological conditions. These medications are associated with several well-known adverse effects. This observational study aims to investigate the reduction of benzodiazepine use in patients using prescribed medical cannabis.

Methods: A retrospective analysis was performed on a cohort of 146 medical cannabis patients (average age 47 years, 61% female, 54% reporting prior use of cannabis) who reported benzodiazepine use at initiation of cannabis therapy. These data are a part of a database gathered by a medical cannabis clinic (Canabo Medical). Descriptive statistics were used to quantify associations of the proportion of benzodiazepine use with time on medical cannabis therapy.

Results: After completing an average 2-month prescription course of medical cannabis, 30.1% of patients had discontinued benzodiazepines. At a follow-up after two prescriptions, 65 total patients (44.5%) had discontinued benzodiazepines. At the final follow-up period after three medical cannabis prescription courses, 66 total patients (45.2%) had discontinued benzodiazepine use, showing a stable cessation rate over an average of 6 months.

Conclusion: Within a cohort of 146 patients initiated on medical cannabis therapy, 45.2% patients successfully discontinued their pre-existing benzodiazepine therapy. This observation merits further investigation into the risks and benefits of the therapeutic use of medical cannabis and its role relating to benzodiazepine use.

Availability and readability of patient education materials for deprescribing: An environmental scan

AIMS

To identify and evaluate content and readability of freely available online deprescribing patient education materials (PEMs).

METHODS

Systematic review of PEMs using MEDLINE, Embase, CINAHL, PsycINFO and The Cochrane Library of Systematic Reviews from inception to 25 September 2017 to identify PEMs. Additionally, deprescribing researchers and health professionals were surveyed to identify additional materials. Known repositories of materials were searched followed by a systematic Google search (22-28 January 2018). Materials were evaluated using an approach informed by the Patient Education Material Assessment Tool and the International Patient Decision Aids Standards Inventory. Readability of text-based materials was assessed using the US-based Gunning-Fog Index and Flesch-Kincaid Grade level.

RESULTS

Forty-eight PEMs were identified. PEMs addressing deprescribing of medications for symptom control (81%) were most common. Preventative medications were rarely addressed and material (39%) focused on older people. Only 37% of PEMs provided information about both potential benefits (e.g. reducing risk of side effects) and harms (e.g. withdrawal symptoms, increased risk of disease) of deprescribing, while 40% focussed on benefits only. Readability indices indicated an average minimum reading level of Grade 12. Option Grids and Decision Aids (mean reading level below Grade 10) were most suitable for people with average literacy levels.

CONCLUSIONS

Over 1/3 of deprescribing PEMs present potential benefits and harms of deprescribing indicating most of the freely available materials are not balanced. Most PEMs are pitched above average reading levels making them inaccessible for low health literacy populations.

Health professionals' and researchers' opinions on conducting clinical deprescribing trials

While clinical deprescribing trials are increasingly being performed, there is no guidance on the optimum conduction of such studies. The aim of this survey was to explore the perspectives, attitudes, interests, barriers, and enablers of conducting clinical deprescribing trials among health professionals and researchers. An anonymous survey was developed, reviewed, and piloted by all investigators and informed by consultation with experts, as well as current deprescribing guidelines. The questions were formulated around current clinical trial frameworks and incorporated identified enablers and barriers of performing deprescribing studies. The survey was sent to members of Australian and international deprescribing, pharmacological, and pharmacy organizations, and other researchers published in deprescribing. A total of 96 respondents completed the survey (92.3% completion rate). Respondents indicated the main deprescribing trial rationale is to generate evidence to optimize patient-centered outcomes (79.2%). Common barriers identified included the time and effort required (18.2%), and apprehension of health professionals involved in trials (17.1%). Studies are enabled by positive attitudes toward deprescribing of treating prescribers (24.4%) and patients (20.9%). Classical randomized controlled trials (RCTs) were deemed the most appropriate methodology (93.2%). Sixty percent of participants indicated a good clinical practice framework is required to guide the conduct of deprescribing trials. There were no significant differences in responses based on previous experience in conducting clinical deprescribing trials. In conclusion, clinical deprescribing trials should be conducted to investigate whether deprescribing medications improves patient care. A future deprescribing trial framework should use classical RCTs as a model, ensure participant safety, and target patient-centered outcomes.

An Insight into Z-Drug Abuse and Dependence: An Examination of Reports to the European Medicines Agency Database of Suspected Adverse Drug Reactions

BACKGROUND

Although originally marketed as safe alternatives to the habit-forming benzodiazepines, growing numbers of zaleplon, zolpidem, and zopiclone ("Z-drugs") clinical concerns relating to their potential of abuse, dependence, and withdrawal have been reported over time. We aimed here at assessing these issues analyzing datasets of adverse drug reactions provided by the European Medicines Agency through the EudraVigilance system.

METHODS

Analyzing the adverse drug reactions databases of each Z-drug, descriptive analyses have been performed on cases and proportional reporting ratios (PRRs) computed.

RESULTS

An overall number of 33 240 (e.g., 23 420 zolpidem; 9283 zopiclone; and 537 zaleplon) misuse-, abuse-, dependence-, and withdrawal-related adverse drug reactions, corresponding to some 6246 unique patients given Z-drugs, were here identified. Cases were studied and described, including demographic characteristics and clinical data such as concomitant drugs, doses, routes of administration, and outcomes of the reactions (being fatalities recorded). Considering PRR values and in comparison with zopiclone, zolpidem was more frequently involved in both misuse/abuse and withdrawal issues. Zolpidem and zopiclone presented with the same dependence risk, but zopiclone was most involved in overdose adverse drug reactions. Compared with zaleplon, zopiclone presented higher dependence and overdose-related issues but slightly lower misuse/abuse and withdrawal PRR values.

CONCLUSION

Current data may only represent a gross underestimate of the real prevalence of Z-drug misuse. Caution should be exercised when prescribing those molecules, especially for patients with psychiatric illnesses and/or history of drug abuse. We recommend the need to invest in proactive pharmacovigilance activities to better and promptly detect, understand, and prevent any possible misuse potential of prescribed medications.

Barriers and Facilitators to the Deprescribing of Nonbenzodiazepine Sedative Medications Among Older Adults

INTRODUCTION

Nonbenzodiazepine sedative-hypnotic medications, or "Z-drugs," are commonly used to treat insomnia among older adults (≥ 65 years), despite a lack of evidence of long-term effectiveness and evidence linking long-term use with poor outcomes.

OBJECTIVE

To understand patient and clinician barriers and facilitators to deprescribing, or discontinuation, of Z-drugs.

METHODS

We conducted a qualitative interview study among older adults who received a deprescribing intervention and among their clinicians at Kaiser Permanente Northwest. Semistructured interviews explored perceived barriers and facilitators to successful deprescribing of Z-drugs. Interviews were audiorecorded with participant permission. Content was analyzed using QSR NVivo 10 software.

RESULTS

From the perspectives of patients, the greatest challenges to deprescribing are factors related to their insomnia, including the need for effective treatment of their insomnia; health care system factors, including a desire for personalized approaches to care; and their own positive personal experiences with sedative medication use. From the clinician perspective, a lack of institutional structures and resources to support deprescribing, the attitudes and practices of previous clinicians, and patient-related factors such as dependence and a lack of alternatives to treat insomnia were the most important barriers to deprescribing.

CONCLUSIONS

Health care systems must provide individualized care that supports patient goals for restful sleep and quality of life while also providing evidence-based care that takes patient safety into account. To accomplish this, systems must support patients and clinicians and provide a multidisciplinary approach that addresses insomnia treatment, provides patient education about sedative medication use, and supports the discontinuation process.

Pharmacologic Treatment of Sleep Disorders in Pregnancy

Pregnancy often predisposes women to new-onset sleep disturbances, as well as exacerbations of preexisting sleep disorders. The goals of treating perinatal sleep disorders include the promotion of restorative sleep and the benefits it brings to both mother and fetus. The prescribing of any sleep aid in pregnancy must include consideration of the risks and benefits for both the patient and her fetus. Although data on the perinatal use of sleep aids is limited, there may be effects on fetal development, timing and duration of delivery, and postnatal outcomes.