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Editorial, Apr/23: Deprescribing long-term use of benzodiazepines in primary care practice: where to next?


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Globally, insomnia management guidelines now mandate that benzodiazepine (BDZ)/benzodiazepine receptor agonist (BZRA) use is limited to short-term periods (up to four weeks) [1]. Patients are provided evidence-based non-pharmacological behavioral treatments such as cognitive behavioral treatment for insomnia (CBTi), and when prescribing occurs, plans are put in place to deimplement, deprescribe, or discontinue use after the recommended period using recommended tapering guidelines. Clinicians are increasingly turning to initiate BDZ/BZRA prescriptions with caution, in a phenomenon referred to as “reluctant pharmaceuticalization,” [2] but often use this resort in the face of the patient, practice, or systemic barriers.

The problem remains that there are significant numbers of long-term benzodiazepine users in communities/institutionalized care settings who continue benzodiazepine use despite not deriving clinically meaningful sleep-related benefits from the medication and yet being exposed to a significant likelihood of experiencing harmful adverse effects [1]. There is increasing recognition that deprescribing or discontinuation of BDZ/BZRAs in long-term users requires more than a stepped reduction in a dose—given the issue of dependence, beliefs about the “need” for the medicine to help sleep, and reduced self-efficacy which need to be addressed through psychological approaches. BDZ/BZRA discontinuation trials are increasing including CBTi as a tool to aid the process [3, 4]. Primary care, where much of the prescribing of benzodiazepines and other sedatives occurs, remains the key point for initiating and supporting the discontinuation process. Examples of studies investigating the effect of CBTi interventions on sedative-hypnotic use in the primary care setting are showcased in Table 1 below. Therapist-delivered and interactive digital CBTi programs delivered concurrently with sedative-hypnotic tapering programs have also been shown to improve insomnia and facilitate sedative-hypnotic cessation in various settings and patient groups [5, 6].





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