patient care perspectives

Deprescribing Benzodiazepine Receptor Agonists Taken for Insomnia

by John W. Winkelman, MD, PhD

Overview

Benzodiazepine receptor agonist (BZRA) deprescribing is recognized as an important yet challenging endeavor, particularly in older patients being treated for insomnia. Given the risks associated with the long-term use of BZRAs, discontinuation should, at the very least, be attempted in most cases, with accompanying tools and appropriately set patient expectations.

Expert Commentary

John W. Winkelman, MD, PhD

Professor of Psychiatry
Chief, Sleep Disorders Clinical Research Program
Department of Psychiatry
Massachusetts General Hospital
Harvard Medical School
Boston, MA

“Deprescribing BZRAs (benzodiazepines and nonbenzodiazepines) for insomnia is an important topic that is not well covered in medical education.”

John W. Winkelman, MD, PhD

Deprescribing BZRAs (benzodiazepines and nonbenzodiazepines) for insomnia is an important topic that is not well covered in medical education. The issue becomes increasingly relevant in older age groups, as shown by Maust et al, who found that the rate of new benzodiazepine visits was relatively constant across age groups. There was, however, an increase in the overall benzodiazepine visit rate among older adults, which was largely due to the increasing rate of continuation visits. Patients aged 80 years and older have much higher rates of BZRA treatment, particularly over the long-term, and long‐term BZRA treatment is associated with increased risk of falls, fractures, motor vehicle accidents, and cognitive impairment. Still, many prescribers hesitate to attempt deprescribing BZRAs, often because the process itself is time consuming and is associated with such withdrawal symptoms as short-term insomnia, anxiety, and restlessness. 

In their review of practice guidelines, Lee et al included the recommendation that, in community or long‑term care settings where BZRAs are used for insomnia, a slow taper of BZRAs should be attempted for all adults aged 65 years and older. While deprescribing is important, it is also recognized as challenging. Patients want to sleep, and they may become distressed by not being able to sleep. It is important to set realistic expectations and to help patients recognize that there may be unwelcomed effects during tapering. Referring patients for short-term cognitive behavioral therapy can also be helpful; however, data showing success with this approach are limited.

On the other hand, it is important to keep in mind that some patients may require long-term BZRA treatment for insomnia and that it is possible to become overzealous with deprescribing. While some practitioners may consider many, if not most, cases of insomnia to be symptomatic of some other underlying disorder, this is not always the case. The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) recognizes that clinical insomnia may be a primary disorder, not simply a symptom of psychiatric, neurologic, or medical illness. The US Food and Drug Administration has set no specific limit on the length of time that BZRAs can be used to treat patients with insomnia. Still, given the risks associated with the long-term use of BZRAs, discontinuation should at least be attempted in most cases, with accompanying tools and appropriately set patient expectations to help maximize the odds of success.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.

Laforgue E-J, Jobert A, Rousselet M, et al. Do older people know why they take benzodiazepines? A national French cross-sectional survey of long-term consumers. Int J Geriatr Psychiatry. 2020;35(8):870-876. doi:10.1002/gps.5307

Lee JY, Farrell B, Holbrook AM. Deprescribing benzodiazepine receptor agonists taken for insomnia: a review and key messages from practice guidelines [published correction appears in Pol Arch Intern Med. 2019;129(2):145]. Pol Arch Intern Med. 2019;129(1):43-49. doi:10.20452/pamw.4391

Lichstein KL, Nau SD, Wilson NM, et al. Psychological treatment of hypnotic-dependent insomnia in a primarily older adult sample. Behav Res Ther. 2013;51(12):787-796. doi:10.1016/j.brat.2013.09.006

Maust DT, Kales HC, Wiechers IR, Blow FC, Olfson M. No end in sight: benzodiazepine use in older adults in the United States. J Am Geriatr Soc. 2016;64(12):2546-2553. doi:10.1111/jgs.14379

Maust DT, Lin LA, Goldstick JE, Haffajee RL, Brownlee R, Bohnert ASB. Association of Medicare Part D benzodiazepine coverage expansion with changes in fall-related injuries and overdoses among Medicare advantage beneficiaries. JAMA Netw Open. 2020;3(4):e202051. doi:10.1001/jamanetworkopen.2020.2051

Moore TJ, Mattison DR. Assessment of patterns of potentially unsafe use of zolpidem. JAMA Intern Med. 2018;178(9):1275‐1277. doi:10.1001/jamainternmed.2018.3031

Morin CM, Bastien C, Guay B, Radouco-Thomas M, Leblanc J, Vallières A. Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. Am J Psychiatry. 2004;161(2):332-342. doi:10.1176/appi.ajp.161.2.332

Ng BJ, Le Couteur DG, Hilmer SN. Deprescribing benzodiazepines in older patients: impact of interventions targeting physicians, pharmacists, and patients. Drugs Aging. 2018;35(6):493-521. doi:10.1007/s40266-018-0544-4

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