Aging & Mental Health

ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20

Interventions to improve benzodiazepine tapering

success in the elderly: a systematic review

Carol Dou, Johannes Rebane & Stan Bardal

To cite this article: Carol Dou, Johannes Rebane & Stan Bardal (2018): Interventions to improve
benzodiazepine tapering success in the elderly: a systematic review, Aging & Mental Health, DOI:
10.1080/13607863.2017.1423030

To link to this article: https://doi.org/10.1080/13607863.2017.1423030

Published online: 16 Jan 2018.

Submit your article to this journal

Article views: 3

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=camh20
AGING & MENTAL HEALTH, 2018
https://doi.org/10.1080/13607863.2017.1423030

Interventions to improve benzodiazepine tapering success in the elderly: a

systematic review
Carol Dou, Johannes Rebane and Stan Bardal
University of British Columbia, Vancouver, Canada

ABSTRACT ARTICLE HISTORY

Background: Long-term benzodiazepine use in the elderly population is a significant public health Received 27 May 2017
problem that leads to impaired cognitive functioning, medication dependence and increased risks for Accepted 23 December 2017
adverse drug reactions. The aim of this review was to examine randomized controlled trials (RCTs) on KEYWORDS
the efficacy of different methods for tapering and discontinuing benzodiazepines. Elderly; senior;
Method: We used four databases (Ovid, PubMed, Academic Search Complete, Web of Science) to benzodiazepine; tapering;
retrieve randomized controlled trials published in peer-reviewed journals that explored different discontinuation; review; CBT;
methods for tapering benzodiazepine use in a primarily geriatric population. cognitive behavioural
Results: Eleven papers met the inclusion criteria. Methods to assist in benzodiazepine tapering therapy; patient education;
included patient education, cognitive behavioural therapy (CBT), and pharmaceutical adjuvants SSRIs; melatonin;
(SSRIs, melatonin, progesterone). Patient education was consistently effective in increasing progesterone
benzodiazepine discontinuation success while CBT had mixed but promising results. The use of
medications to help improve tapering success was inconclusive.
Conclusions: Patient education is a successful, time- and cost-effective intervention that can
significantly help with benzodiazepine discontinuation success. CBT may also be an effective
approach. However, cost can be an issue since public healthcare coverage in Canada does not cover
psychotherapy. More research is needed in looking at pharmaceutical adjuvants and their role in
assisting with benzodiazepine discontinuation.

Introduction largest significant impact on the probability of being a long-

term benzodiazepine user, and further, that benzodiazepine
Benzodiazepines (BZD) are generally indicated for the short-
users 75 or older were the most likely to use long-term (Wey-
term treatment of anxiety and sleep disorders. However, they
mann et al., 2017).
are commonly prescribed for long-term use in the senior pop-
Current Canadian opioid prescription guidelines call for
ulation. Problems arising from continual use of BZD include
tapering of BZDs to reduce the risk of adverse drug-related
dependence, tolerance, cognitive impairment, and psycho-
events such as falls, and to increase alertness and energy in
motor impairment leading to increased risks of falls in the frail
patients (Kahan, Mailis-Gagnon, Wilson, & Srivastava, 2011).
elderly (Tannenbaum, 2015).
There are currently no evidence-based guidelines in Canada
Current Canadian prescribing guidelines warn against the
for the discontinuation of long-term BZD use in the elderly
prescription of BZD for the elderly and cite delirium, falls, hip
population. Simple medication tapering may not be effective
fractures, and cognitive impairment as associated factors with
in long-term users and little evidence is available for health-
use in this population (Katzman et al., 2014). Guidelines also
care practitioners on the optimal methods to reduce patient
suggest limiting prescriptions to two to four weeks with regu-
BZD use. This review consolidates current RCT results to eluci-
lar prescription reviews to assess the safety and efficacy of
date an approach for healthcare professionals to encourage
the medication (Katzman et al., 2014). Despite these recom-
BZD discontinuation in elderly users.
mendations, the prevalence of long-term BZD use in the
The objective of this paper is to review and assess random-
elderly in British Columbia (BC), Canada is high (Canadian
ized controlled trials that address the ensuing research ques-
Society of Family Physicians, 2005). BC is a province of 4.5 mil-
tion: Are there certain interventions for reducing
lion people on Canada’s west coast with a diverse population
benzodiazepine use that are more effective than simple BZD
and an extensive, publicly-funded health care system. There is
dose tapering that is the current standard in Canada? To
a publicly-funded drug plan which functions under a co-pay
address this research question, a systematic review of the lit-
system, and all prescriptions (with the exception of specialty
erature was performed, including a critical appraisal of
areas such as cancer and HIV) in the province are tracked in
included studies.
an administrative database known as PharmaNet (Caetano,
Raymond, Morgan, & Yan, 2006). Analysis of PharmaNet data
shows that 3.5% of BC residents use BZD long-term with Methods
nearly half of all long-term users over the age of 65 and more
than a quarter are 75 or older (Weymann, Gladstone, Smolina, Literature search strategy
& Morgan, 2017). In a 2017 paper by Weymann et al. using BC The literature search aimed to identify randomized controlled
PharmaNet data, it was found that being a senior had the trials which assessed BZD withdrawal success as an outcome

CONTACT Carol Dou [email protected]

© 2018 Informa UK Limited, trading as Taylor & Francis Group
2 C. DOU ET AL.

Table 1. Concepts and terms used for literature search. Description and assessment of selected studies
Concepts Terms
Eleven studies were selected based on the inclusion crite-
Benzodiazepine Benzodiazepine, BZD, [exploded]
Tapering Taper, Tapering, withdrawal, discontinuation ria above to ensure that they focused on a primarily
Elderly Elder, Elderly, Senior, Aged, [exploded] elderly population who used benzodiazepines on a regular
basis. These studies were then reviewed and assessed
based on study design, primary objective, population, out-
come, exposure, comparison, result, strengths and weak-
variable and differing withdrawal interventions as a primary
nesses, and risks and sources of bias leading to potential
explanatory variable in elderly populations. The research
underestimation or overestimation of measured effects.
question was assessed for male and female seniors with aver-
The Cochrane Risk of Bias Tool was used and any potential
age age >60 and minimum age of 50 who used benzodiaze-
biases are noted in the discussion (Higgins et al., 2011). In
pines for a minimum of 3 months, regardless of nationality,
addition to the individual assessment of these factors, the
and compared the outcomes of seniors given standard treat-
studies within each thematic group were compared and
ment versus different interventions. The primary outcome
contrasted based on their exposures, outcomes, and sour-
was the percentage of participants completely tapered off
ces of potential bias.
BZD by the end of the study or follow-up period.
Studies were identified using four databases spanning the
medical and health sciences (Ovid, PubMed, Academic Search
Complete, Web of Science). Grey literature and other non- Results
indexed articles were examined using Google Scholar and the Eleven RCTs met the inclusion criteria and compared standard
University of British Columbia’s library search function. Vari- BZD tapering to tapering in conjunction with CBT (Baillar-
ous terms (identified in Table 1) were used across the data- geon, Landreville, Verreault, Beauchemin, & Morin, 2003;
bases to search for the concepts relevant to the question B

elanger, Morin, Bastien, & Ladouceur, 2005; Voshaar, Gorgels,
being assessed. & Zitman, 2003), patient education (Tannenbaum, Martin,
Where databases allowed it, the keywords outlined in Tamblyn, Benedetti, & Ahmed, 2014; Vicens et al., 2006, 2014),
Table 1 were ‘exploded’ to include subtopics based on terms and medication (Garfinkel, Zisapel, Wainstein, & Laudon,
selected from MeSH terms. Otherwise, the keywords were 1999; Nakao, Takeuchi, Nomura, Teramoto, & Yano, 2006;
included as ‘Subjects’ and, additionally, searched for based on Schweizer, Case, Garcia-Espana, Greenblatt, & Rickels, 1995;
presence in the title and abstract of the journal article. A total Vissers, Knipschild, & Crebolder, 2007). The studies are sum-
of 10 subjects were used. marized in Tables 2–4 and Figure 2.
From the database searches completed, titles and
abstracts of relevant articles (n = 257) were exported to Micro-
soft Excel. After screening for duplicates (n = 46), articles
CBT and tapering
which had relevant explanatory and outcome variables, dis-
cussed a relevant randomized controlled study, studied a All three studies had similar design but lacked blinding. The
population with an average age older than 60 years, were lack of a blinded control group makes it difficult to tease out
written in English, published after 1990, and patients without the added placebo effect associated with the treatment arm.
any other significant psychiatric comorbidities were included The primary outcome measure was number of patients who
in the final set of studies for further review (n = 11). We used were BZD-free at the end of the intervention (10 weeks in
1990 as a cut-off date since there were few papers published Study 1, 12 weeks in Study 2, 6 weeks in Study 3) analyzed
on the topic before then, and BZDs did not become com- with intention to treat analysis. Study 2 also included a 12-
monly prescribed medications with known risks until the month follow-up. Study 2 and 3 had objective outcome meas-
1990s (Wick, 2013). An outline of the search strategy is pro- ures, using blood screening for BZD and family physician pre-
vided in Figure 1. scribing records to verify BZD discontinuation, respectively.
Study 1 relied solely on patient sleep diary data, which may
be more unreliable.
While the first two studies found significant benefit in
CBT, the third study found tapering alone to be equally as
effective. Lack of efficacy in Study 3 may be attributed to
fewer CBT sessions. Participants were offered 5 sessions as
compared to 8 and 10 in Studies 2 and 1, respectively.
Adherence to attending CBT was poor and the rate of
study drop-out was also markedly higher in Study 3: 30%
as compared to 10% in study 1 and 11% in study 2. This
may reflect an overall resistance to therapy within the
group as well as a lack of access to a sufficient number of
CBT sessions.
Tapering off and CBT were tolerated well and health care
professionals did not report any major adverse event during
the process. Overall, studies suggest that tapering and CBT
combined are beneficial, but where CBT is not available,
tapering itself with good primary care may be a good alterna-
Figure 1. Literature search strategy. tive (Figure 3).
 AGING & MENTAL HEALTH 3

Table 2. Description and characteristics of CBT + tapering studies.

Study 1 Study 2 Study 3
Title Self-efficacy and compliance with Discontinuation of benzodiazepines among older Tapering off long-term benzodiazepine use with
benzodiazepine taper in older insomniac adults treated with cognitive- or without group cognitive-behavioural
adults with chronic insomnia behavioural therapy combined with gradual therapy: three-condition, randomised controlled
tapering: a randomized trial trial
Authors and year B
elanger et al. (2005) Baillargeon et al. (2003) Voshaar et al. (2003)
Study Single centre Single centre Single centre
characteristics Non-blinded Non-blinded Non-blinded
Canada Canada Netherlands
Primary objective Patients completely discontinued Patients completely discontinued BZD at 3 month Patients completely discontinued BZD at end of 6
BZD at end of 10 week taper and 12 month post-taper follow up week taper
Population N = 52 N = 65 N = 180
Mean age: 63 Mean age: 67 Mean age: 63
Chronic insomnia taking BZD for Chronic insomnia taking BZD every night for >3 Taking BZD >3 months for at least 60 days out
>3 months for at least 50% of months of the last 3 months
nights 57%F 70%F
48%F
Exposure 10 week physician supervised 8 week physician supervised tapering with weekly Transferred to equivalent dose of diazepam, then
tapering with weekly small- small-group CBT sessions tapered 25% per week for 4 weeks. 5 small-
group CBT group CBT sessions started halfway through
tapering period and finished 2 weeks after
conclusion
Outcome Significant Significant CBT did not increase the success rate (58% vs.
CBT 85% success rate compared At 12-months, CBT 70% success rate compared to 62%)
with 48% in taper only group (p 24% in taper only group (p < 0.05)
< 0.01)
%F: percent of study group that were female. Success rate defined as percentage of participants completely discontinued BZD usage.

Table 3. Description and characteristics of patient education + tapering studies.

Study 4 Study 5 Study 6
Title Withdrawal from long-term Comparative efficacy of two interventions to Reduction of inappropriate benzodiazepine
benzodiazepine use: randomised discontinue long-term benzodiazepine use: prescriptions among older adults through direct
trial in family practice cluster randomised controlled trial in primary patient education: the EMPOWER cluster
care randomized trial
Authors and year Vicens et al. (2006) Vicens et al. (2014) Tannenbaum et al. (2014)
Study Multicentre Multicentre Multicentre
characteristics Non-blinded Non-blinded Blinded
Spain Spain Canada
Primary objective Patients completely discontinued Patients completely discontinued from BZD at Patients completely discontinued from BZD at 6
from BZD at 12 months 12 months months
Population N = 139 N = 532 N = 303
Mean age: 60 Mean age: 65 Mean age: 75
Taking BZD daily >1 year Taking BZD >6 months Taking BZD >3 months
82%F 71%F 69%F
Exposure Standardized advice from GPs and a GPs give usual care, tapering with office visits, Written document describing risks of BZD use and
tapering schedule (25% per visit) or tapering with written instructions stepwise tapering protocol from pharmacy
with biweekly follow up visits
Outcome 45% success rate in intervention 45% success rate in both intervention groups 27% success rate in intervention group vs. 5% in
group vs. 9% in control group vs. 15% in control group control group
relative risk = 4.97 Relative risk = 3.01 NNT = 4p < 0.01
p < 0.01 p < 0.0001
GP: general practitioner; %F: percent of study group that were female. Success rate defined as percentage of participants completely discontinued BZD usage.

Patient education and tapering Medication and tapering

The three included studies compared standardized advice Melatonin in all three included studies was well-tolerated and
from healthcare professionals to usual care. The control sleep quality either remained the same or improved for users.
arm received usual care and did not have any tapering However, there is insufficient evidence to support the use of
protocol while the treatment arm received both a tapering melatonin for increasing BZD tapering success. Studies 8 and
schedule and patient education. Due to this, the effect of 9 found no benefit to using melatonin when compared to pla-
tapering cannot be distinguished from the effect of the cebo. Study 7 found significant benefit to melatonin therapy.
patient education. Studies 4 and 5 were unblinded, which Conflicting results about efficacy may have been due to differ-
may contribute to patient, observer, and care provider ent study designs. While in study 7 patients were given the
bias. Despite minor differences in study design and follow- opportunity to continue taking melatonin throughout the fol-
up lengths, all three studies found that patient education, low-up period, studies 8 and 9 did not offer this option. Study
ranging from standardized FP advice to written instruc- 9 provided psychosocial support for participants which makes
tions to pharmacist counselling could significantly increase separating the effects of patient education with that of mela-
patient BZD tapering efficacy. Study 5 showed that there tonin difficult. Sample size for studies 7 and 8 were relatively
is also no difference between regular in-person education small.
sessions with the FP and written instructions given to Some research has suggested that progesterone metabo-
patients (Figure 4). lites are barbiturate-like modulators of GABAergic function.
4 C. DOU ET AL.

Table 4. Description and characteristics of medications + tapering studies.

Study 7 Study 8 Study 9 Study 10 Study 11
Title Facilitation of Is melatonin helpful in Melatonin for sedative Progesterone co- Clinical application of
benzodiazepine stopping the long-term withdrawal in older administration in paroxetine for tapering
discontinuation by use of hypnotics? A patients with primary patients discontinuing benzodiazepine use in
melatonin: a new clinical discontinuation trial insomnia: a long-term non-major-depressive
approach randomized double- benzodiazepine therapy: outpatients visiting an
blind placebo- effects on withdrawal internal medicine clinic
controlled trial severity and taper
outcome
Authors and year Garfinkel et al. (1999) Vissers et al. (2007) L€ahteenm€aki, Schweizer et al. (1995) Nakao et al. (2006)
Puustinen, and
Vahlberg (2014)
Study Double blinded Double blinded Double blinded Double blinded Non-blinded
characteristics Single centre Multicentre Single centre Single centre Single centre
Israel Netherlands Finland USA Japan
Primary objective Patients completely Patients completely Patients completely Patients completely Patients completely
discontinued BZD at end discontinued BZD 1 discontinued BZD 1 discontinued BZD 12 discontinued BZD 8
of study and 6 months year post intervention month and 6 months weeks post taper weeks after start of taper
follow-up post start of
intervention
Population N = 34 N = 38 N = 92 N = 43 N = 97
Mean age: 68 Mean age: 68 Mean age: 65 Mean age: 60 Mean age: 60
Using BZD daily for 6 Using BZD for sleep >3 Using BZD for >1 year of continual BZD Using BZD for >3
months months, minimum insomnia >1 month use months
74%F 3 days per week 30%F 34%F 67%F
58%F
Exposure 2 mg melatonin CR daily for BZD converted to Melatonin 2 mg for 1 Progesterone was titrated 10–20 mg of paroxetine
6 weeks, and patients equivalent dose of month while tapering to a mean daily dose of daily while tapering BZD
encouraged to reduce BZD diazepam Tapered 25% BZD. Sleep hygiene 1983 mg, given until 4 25% every 2 weeks
dosage to 0 by week 5/6. per week. 5 mg counselling provided weeks after stopping
Allowed to continue taking melatonin daily until 6 BZD. BZD tapered 25%
melatonin following end of weeks after stopping per week
taper BZD
Outcome 78% success rate in No significant differences No significant No significant differences 46% success rate in
melantonin group vs. 25% differences intervention group vs.
in control group 17% in control group (p
(p = 0.006) < 0.03)
GP: general practitioner; %F: percent of study group that were female. Success rate defined as percentage of participants completely discontinued BZD usage.

(Dijk & Cajochen, 1997) Thus, the effects of micronized pro- Although several studies investigated the use of SSRI anti-
gesterone in facilitating discontinuation in long-term BZD depressant medication for BZD tapering, only one fit our
patients was investigated in one study. A double blinded RCT inclusion criteria for average age >60. The study compared
compared 2 g progesterone administered daily during a 7- paroxetine with tapering to standard tapering for BZD discon-
week BZD taper to placebo and found no difference in taper- tinuation. At the end of the 8-week intervention, SSRI signifi-
ing success. Progesterone was well-tolerated and withdrawal cantly predicted the success of becoming BZD-free. However,
symptoms and anxiety levels were not significantly different the study was not blinded which increases risk for bias. The
between the groups. lack of placebo also makes it difficult to evaluate the actual

Figure 2. Forest plot for CBT intervention studies.

Figure 3. Forest plot for education intervention studies.

 AGING & MENTAL HEALTH 5

Figure 4. Forest plot for melatonin intervention studies.

efficacy of the SSRI versus the placebo effect. The quality of as BZD tapering adjuncts are not well established due to the
this study was poor overall, and further studies should be con- lack of studies conducted on these topics in the elderly. Mela-
ducted to verify the efficacy of SSRIs for BZD tapering. tonin was shown to be helpful in one out of three studies. All
three studies demonstrated melatonin to be safe and well-tol-
erated without any severe reported adverse events. Contrast-
Discussion ing results from the three studies may be attributed to small
RCTs included in this review that had a ‘Standard Care’ arm all sample sizes and differences in methodology. Further studies
confirmed that tapering was superior to standard care for suc- on this topic are required to elucidate the efficacy of adjunct
cessful BZD discontinuation. Patient education consistently medication for tapering success. Melatonin still remains a
led to significantly increased discontinuation success. More plausible option for symptom relief by improving sleep qual-
time spent with patients and a consistent tapering schedule ity for certain individuals (Laudon & Frydman-Marom, 2014).
was demonstrated to be superior to standard care in which Few systematic reviews have been conducted on this topic
FPs only provided brief advice on the benefits of decreasing but all are generally consistent with our results. A rapid review
BZD use. The three studies excluded patients with active psy- by Canadian Centre on Substance Abuse (CCSA) and another
chiatric illness including severe depression, anxiety, psychosis, by Canadian Agency for Drugs and Technologies in Health
or personality disorders. Anyone currently being followed by (CADTH) described patient education and psychotherapy to
a psychiatrist was also excluded. be beneficial, but did not elaborate on pharmacotherapy
Education combined with a tapering schedule is a cost- measures (Canadian Centre on Substance Abuse, 2014; Rapid
effective, highly beneficial approach to helping seniors dis- Response Team 2015). A meta-analysis by Gould et al found
continue long-term BZD use. This approach can be applied in significantly higher rates of success of discontinuation with
a variety of different healthcare settings, from visits with FPs psychotherapy and prescribing interventions (Gould, Coulson,
to counselling by pharmacists, nurses, and community health Patel, Highton-Williamson, & Howard, 2014). However, all
workers. Study 5 demonstrated that there was no difference pharmacotherapy was grouped into one broad category, and
between FP in-person counselling versus written instructions. CBT and education were both considered psychotherapy.
For health professionals on a tight schedule, a standard BZD
tapering package can be put together and distributed to
Limitations
long-term BZD users who would benefit from discontinuation.
Studies showed favourable outcomes when CBT is com- Limitations of this review include a relatively small pool of
bined with tapering although there was heterogeneity within published RCTs addressing our research question. Even fewer
the three studies. The number of CBT sessions is important in studies focused on the elderly population. Only one study
treatment success: both studies which showed significant addressed progesterone use or SSRI for BZD tapering, making
benefit of CBT had more sessions (8 and 10 CBT sessions) it difficult to draw definitive conclusions. The number of sub-
than the second study which showed no benefit (5 CBT ses- jects enrolled in each RCT was also small and decreases their
sions). The exclusion criteria of all three studies were similar, statistical power. We would need more research in the future
composed of only healthy older adults with isolated chronic on this topic, with larger sample sizes to make better evi-
insomnia without other chronic medical or mental health dence-based recommendations for BZD tapering.
problems. This may preclude generalization to all older adults The exclusion criteria for the studies were stringent and
using BZDs. Future studies should aim to ascertain the effect excluded patients with psychiatric comorbidities. They also
of CBT while accounting for other factors such as placebo did not include seniors who lived in nursing homes, many of
effect, patient motivation, and initial BZD dose and severity of whom have significant comorbidities and dementia which
insomnia. We recognize that blinding is difficult to achieve affects their ability to provide informed consent for participa-
when CBT is the intervention. Although more studies need to tion in studies. Study populations therefore do not accurately
be conducted to ascertain whether CBT can be helpful, for portray actual long-term BZD users in the community, many
patients who have difficulty tapering off BZD with education of whom have multiple comorbidities or live in residential
alone, a trial of 10 CBT sessions may be beneficial. However, a care settings.
significant barrier to CBT is the cost associated with therapy Selection bias may be present since participants are volun-
which is not often covered in publicly-funded health care sys- teers and there may be a predilection towards more moti-
tems. Furthermore, attending CBT sessions is time consuming, vated individuals who want to decrease their BZD use. The
and benefits of CBT might not always be evident to the lack of blinding in several studies reflect poor study design
patient, which may decrease adherence. that could increase the likelihood for selection bias, perfor-
Medication as an adjunct to facilitate BZD tapering may be mance and ascertainment bias (Karanicolas, Farrokhyar, &
helpful in certain cases. Plausibility of an SSRI or progesterone Bhandari, 2010).
6 C. DOU ET AL.

Conclusion Gould, R. L., Coulson, M. C., Patel, N., Highton-Williamson, E., & Howard, R.
J. (2014). Interventions for reducing benzodiazepine use in older peo-
Long-term benzodiazepine use in elderly patients for the ple: Meta-analysis of randomised controlled trials. British Journal of
treatment of insomnia carries a high risk of adverse drug Psychiatry, 204(2), 98–107. doi:10.1192/bjp.bp.113.126003
effects such as risks of falling, cognitive impairment and Higgins, J. P. T., Altman, D. G., Gøtzsche, P. C., J€
uni, P., Moher, D., Oxman, A.
dependence. These can lead to significant quality of life issues D., & Sterne, J. A. C. (2011). The Cochrane Collaboration’s tool for assess-
ing risk of bias in randomised trials. British Medical Journal, 343, d5928.
and also increased mortality, especially in patients of this age Retrieved from http://www.bmj.com/content/343/bmj.d5928.abstract
group. Patient education is a successful, time- and cost-effec- Kahan, M., Mailis-Gagnon, A., Wilson, L., & Srivastava, A. (2011). Canadian
tive intervention that can significantly help with BZD discon- guideline for safe and effective use of opioids for chronic noncancer
tinuation success. This can range from a comprehensive pain: Clinical summary for family physicians. Part 1: General popula-
tion. Canadian Family Physician, 57(11), 1257–1266. Retrieved from
meeting with a GP to discuss a tapering strategy or written
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215602/
instructions from the pharmacist or physician. Karanicolas, P. J., Farrokhyar, F., & Bhandari, M. (2010). Blinding: Who,
There is also evidence that CBT is an effective intervention. what, when, why, how ? Canadian Journal of Surgery, 53(5), 345–348.
However, there may be a minimum number of sessions Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/
required to achieve success tapering off BZDs. Cost is an issue PMC2947122/
with this intervention since most jurisdictions in Canada do Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., Van Amerin-
gen, M. & Canadian Anxiety Guidelines Initiative Group (2014). Cana-
not cover psychotherapy. Publicly funded healthcare plans dian clinical practice guidelines for the management of anxiety,
might consider funding CBT for specific interventions such as posttraumatic stress and obsessive-compulsive disorders. BMC Psychi-
BZD withdrawal, as cost savings may be achieved in the long atry, 14(Suppl 1), S1. doi:10.1186/1471-244X-14-S1-S1
run, if the number of elderly using BZD chronically can be Laudon, M., & Frydman-Marom, A. (2014). Therapeutic effects of melato-
reduced. nin receptor agonists on sleep and comorbid disorders. International
Journal of Molecular Sciences, 15(9), 15924–15950. doi:10.3390/
Although no specific guidelines currently exist in Canada ijms150915924
for benzodiazepine use in the elderly, the basic rules for any L€ahteenm€aki, R., Puustinen, J., & Vahlberg, T. (2014). Melatonin for seda-
medication that can cause dependency apply: use for the tive withdrawal in older patients with primary insomnia: A random-
shortest time possible with the lowest therapeutic dose ( ized double-blind placebo-controlled trial. British Journal of Clinical
Kahan et al., 2011 ). In cases when simple tapering is not effec- Pharmacology, 77(6), 975–985. doi:10.1111/bcp.12294
Nakao, M., Takeuchi, T., Nomura, K., Teramoto, T., & Yano, E. (2006). Clinical
tive, the methods outlined in this review such as patient edu- application of paroxetine for tapering benzodiazepine use in non-
cation and CBT can be employed. GPs who encounter major-depressive outpatients visiting an internal medicine clinic. Psy-
patients with BZD dependency should be aware of the harm- chiatry and Clinical Neurosciences, 60(5), 605–610. doi:10.1111/j.1440-
ful effects of these medications, and take time to counsel 1819.2006.01565.x
them on discontinuation. Further research on chronic BZD Rapid Response Team (2015). Discontinuation Strategies for Patients with
long-term benzodiazepine use: a review of clinical evidence and guide-
use is necessary to help create guidelines for physicians in lines (pp. 1–9). Canada: Canadian Agency for Drugs and Technologies
Canada on BZD deprescribing and to provide options to in Health.
increase tapering success rates. Schweizer, E., Case, W. G., Garcia-Espana, F., Greenblatt, D. J., & Rickels, K.
(1995). Progesterone co-administration in patients discontinuing
long-term benzodiazepine therapy: Effects on withdrawal severity and
taper outcome. Psychopharmacology, 117, 424–429.
Disclosure statement Tannenbaum, C., Martin, P., Tamblyn, R., Benedetti, A., & Ahmed, S. (2014).
No potential conflict of interest was reported by the authors. Reduction of inappropriate benzodiazepine prescriptions among
older adults through direct patient education: The EMPOWER cluster
randomized trial. JAMA Internal Medicine, 174(6), 890–898.
doi:10.1001/jamainternmed.2014.949
References Tannenbaum, M. D. (2015). Inappropriate benzodiazepine use in elderly
Baillargeon, L., Landreville, P., Verreault, R., Beauchemin, J. P., & Morin, C. patients and its reduction. Journal of Psychiatry & Neuroscience, 40(3),
M. (2003). Discontinuation of benzodiazepines among older insom- E27–E28. doi:10.1503/jpn.140355
niac adults treated with cognitive-behavioural therapy combined with Vicens, C., Bejarano, F., Sempere, E., Mateu, C., Fiol, F., Socias, I., … Leiva, A.
(2014). Comparative efficacy of two interventions to discontinue long-
gradual tapering: A randomized trial. Canadian Medical Association
Journal, 169(10), 1015–1020. doi:10.1053/SMRV.2002.0274 term benzodiazepine use: Cluster randomised controlled trial in pri-
Benzodiazepine use in British Columbia: Is it consistent with recommen- mary care. British Journal of Psychiatry, 204(6), 471–479. doi:10.1192/
dations? (2005). Canadian Family Physician, 51(4), 514. Retrieved from bjp.bp.113.134650
Vicens, C., Fiol, F., Llobera, J., Campoamor, F., Mateu, C., Alegret, S., &
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472944/
B

elanger, L., Morin, C. M., Bastien, C., & Ladouceur, R. (2005). Self-efficacy Soc
ıas, I. (2006). Withdrawal from long-term benzodiazepine use:
and compliance with benzodiazepine taper in older adults with Randomised trial in family practice. British Journal of General Practice,
56(533), 958–963. doi:10.3399/bjgp11£549018
chronic insomnia. Health Psychology, 24(3), 281–287. doi:10.1037/
0278-6133.24.3.281 Vissers, F. H. J. A., Knipschild, P. G., & Crebolder, H. F. J. M. (2007). Is melato-
Caetano, P. A., Raymond, C. B., Morgan, S., & Yan, L. (2006). Income-based nin helpful in stopping the long-term use of hypnotics? A discontinua-
drug coverage in British Columbia: The impact on access to medicines. tion trial. Pharmacy World and Science, 29(6), 641–646. doi:10.1007/
s11096-007-9118-y
Healthcare Policy, 2(2), e154–e169. Retrieved from http://www.ncbi.
nlm.nih.gov/pmc/articles/PMC2585444/ Voshaar, R. C. O., Gorgels, W. I., & Zitman, F. G. (2003). Tapering off long-
Canadian Centre on Substance Abuse (2014, November). Effective inter- term benzodiazepine use with or without group cognitive–
ventions to manage symptoms of benzodiazepine withdrawal in behavioural therapy: Three-condition, randomised controlled trial. The
British Journal of Psychiatry, 182(6), 498–504. Retrieved from http://bjp.
seniors, 1–9.
Dijk, D. J., & Cajochen, C. (1997). Melatonin and the circadian regulation of rcpsych.org/content/182/6/498.abstract
sleep initiation, consolidation, structure, and the sleep EEG. Journal of Weymann, D., Gladstone, E. J., Smolina, K., & Morgan, S. G. (2017). Long-term
sedative use among community-dwelling adults: A population-based
Biological Rhythms, 12(6), 627–635. doi:10.1177/074873049701200618
Garfinkel, D., Zisapel, N., Wainstein, J., & Laudon, M. (1999). Facilitation of analysis. CMAJ Open, 5(1), E52–E60. doi:10.9778/cmajo.20160056
benzodiazepine discontinuation by melatonin: A new clinical Wick, J., 538–548(11) (2013). The history of benzodiazepines. The Consul-
approach. Archives of Internal Medicine, 159(20), 2456–2460. tant Pharmacist : The Journal of the American Society of Consultant
Pharmacists, 28. doi:10.4140/TCP.n.2013.538
doi:10.1001/archinte.159.20.2456