Do we need so many benzodiazepines? From abuse to good use of medicines

Benzodiazepines are drugs that are mainly used for short-term treatment of disorders such as anxiety and insomnia, but are also effective as muscle relaxants, anticonvulsants or in alcohol detoxification.

The duration of treatment with benzodiazepines ranges from two to four weeks in the case of insomnia, and from 8 to 12 weeks in the case of anxiety, including gradual withdrawal. However, these are prescriptions that usually become chronic, leading to problems of tolerance and dependence, withdrawal syndrome, abuse and paradoxical behaviour, when their use is uninterrupted.

This is particularly relevant in the case of older people, who are considered a population at risk of uncontrolled use of drugs such as benzodiazepines. In general, these people are more sensitive to their adverse effects and metabolise them more slowly, which favours the accumulation of these drugs in the body, and implies effects such as muscle weakness, loss of reflexes and agility, excessive sedation, falls, and other risks such as memory impairment and influence on cognitive deterioration.

In institutionalised elderly people, several studies show that a large proportion of prescriptions do not follow existing pharmacological guidelines regarding their indication, exceeding the recommended duration and lacking timely assessment.

Living institutionalised in a nursing home, having two or more different prescribers and having six or more diagnoses are independent risk factors for polymedication, as well as for the use of potentially inappropriate drugs and the use of psychotropic drugs, as would be the case here.

There are different strategies aimed at the general population to carry out a process of de-prescription of this medication.  Thus, it has been shown that a simple intervention, in which the patient is instructed on the withdrawal guidelines and informed of the possible effects of withdrawal and their solution, has proved to be effective and long-lasting, allowing, without follow-up visits, a reduction in consumption after 12 months of between 18% and 62%, depending on the strategy adopted.

Similarly, the review of pharmacological treatment, as well as the regular use of software to systematise the review of prescribed benzodiazepines, helps to reduce the risk of problems related to these drugs and their use in institutionalised patients who have been treated with these psychotropic drugs for more than three months.

By applying the different strategies, we can predict a significant impact given that around 40% of institutionalised patients are prescribed at least one medication of this kind, with the added bonus of having sufficient scientific evidence to show that discontinuation does not imply risks for the patient, but on the contrary, brings benefits.

We would like to conclude by pointing out the need to continue supporting healthcare professionals working in social and healthcare centres in order to strengthen existing deprescribing strategies, as well as to ensure that the selection and prescription of benzodiazepines is appropriate from the outset.

It is also necessary to continue carrying out studies and progressive reduction plans through periodic and systematic reviews, and to develop digital tools that enable the de-medicalisation of the population.

And the fact is that, as Hippocrates said, "The best medicine of all is to teach people how not to need it."

Recommended reading:

» Deprescribing.org (2019), Benzodiazepine & Z-Drug (BZRA) Deprescribing Algorithm. Deprescribing.org.