Long-term use persists among institutionalized subjects
Despite the recommendations, the long-term use of benzodiazepines remains significant, in particular among institutionalized people, and this despite insignificant clinical benefits on sleep.
The dependence and belief of patients as to their inability to sleep without these treatments limits the effectiveness of a gradual reduction in doses and requires psychological support. This is why cognitive and behavioral therapies for insomnia (iCBT) are increasingly being evaluated in clinical trials as a complementary approach.
CITTs, increasingly used, but still discussed
Several studies have shown that a digital interactive CBTi program led by a therapist, combined with a gradual reduction in the doses of sedatives/hypnotics, can improve insomnia and help weaning off these molecules in different groups of patients.
However, differences remain. For example the Coteur study et al. (2), carried out in Belgium, had evaluated the interest of associating an interactive digital CBTi, initiated by the general practitioner, to increase the chances of stopping BZDs or AR-BDZs following 12 months of intervention in subjects using these molecules for a long time (> 6 months of daily use before inclusion). The results were disappointing, revealing low discontinuation rates (19-20%), with no significant difference between the intervention group with CBTi and the group without (standard treatment, GPs trained in sleep hygiene education in both groups). In view of these results, and given that TCCi use a dynamic and multifaceted approach, it seems important to standardize the interventions and to refine the strategies to be used within populations dependent on BZDs/AR-BZDs for a long time.
Motivational help with withdrawal
Patients often have a very low perception of the risks associated with their consumption of BZDs (3). Personalized interventions aimed at directing their perception of this risk at the start of a BZD dose reduction might therefore be effective (3,4). For a small proportion of subjects motivated to quit (3-8%), the mere realization that their use of BZDs was problematic was enough for them to stop their consumption (2). For others, on the contrary, awareness was not enough to push them to action (3).
Allary et al. pointed out that the predictive psychosocial factors of stopping BZD consumption were often overlooked in trials evaluating the deprescription of these molecules (5). And they showed that boosting patients’ perceptions of their sense of self-efficacy and competence might be an important first step.
Multi-component deprescribing strategies
GPs being the first initiators of BZD, they appear on the front line to initiate a process of deprescribing. But other health professionals easily accessible in primary care also have a role to play, in particular community pharmacists. They have both expertise in this area and the opportunity to discuss drug use with patients. Several trials have described BZD deprescribing processes conducted by pharmacists, within a multidisciplinary team. The EMPOWER trial, for example (6-8), consisted of sending an information brochure to long-term users (intervention group). At 6 months, 62% of them had discussed stopping BZDs with their pharmacist, 27% had stopped and 11% had reduced their consumption. These figures were higher than those of the control group (no intervention).
Another successful attempt is the Australian RedUse (Australian Reducing Use of Sedatives) longitudinal study (9). It had included more than 12,000 residents from 150 retirement homes, and had obtained excellent results (40% cessation or reduction of BZD doses in residents) by combining different strategies: observation of the history of issuance of BZDs, education of nursing staff, and encouragement of prescribers to deprescribe.
