Background:Benzodiazepine receptor agonists (BZRA) are frequently tapered because of risk of dependence and hazards of use in ageing. Standard tapering protocols may fail or result in harm from improper utilization of pharmacologic principles, lack of recognition of withdrawal and/or failures in shared decision-making. Objective:The aim of this work was to derive principles from experts to optimize deprescribing success while minimizing withdrawal among patients who use BZRA medication long-term. Design:Modified Delphi consensus study among experts from two not-for-profit organizations dedicated to BZRA use issues. Methods:Three stages of anonymized voting were conducted among clinical experts and patient representatives. An 80% agreement ('agree' or 'strongly agree' on a five item Likert-type scale) was required for consensus. Recommendations which failed to reach initial consensus, were modified from feedback and downgraded to 'moderate' (>80% agreement) or 'weak' consensus (50%-80% agreement) in the subsequent rounds. Results:A total of 35 of 48 invitees participated (73% response rate) which included seven family physicians, nine psychiatrists, five pharmacists, six patient advocates, two nurse practitioners, two licensed clinical social workers, two health service policy researchers, a physician assistant and a psychotherapist. A total of 31 of 35 participants were from the United States, with the remaining representatives from Canada, the UK and Ireland. Strong consensus was achieved for attaining informed consent prior to deprescribing (recommendation 1), using a flexible and gradual tapering approach (recommendation 2) characterized by shared decision-making (recommendation 3) with hyperbolic dose reductions (recommendation 4) facilitated via novel preparation techniques or compounded pharmaceutical formulations (recommendation 7). Reversion to previous doses may occur if necessary to reduce the incidence of withdrawal (recommendation 6). Strong consensus was also reached for adjunctive psychosocial interventions (recommendation 8) and/or peer-support resources (recommendation 9). Moderate and weak consensus was achieved, respectively, for step-wise conversion to a longer-acting BZRA (recommendation 5) and the avoidance of adjunctive non-BZRA pharmacotherapy (recommendation 10). Conclusion:This consensus guidance document for primary care providers, mental health clinicians and long-term users of BZRA outlines ten principles/recommendations intended for improving deprescribing outcomes with an emphasis on minimizing withdrawal risk.

BackgroundClinical practice guidelines and guidance documents routinely offer prescribing clinicians’ recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion.MethodsA Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing.Findings113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being “International” (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents.InterpretationDocuments were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to “short-term” use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or ‘as needed’) selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering.FundingThe authors received no funding for this work.

These agents are not first-line treatments for many of the conditions for which they are used. When they are used, there should be a plan in place for deprescribing.

Although benzodiazepines have been used for 6 decades, many questions remain unanswered by research. The lived experiences of those adversely affected long term can provide insights into how these agents might be more thoughtfully prescribed. Here, perspectives of one such experience encompassing benzodiazepine initiation, ongoing use with adverse consequences and difficult discontinuation are presented through the eyes of an affected individual and a clinician. This experience highlights the importance of limited initiation and duration of use (2–4 weeks) as well as a supported, slow tapering process led by patients. Because researched evidence about deprescribing benzodiazepines is insufficient and because individual experiences vary so widely, it is the patient’s expertise—that of her or his lived experience—that should assume a primary role in determining the course and pace of discontinuing these medications.

Controversy and uncertainty exist about the use of benzodiazepine receptor agonists (BZRAs) in pain management. This article curates available research to determine the appropriate role of BZRAs in the course of pain management, and how prescribers might address these challenges. A narrative review was performed to determine the appropriate role of BZRAs in pain management and to develop practice recommendations. Publications were identified by a search of PubMed, references of retrieved reports, guidelines, and the author’s personal files. BZRAs were found to have analgesic benefit for two pain conditions: burning mouth syndrome and stiff person syndrome. Absence of research, heterogeneity of trials, and small sample sizes precluded drawing conclusions about efficacy of BZRAs for the other 109 pain conditions explored. Data supports the use of BZRAs to treat co-occurring insomnia and anxiety disorders but only when alternatives are inadequate and only for short periods of time (2–4 weeks). The utility of BZRAs is limited by loss of efficacy that may be seen with continued use and adverse reactions including physiologic dependence which develops in 20–100% of those who take these agents for more than a month. BZRAs are often used inappropriately in pain management. Their initiation and duration of use should be limited to a narrow range of conditions. When prescribed for 4 weeks or more, patients should be encouraged to discontinue them through a supported, slow tapering process that may take 12–18 months or longer.

CONTEXT:Despite attention to federal and state governments' response to the US opioid crisis, few studies have systematically examined local governments' role in tackling this problem.OBJECTIVES:To determine what opioid policy and programmatic activities local governments are implementing, which activities are more challenging and require a greater latent ability to implement, and what community, environmental, and institutional factors shape such ability.DESIGN:A cross-sectional survey and multistage sampling procedure.SETTING/PARTICIPANTS:Of all 358 county governments in 5 purposively selected states (Colorado, North Carolina, Ohio, Pennsylvania, and Washington) surveyed, 171 counties (response rate = 47.8%) with complete data on self-reported policy and programmatic activities and predictor variables were eligible for analysis.MAIN OUTCOME MEASURES:Nineteen opioid policy and programmatic activities were analyzed individually and combined into a latent implementation ability index using empirical Bayes means estimates.RESULTS:Item response theory and bivariate analysis were applied. Item response theory estimates suggested that having police officers carry naloxone and establishing a task force of community leaders were easier to implement than more challenging activities such as establishing needle exchanges and allowing arrest alternatives for opioid offenses. Covering individuals' treatment costs was predicted to involve the highest ability. County population size (r = 0.34; 95% confidence interval [CI], 0.20-0.47), population density (r = 0.35; 95% CI, 0.21-0.47), and being a Pennsylvania county (r = 0.45; 95% CI, 0.32-0.56) showed the strongest associations with latent implementation ability.CONCLUSIONS:Counties appear engaged in opioid policy and programmatic activity, although some activities are likely more difficult and may require greater ability to implement than others. More sparsely populated counties appear more disadvantaged in implementing activities for tackling the opioid crisis and may need additional assistance to leverage their ability to build a comprehensive policy and programmatic infrastructure.

With medical marijuana available in more and more states, family physicians need to know what the evidence says about its use. This review includes a step-by-step guide and a list of red flags to watch for.

Marijuana use can cause concerning physical, psychomotor, cognitive, and psychiatric effects, not to mention a near-doubling of car accidents.