Deprescription of benzodiazepines and Z drugs: A shared responsibility

Dear Editor,

We would like to make a series of observations with regard to the recent publication of the study “Benzodiazepine prescriptions and falls in older men and women”¹ in this journal. The Health Promotion and Prevention Strategy in the National Health System (SNS),² approved in December 2013 by the Interterritorial Council of the SNS, in the framework of the approach to chronicity, placed special emphasis on the detection and management of frailty and falls in the elderly. Benzodiazepines (BZD) and the hypnotics referred to as Z-drugs (zolpidem, zopiclone) constitute one of the essential pillars in reducing the risk of falls in the elderly as the published study mentions.

The finding was significant that the daily defined dose (DDD) in elderly people aged 65 and over was above the recommended levels in 70% of males and 58% of females, with at least 20% polytherapy with BZD and/or Z-drugs (there is evidence of no superiority over monotherapy), with the difficulties that high doses add to the subsequent deprescription of these drugs. The Spanish version of the Screening Tool of Older Person's potentially inappropriate Prescriptions (STOPP)-START has been available since 2009. This tool has been better assessed in Spain³ than others such as the Beers criteria, and not only gathers the most common treatment errors but also prescription omissions, is easy to relate to active diagnoses and the list of drugs that appear in computerised clinical histories. It is suggested that this high DDD could be associated with underuse of non-pharmacological interventions (sleep hygiene measures, cognitive therapies or mindfulness for example), and gradual reduction of the dose is suggested combined or otherwise with cognitive behavioural therapy as a procedure for withdrawal of the drugs. We must not forget that not only has it been suggested that a BZD should be prescribed as treatment for insomnia when sleep hygiene measures have failed,⁴ a situation which could be approached in primary care, but that it is quite common for it not to have been tried when a patient is first assessed in mental health clinics. It is claimed that short half-life BZD present a lower risk of falls, as a consequence of a lower risk of accumulation; however, other studies have not found this assertion to be true, finding a similar risk of falls regardless of the half-life of the drug used.⁵ In addition to the risk of falls, it has been observed that withdrawal of BZD improves cognitive and psychomotor aspects,⁶ and often tolerance makes the beneficial effect of the drug on sleep patterns disappear (loss of efficacy, which would be a STOPP criterion to then discontinue the drug). With regard to deprescription itself, we noted that other strategies of proven efficacy were not mentioned, such as replacing short or ultra-short half-life BZD for others with a long half life at equivalent doses, in order to start their gradual withdrawal, increasing success rates.^3,7 The use of individual psychotherapy with individualised deprescription strategies has proven effective in a population with a predominant diagnosis of anxiety disorder treated with BZD, as shown in a recent study⁸ where success rates (total withdrawal of BZD) reached 57%. This confirms the importance of combining psychotherapeutic^4,8 techniques with descending dosage or temporary substitution by other drugs.

Deprescription should not fall to the prescribing physician alone. In order for patients to receive effective and comprehensive treatment, as required by the basic ethical principles of dignity, integrity and justice (as Fernando Lolas-Stepke reminds us in an article published in this same journal⁹), this responsibility should be shared by the different care levels.