Predictors of the long-term use of identified benzodiazepines

Poor sleep, prolonged prescription and the Caucasian are key factors that predict the long-term conversion to the use of benzodiazepines in the elderly, a practice strongly linked to poor outcomes, including death.

The findings underscore the need to "start at the end" when prescribing a benzodiazepine, according to author Lauren B. Gerlach, DO, Geriatric Psychiatrist and Assistant Professor in the Department of Psychiatry and Positive Aging Program. from the University of Michigan to Ann. Arbor says Medscape Medical News.

It means "starting with a short-term prescription and engaging patients in discussions about when to re-evaluate their symptoms and start reducing the patient," she said.

Gerlach said more work is needed to improve access to effective non-pharmacological treatments, such as cognitive-behavioral therapy, as well as to provide access to education about these treatments.

The study was published online September 10 JAMA Psychiatry.

A common practice

Treatment guidelines recommend that benzodiazepines be used in the short term. However, research suggests that up to one-third of use is long-term and that this use is most prevalent among older people.

The researchers point out that the factors that predict the long-term use of benzodiazepines are poorly understood.

To identify these risk factors, the researchers used data from the SUSTAIN (Supporting Seniors Receiving Treatment and Intervention) program, which complements a Pennsylvania drug coverage program for low-income seniors.

The program's services included detailed interviews to screen for mental health issues, such as anxiety, depression and sleep problems, as well as pain, and analysis of prescribing records and cases. 39, other clinical data.

The investigators examined how many seniors who received a new benzodiazepine prescription from a non-psychiatric provider continued to use the drug in the long term. They also assessed clinical features and patients who predicted long-term use.

Long-term use was defined as a drug possession ratio (TPM) greater than 30% in the year following the initial prescription. Gerlach explained that the RPM was calculated by dividing the number of drug days provided by 365 days.

The study included 576 elderly people (mean age, 78.4 years).

The analysis showed that 1 year after the prescription of the index, 26.4% of patients met the criteria for long-term use. Benzodiazepines were given an average of 232.7 days.

Although treatment guidelines only recommend short-term prescription, "these long-term patients were prescribed almost 8 months of medication after their initial prescription," Gerlach said.

In adjusted analyzes, Caucasian (odds ratio [OR]4.19; 95% confidence interval [CI] 1.51 – 11.59; P = 0.006), days provided in the prescription of the index (OR, 1.94, 95% CI, 1.52 – 2.47; P <0.001), and poor sleep quality (OR for very, very poor vs very good, 4.05, 95% CI, 1.44 – 11.43; P = 0.008) were factors associated with prolonged use of benzodiazepines.

"Source of concern"

"It's a cause for concern" that non-clinical factors are associated with the prescription of benzodiazepines, Gerlach said.

"The decision to prescribe and then to continue a benzodiazepine – or any other medical treatment – should be dictated by a clinical need," she said.

Gerlach said that it was "particularly striking" that for every ten days of prescribed treatment, "the risk of long-term use of a patient nearly doubled during the year. next".

This finding "suggests that providers need to pause and think more carefully when they are providing a new prescription for benzodiazepines, such as considering a 14-day supply rather than a 30-day drug intake," he said. declared Gerlach.

The average age of study participants when they were given a benzodiazepine prescription (78 years) was also of concern, as national guidelines state that these drugs "should rarely be administered to adults over the age of 65 years old, "she said.

Among the clinical measures evaluated by researchers, namely depression, anxiety, sleep and pain, only poor sleep quality was associated with the likelihood of continued use of benzodiazepines.

"Despite the fact that benzodiazepines are not recommended for long-term use as sleeping pills, and may even worsen the effects of sleep, the longer they have been used for a long time," Gerlach said.

As non-psychiatric clinicians prescribe more and more psychotropic medications to the elderly, the authors write that it is "essential" to improve access to non-pharmacological treatments and their education.

The authors note that the study did not consider drug use as needed, which may have had an effect on the calculation of long-term use. In addition, the analysis was limited to low-income seniors in Pennsylvania, which may limit the possibility of generalization.

The authors also point out that definitions of the long-term use of benzodiazepines vary and that it is possible that a different definition of long-term use has yielded different results. However, the investigators used three different definitions, with no significant variation in the results.

Important message

Commenting on the article for Medscape Medical NewsPeter Yellowlees, MD, professor of psychiatry and vice-chair for faculty development at the Department of Psychiatry at the University of California at Davis, is a little surprised that more patients are converting to benzodiazepines at long term. more likely to be prescribed these drugs in the long run.

He said the "most important message" of the study is that patients should know from the outset that their benzodiazepine prescription will be short-lived.

In his own practice, Yellowlees stated that he "very rarely prescribes" benzodiazepines and "it is much more likely" that patients will take these drugs.

He wants patients to take these addictive medications only three or four times a week – not every day – to avoid "becoming addicted" and reducing drugs "extremely slowly" – over 3 to 6 months.

"Most people are trying to kill patients in two or three weeks, for example, from 10 mg a week to 5 mg next week, and honestly, it's too difficult for many patients," he says. did he declare.

The problem is that such a slow approach can take time and that primary care practitioners have only one 15-minute consultation per patient.

Benzodiazepines have been associated with falls and cognitive impairment, the Yellowlees said.

"The effects can mimic early dementia, people get confused, which leads to a fall and an inability to manage at home, so patients have to go to a retirement home," he said.

There are also risks of taking these medications and driving, says Yellowlees.

Instead of benzodiazepines, he often uses cognitive-behavioral therapy in patients who have sleep problems or who have anxiety.

The study was funded by the Pharmaceutical Assistance Contract for the Commonwealth of Pennsylvania Seniors. Dr. Gerlach and Dr. Yellowless have not revealed any relevant financial relationship.

JAMA Psychiatry. Posted online September 10, 2018. Summary

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