Benzodiazepines (drugs like Diazepam, Oxazepam, Lorazepam) are often prescribed for insomnia, anxiety, epileptic seizures, muscles relaxants and sedation. They work by slowing down the central nervous system, and should only be used as a short term intervention (less than 4 weeks). Prolonged use can lead to tolerance, and dependency. They are incredibly difficult to stop and are known to cause a withdrawal syndrome, which can include rebound anxiety, insomnia and agitation. The most common method for reducing use is tapering, a gradual reduction in the prescribed dose over time.

The authors of a recent systematic review (Darker et al, 2015) wanted to evaluate whether psychosocial interventions (any non-pharmacological intervention) could lead to a reduction (half of the dose/discontinuation) in benzodiazepine use, when compared to treatment as usual or other alternative interventions.

Methods

This was a Cochrane systematic review, and they followed the standard Cochrane guidelines.

The authors tried to identify any current or published RCT of psychosocial interventions through widespread electronic, grey literature and hand searches.

Studies that focused on young people or those with dual diagnosis were excluded.

Results

• 25 studies (31 papers) where identified and included in the synthesis, of which 11 studies (15 papers) were included in the meta-analysis (CBT studies).
• There was a range of interventions used in the studies including:
  • CBT plus tapering (n=11)
  • Motivational interviewing (n=4)
  • Relaxation (n=4)
  • CBT without tapering (n=2)
  • Letters (n=2)
  • e-counselling (n=1)
  • GP advice (n=1)
• Of the CBT studies, most were Canadian (n=6), and the total sample size was 575 people
• CBT plus tapering appeared to be more effective at enabling service users to stop rather than reduce (>50%) benzodiazepine use
  • Particularly in the first four weeks (RR 1.40, 95% CI 1.05 to 1.86)
  • And at 3 month follow-up (RR 1.51, 95% CI 1.15 to 1.98)
• The Motivational Interviewing (MI) studies included 80 participants. There didn’t appear to be a significant difference between MI and treatment as usual at either 4 weeks (RR 4.43, 95% CI 0.16 to 125.35) or 3 months (RR 3.45, 95% CI 0.17 to 2.88) for discontinuation. Evidence for reduction was also not significant.
• Other interventions, for example, GP letters and relaxation were not included in the meta-analysis and often only included data from 1 or 2 small scale studies, but these appeared to significantly reduce use.

Authors’ conclusions

CBT plus taper is effective in the short term (three month time period) in reducing benzodiazepine (BZD) use. However, this is not sustained at six months and subsequently.

Currently there is insufficient evidence to support the use of MI to reduce BZD use.

There is emerging evidence to suggest that a tailored GP letter versus a generic GP letter, a standardised interview versus treatment as usual (TAU), and relaxation versus TAU could be effective for BZD reduction.

There is currently insufficient evidence for other approaches to reduce BZD use.

Discussion

Considering that dependence to benzodiazepines is a global health problem, interventions to enable service users to reduce and stop using them remains under-researched. There seems to lack of consistency in the intervention, and all had limited proven effectiveness beyond 3 months. Only half of the identified studies could be included in the meta-analysis. Of more concern was that the analysis did not include quality of life, adverse events or self-harm choosing only to focus on benzodiazepines.

The authors were concerned about the quality of the evidence of most studies, primarily because the primary outcomes were often based on self-report, the samples were small, and there were concerns around the fidelity of the interventions. As such they reduced the quality score of papers included in this review.

The authors commented on a number of other reviews in this area (non-Cochrane) and it would appear that similar findings and concerns about the quality of the evidence were identified. Clinically there is probably some benefit in structuring sessions based on CBT principles, and ensuring that GP letters are individualised in addition to tapering doses. Further advice on managing withdrawal can be found on the Clinical Knowledge Summaries website.

Links

Primary paper

Darker CD, Sweeney BP, Barry JM, Farrell MF, Donnelly-Swift E. Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. Cochrane Database of Systematic Reviews 2015, Issue 5. Art. No.: CD009652. DOI:10.1002/14651858.CD009652.pub2

Other references

Benzodiazepines. British National Formulary, October 2015.

Benzodiazepines. Royal College of Psychiatrists, July 2013.

Ashton CH. (2002) Benzodiazepines: how they work and how to withdraw. The Ashton Manual, 2002.

Benzodiazepine and z-drug withdrawal. Clinical Knowledge Summaries, April 2015.

Photo credits

• epSos .de CC BY 2.0
• Alan Levine CC BY 2.0
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