Qualitative results
Qualitative findings are presented to first outline the prescriber influence on reducing long-term BZD use followed by the patient influence. Each section offers a figure summarising the barriers and facilitators, which are then explained in greater depth (see Supplementary Table S1 for coding frame with exemplar quotes).
Prescriber influence
The participants’ perception of the prescriber influence on reducing their BZD were characterised into three broad categories (Figure 1). Barriers and facilitators are listed from the most to least common. Participant experiences of their prescriber reflected a broad divide between those in the process of reducing (that is, preparation, action, and maintenance) and those not currently reducing (precontemplation and contemplation), so themes are discussed to compare and contrast the experiences of these two groups.
Figure 1. Overview of the prescriber influence perceived to act as barriers or facilitators to reducing long-term use of BZDs. BZD = benzodiazepine.
Prescriber barriers
a) Prescribing behaviours: the majority of participants reducing, and a few not reducing, perceived issues with prescribers’ tendency to overprescribe and lack of sufficient knowledge about BZDs. Participants indicated that these behaviours led to their current dependent state, underpinned by a relaxed attitude towards their medication, inadequate awareness of harms, and little exploration of other evidence-based treatment options. Several participants described this as lacking a duty of care and expressed a generalised frustration towards the medical profession:
‘… now at no stage did the GP say look we have to be careful ‘cause these are addictive, or you’ll get dependent on them.’
(Participant [P]26, Action)
b) Prescriber treatment approach: more of those reducing than not expressed frustration or disappointment about behaviours that undermined their agency in their treatment, largely owing to limited consultation in decision making. Some described their prescriber adopting a one size fits all approach where they maintained control and authority in the relationship.
c) Prescriber attitude: common among reducers was the report of feeling stigmatised by their prescriber, that there was little effort to understand them, and that the level of support/compassion was insufficient. This meant participants felt unable to talk openly about their BZDs, and some interpreted the prescriber attitude as being dismissive or even punitive:
‘And I said, “why did you put me on that, why did you tell me that it’s safe to use and it’s not addictive as long as you take it as prescribed?” I said, “I read all this on the internet, and I spoke to people”, and he said, “oh […] that’s all poppycock I wouldn’t listen to a word they say”, so […] just dismissed it out of hand.’
(P10, Maintenance)
Prescriber facilitators
a) Prescribing behaviours: participants consistently spoke about prescriber behaviours described as a ‘duty of care’, consisting of satisfactory knowledge about BZDs, diligence in monitoring use, and regular suggestion of reducing. Participants indicated this conveyed confidence that their prescriber was supervising their use and promoted a feeling of safety. It also illustrated BZDs were a potentially harmful medication, so participants were conscious of not overrelying on their BZD:
‘ … with my other medications he’ll give me repeats, but with my benzodiazepines he won’t, and he’ll monitor how often he prescribes them to keep me safe.’
(P33, Precontemplation)
b) Prescriber treatment approach: the importance of being actively involved in their treatment was expressed equally by both groups, characterised by participating in decision making and voicing their opinion. Notable features of this prescriber approach were flexibility and collaboration with other healthcare providers (HCPs), and participants reporting a strong overall alliance with their prescriber:
‘I think that if I was presenting more frequently […] she would have conversation with me about why […] because I don’t think she would want me to be taking more than what is prescribed or what is necessary, and she knows I don’t want to do that either.’
(P17, Precontemplation)
c) Prescriber attitude: again, groups uniformly reported the importance of their prescriber making the effort to really understand them, sometimes meaning they went beyond their better judgement to support the patient (that is, to continue prescribing). Participants felt their prescriber demonstrated compassion and that their wellbeing was the prescribers’ first priority:
‘If I take a double dose, then I say to her “I’ve had to double up”, she understands. I mean, because she has studied up on it [medical condition] , and she’s said to me “I’m really proud of you, what you’re taking” the low doses I’m taking of everything, compared to what she has read that others are taking. So, that made me feel good.’
(P30, Precontemplation)
Patient influence
An overview of the major themes identified as patient barriers and facilitators to reducing BZD use are displayed in Figure 2. These are presented in terms of the participants’ stage of change, highlighting the prominent barriers and facilitators at each stage to demonstrate how these experiences vary over time. Themes within each category are listed from the most to least commonly reported by participants.
Figure 2. Overview of patient influences that act as barriers or facilitators to reducing long-term use of BZDs. BZD = benzodiazepine. LOC = locus of control.
Participants in precontemplation and contemplation stages
a) Barriers to reducing: for those not ready to reduce the most common barrier reflected a range of conditions and symptom severity. In some, the underlying condition was physical (for example, epilepsy) meaning they had little control over the need for their medication, but, for most, it was the impairing symptoms of their psychological condition (for example, post-traumatic stress disorder) that could not be managed by psychological intervention alone, and explained the need for the BZD to cope. A smaller number reported more generalised symptoms and were not trying to replace their BZD with other interventions. Participants also reported signs of dependence perpetuated BZD use, suggesting the primary benefit was either psychological relief or holding back withdrawal. The main contrast between these two stages was the greater focus on the impacts of stress in contemplators:
‘ … it’s probably got to the point where it almost isn’t working as it should. Umm […] psychological thing, that you think, well if I don’t take it, I know I’m not going to sleep, and if I do take it, I’ll get a few hours.’
(P29, Precontemplation)
b) Facilitators to reducing: although enablers did not outweigh the barriers for these two groups, knowing the harms associated with long-term use and experiencing impairing side effects did promote a more cautious attitude, with several participants limiting use where possible. Those in precontemplation described alternative coping strategies helping reduce their need for the BZD, whereas those in contemplation noted the prescribers’ support promoted a belief that they could reduce.
When thinking about reducing in the future, participants in both stages recognised the need to change their beliefs and attitude towards their medication (that is, internal locus of control [LOC]), but those in precontemplation were more likely to indicate they needed an alternative medication to replace their BZD:
‘I’ve noticed that if I rely on having more than say two half tablets of diazepam in a day, I tend to be a bit too zonked out the following day. So, I try to limit myself to, say a half in the morning or a half at lunch, ideally less if I can, because of the work that I do […] I sort of need to be sharp.’
(P18, Contemplation)
Participants in preparation stage
a) Barriers to reducing: participants in the preparation stage identified a greater number of pressing barriers than any other stage, suggesting that, when taking steps towards reducing, barriers become much more salient. This group were tentative about committing to permanent changes regarding their medication, and most needed access to their BZD assured, even if they planned to stop taking them.
b) Facilitators to reducing: facilitators for preparation and action stages were equal, so are discussed together.
Participants in action stage
a) Barriers to reducing: at this stage, withdrawal symptoms were the most significant barrier, which were exacerbated by life stressors. Participants were often unsure if these symptoms were their original problem or withdrawal related. In contrast to the precontemplation and contemplation stages, the reason these participants needed BZDs to cope was not just to improve functioning but also to make life easier in general and symptoms more tolerable:
‘Yeah, it’s just the withdrawal, not only do I get the physical symptoms, like cold or flu, gastrointestinal problems, lumped on top of that I get high anxiety again and my thoughts race, I mean that’s what it seems like unless it’s still my condition.’
(P34, Action)
b) Facilitators to reducing: participants in preparation and action stages placed equal significance not only on knowing the harms but also on the need for additional support and understanding to reduce, a sign they were taking steps to aid the process. They also described a growing sense of confidence and control about reducing — underpinned by an internal LOC — which was the benefit of the prescribers’ ongoing encouragement and a gradual dose reduction. Of note, this group uniquely reported the influence of increased regulation on prompting their decision to discontinue use:
‘It was never my intention to get it like, illegally or through you know, manipulation or anything like that. And when it started getting harder and hard to get, I just thought, ‘’well screw it, I’m going off it, cause I don’t want to feel that way’’.’
(P34, Action)
Participants in maintenance stage
a) Barriers to reducing: in the maintenance stage, withdrawal symptoms remained the primary barrier to coming off the BZD; and, again, the impact of stress on these symptoms was also perceived to hinder the process. In addition, insufficient support from HCPs and a lack of understanding from family/friends further affected this group’s ability to reduce.
b) Facilitators to reducing: as the group with the longest experience reducing, beyond knowing the harms, a gradual dose reduction was now considered the most important facilitator. Nearly all who spoke about a gradual taper also expressed agency over this process, where the reduction rate was guided by them and how well they were coping:
‘Well going off ‘em slowly, each dose drop adjusts into my system. I’ll judge on how I’m feeling with each taper, and adjust it from there, whether I stay on that extra dose for a bit longer, or I’m feeling OK and drop the next milligram and so forth.’
(P23, Maintenance)
