Role of the prescriber in supporting patients to discontinue benzodiazepines: a qualitative study

Erin Oldenhof; Timothy Mason; Jane Anderson-Wurf; Petra K Staiger

doi:10.3399/BJGP.2020.1062

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Figure 1.
Overview of the prescriber influence perceived to act as barriers or facilitators to reducing long-term use of BZDs. BZD = benzodiazepine.
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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.

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How this fits in

The introduction of prescription monitoring programmes (PMPs) has highlighted the need for increased support and guidance to ensure GPs improve on current deprescribing practice. This study revealed the importance of GPs understanding how to empower patients through patient-centred care, to foster a willingness to try reducing, build motivation, and promote confidence in the patients’ ability to reduce. By understanding the patient experience with their prescriber involved in long-term BZD use, this study advances current knowledge of the ‘patient-centredness’ of deprescribing interventions and offers GPs clearer guidance on how to deliver these strategies effectively.

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Box 1.

A stage-based approach to deprescribing BZDs

	Patient Influence		Prescriber Influence
Stage of change	Main barriers	Main facilitators	Facilitatory behaviours	Facilitatory approach
Precontemplation
(No intention to reduce in the next 6 months)	Original problem persists	Knowledge of harms Experiencing impairing side effects	→ Inform patient of potential harms → Monitor use and review efficacy → Regularly encourage reducing	→ Open conversation around BZD harms and side effects → Cautious approach to prescribing (that is, rational prescribing)
Contemplation
(Considering reducing in the next 6 months)	Original problem persists Stress exacerbates symptoms	Knowledge of harms Experiencing impairing side effects	→ Monitor use and review efficacy → Promote other evidence-based treatments → Support reducing	→ Curious approach to understand patient experience of harms and benefits → Support patient to choose change
Preparation
(Actively planning to reduce in the next month)	Original problem persists Need BZDs as a safety net Stress exacerbates symptoms Lack sufficient support and understanding	Knowledge of harms Professional support and understanding from family and/or friends	→ Generate a GDR plan → Psychoeducation around withdrawal → Coordination of care → Explore informal supports	→ Explore the ‘role’ that BZDs play in patient’s life → Collaborative approach to exploring how patient will eventually replace BZD (that is, internal and external coping strategies)
Action
(Reducing for <6 months)	Withdrawal symptoms Original problem persists Stress exacerbates symptoms	Knowledge of harms Professional support and understanding from family and/or friends	→ Review and adjust GDR with patient as required → Ensure patient is sufficiently supported (formal and informal support)	→ Offer ongoing encouragement → Supportive approach to normalise worries about ability to reduce
Maintenance
(Reducing for >6 months)	Withdrawal symptoms	Knowledge of harms Gradual dose reduction	→ Review and adjust GDR with patient as required → Consider if other treatments are required	→ Explore efficacy of other interventions → Collaborative and flexible approach for duration of reduction

BZD = benzodiazepine. GDR = gradual dose reduction.

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Table 1.

Participant characteristics

Characteristic	Total (N= 22)
Age, mean ± SD	42.6 ± 15.9

Identified gender, n (%)
Female	12 (54.5)
Male	7 (31.8)
Non-binary	3 (13.6)

Employment status, n (%)
Student (casual)	2 (9.1)
Part time	2 (9.1)
Full time	8 (36.4)
Retired	3 (13.6)
Unemployed/disability pension	4 (18.2)/3 (13.6)

BZD/Z-drug	Primary	Secondary
BZD/Z-drug
Alprazolam	1	—
Clonazepam	2	—
Diazepam	14	1
Lorazepam	2	1
Nitrazepam	1	—
Oxazepam	1	1
Temazepam	—	3
Zopiclone/Zolpidem	1	4

Duration of use, mean ± SD	10.4 years ± 8.6
1–2 years	7 (31.8%)
5–10 years	6 (27.3%)
11–≥20 years	9 (40.9%)

Reason prescribed	Primary	Secondary
Reason prescribed
Anxiety disorder (including PTSD)	16	3
Insomnia	2	6
Medical condition	2	—
Substance withdrawal	2	—

SDS scores (mean ± SD)	5.0 ± 3.7
PHQ-9 scores (mean ± SD)	11.4 ± 7.0
GAD-7 scores (mean ± SD)	10.1 ± 5.0
SF-8 scores (mean ± SD)	25.5 ± 5.3

BZD = benzodiazepine. GAD-7 = Generalised Anxiety Disorder-7. PHQ-9 = Patient Health Questionnaire-9. PTSD = post-traumatic stress disorder. SD = standard deviation. SDS = Severity of Dependence Scale. SF-8 = Health Survey Short-Form-8.

Supplementary Data

Supplementary material is not copyedited or typeset, and is published as supplied by the author(s). The author(s) retain(s) responsibility for its accuracy.