By James J. Cotter, MD, MPH, Regional Medical Director

Benzodiazepine Tapering

Benzodiazepines are one of the most used psychotropic medications in the US. Although the indications for short term use include anxiety or sleep disturbances, many adults are prescribed benzodiazepines for years to decades despite warnings against long term use. Side effects of benzodiazepines include sedation and lethargy, impaired cognition and memory, dependency and abuse and increased risk of falls in older adults.  Alcohol increases the risks of side effects as does co-prescription with opioid medications.

Long term use of benzodiazepines is problematic and the significant risks of long term use outweigh any potential (and poorly proven) benefits.  If benzodiazepines are to be used long term, it is preferable to avoid short acting agents and to use the lowest effective dose.  Some benzodiazepines, such as alprazolam, appear more associated with misuse and should be avoided.  Patients using short acting benzodiazepines may increase the dose and frequency due to anxiety or restlessness between doses or difficulty sleeping at night. Warning signs for abuse or diversion include escalating dose or frequency, deteriorating function, “lost” pills, or other evidence suggesting misuse of the drug.  The risk of dependency and abuse is particularly worrisome on opioids and those individuals with a history of substance use disorders.

In some cases, the patient may notice decreased cognitive function or begin having falls and then ask for help in tapering off the benzodiazepine.  One should definitely consider tapering benzodiazepines for your patients who are over 65 years of age, are taking multiple benzodiazepines, or those who have cognitive difficulties and patients with substance or alcohol use disorder.

Outpatient Tapering

Once the decision to taper has been made, what methods work best to safely and effectively taper?  Assuming this is an outpatient setting and there is no evidence of drug abuse or diversion, there are many algorithms for the safe tapering of benzodiazepines. For patients under 65 years of age, most algorithms recommend switching to a long acting benzodiazepine, such as diazepam.  When switching to diazepam, choose a dose equivalent to the short acting agent’s dose.  However, the starting dose of diazepam should not exceed 40 mg daily.  In older patients, the safest options are lorazepam or temazepam since they do not have active metabolites.

If the patient is on a high dose of benzodiazepines (over 40 mg of diazepam or equivalent), it may be possible to initially reduce the dose by as much as 25% and then continue decreasing the dose by 10% per week.  Usual therapeutic doses may begin tapering at 10% per week.  Side effects of tapering include anxiety and restlessness, agitation, tremors and panic attacks.  Long term withdrawal symptoms may include anxiety, confusion, depression and cognition/memory symptoms.  Anxiety-related withdrawal symptoms may be mitigated by beginning cognitive behavioral therapy, SSRIs, TCAs or buspirone prior to tapering the benzodiazepine.  Insomnia can be “pre-treated” by cognitive behavioral therapy, TCAs and sleep hygiene education.

For patients with a history of seizures or current active drug use, assistance from an addiction specialist may be necessary.  Patients with severe mood disorders or suicidality may require psychiatric consultation.

A standardized office based approach to dose reduction of benzodiazepines can be very successful. Studies have shown success achieving complete withdrawal in about half of patients on benzodiazepines and a significant dose reduction in another quarter of benzodiazepine patients. The factors indicating the highest likelihood of success are:  a caring clinician, current use of benzodiazepines at a diazepam dose equivalent to 10 mg or less and patients without underlying depression.

Summary:

• Taper benzodiazepines in patients who are 65 or older, those on multiple benzodiazepines, those with cognitive issues and patients with alcohol or substance use disorder
• Consider non-benzodiazepine treatment for anxiety or sleep disorders prior to tapering benzodiazepines.
• Convert patients under 65 to the long acting diazepam at an equivalent dose, but do not exceed 40 mg of diazepam daily.
• Taper by 10% per week for most patients.
• Get assistance in tapering for patients with substance use disorder, a history of seizures and patients with significant mental health disorders.

References:

Management of benzodiazepine misuse and dependence. Aust Prescr 2015;38:152-5

Benzodiazepine: Use and Taper.  Canadian Guideline http://nationalpaincentre.mcmaster.ca/opioid/

Helping Patients Taper from Benzodiazepines. National Center for PTSD 2017

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

Partnership HealthPlan’s new Intensive Palliative Care Benefit has been in place since last winter, but we are seeing wide variation in its use.

In Mendocino, Humboldt and Del Norte Counties, we are seeing strong use of the program, with over 80 patients currently enrolled.  In all the remaining counties, enrollment rates have been very low.

Several studies of intensive outpatient palliative care have shown:

1. Excellent patient experience/better quality of life
2. Patients live longer (not shorter)
3. Health care costs are significantly lower, mostly due to decreased hospital use in the month before death.

What is the explanation for under-use of palliative care in 11 out of 14 counties?

It is not due to an inadequate network.  Partnership has worked diligently to provide a network of intensive palliative care providers that can cover all parts of our service area, including remote frontier areas.

It is also not due to having few patients who qualify.  The eligibility criteria includes:

1. Stage 3-4 Cancer
2. Advanced cirrhosis/liver disease
3. Severe COPD
4. Severe CHF

Other patients with advanced disease but without these 4 conditions may not be eligible for the full benefit, but may still be referred to palliative care for a comprehensive evaluation with development of a treatment plan.

If you aren’t sure if a patient qualifies:  make the referral!  The palliative care team will assess the patient and get them on the right track.

Low rates of use of intensive outpatient palliative care are primarily related to low rates of referrals of appropriate patients.  Specialists, hospitalists, and primary care physicians are not identifying patients who are good candidates and referring them to their palliative care colleagues for evaluation and management.  Many physicians interpret the term “palliative care” as being the same as hospice.   While hospice care is part of the spectrum of palliative care, the rules for enrollment into hospice are rather rigid:  no curative care; patient expected to live 6 months or less.     In intensive outpatient palliative care, the patient has an expected life expectancy of less than 1 year, and may be receiving concurrent care whose goal is to cure the disease or otherwise ameliorate symptoms.

Which organizations are providing Intensive Outpatient Palliative Care in your region?  See the chart below.

Get help for your patients who are nearing the end of their lives, but may not be ready for hospice.  Refer them to your local palliative care team!

Robert Moore, MD MPH

Chief Medical Officer