By Phil Emberley and Wendy Levinson
Sleep doesn’t come easy as we age. Take Ilsa; she is a 78-year-old recent widow. Since her husband passed away, she has slept poorly. A recent hospitalization and the disorienting bright lights and noises of the inpatient ward made her irritated and exhausted. She was given a short-term benzodiazepine to help her get some sleep.
A few weeks after being discharged from hospital, her family doctor suggested she might want to try to stop taking the benzodiazepine, which she did cold turkey. Ilsa experienced significant rebound insomnia and felt horrible, and within a few days was back on the medication.
One year later and she is still hooked.
Ilsa isn’t alone in her long-term use and dependence on these powerful drugs for sleep or anxiety. The Canadian Institute for Health Information recently released data that over one in 10 Canadian seniors take these highly addictive medications on a regular basis. And that number climbs to nearly one in four seniors in Newfoundland and New Brunswick.
At one time, benzodiazepines, like alprazolam, diazepam and lorazepam, were assumed to be considerably safer than alternatives, and were prescribed quite freely, particularly among seniors. While these drugs are now frequently abused and misused across all ages, long-term use is especially harmful. The short-term assistance of helping Ilsa get some sleep during a stressful period in her life is outweighed by the risks of long-term use. Side effects include impaired thinking, reduced mobility and increased risk of injury from falls or car accidents.
As health care providers, we commonly prescribe and dispense these medications. But in addition to providing a prescription, increasingly we are offering advice and talking to patients about the harms of long-term use and how they can avoid getting hooked on these medications over the long-term.
We know that seniors especially need support on how to taper medications.
It is not enough to just tell a patient that they should stop taking that pill, they need support and tools to safely wean themselves from these powerful medications. In fact, often seniors come to us and ask about whether or not these medications can be addictive; this is an excellent time to discuss the potential pitfalls of long-term benzodiazepine use.
A ground breaking study from researchers and doctors at the University of Montreal tested whether community pharmacists could help seniors taper benzodiazepine use. The study tested this by providing education to pharmacists on how to do this safely. Alongside health professional education were materials developed specifically for patients on the harms of benzodiazepines and safer alternatives — medications or strategies that could replace their pills.
The study found that when provided with information and tools, a significant number of patients were able to safely taper and ultimately stop taking their daily benzodiazepine. This is an important finding because both too fast and too slow tapers can ultimately fail, resulting in seniors continuing to take the medication.
Pharmacists have the drug therapy knowledge and tools to help patients successfully taper.
Now, as part of the national Choosing Wisely Canada campaign, the Canadian Pharmacists Association (CPhA) is informing the 42,000 pharmacists who practice in community and hospital pharmacies across the country to dispense not only prescriptions, but information on how to stop dangerous medications. Research shows that starting the conversation with patients about stopping or tapering dangerous medications, like benzodiazepines, can help curb long-term use and dependence.
Pharmacists can also reinforce other options to address sleep disturbances and anxiety, as well as help coach patients as they attempt these other options.
Last month, CPhA with the Choosing Wisely Canada campaign, released a list of ‘Six Things Pharmacists and Patients Should Question.’ One of the recommendation on this list, which is being distributed to pharmacists across the country is “Don’t prescribe or dispense benzodiazepines without building a discontinuation strategy into the patient’s treatment plan.”
This recommendation is something we urge all clinicians who prescribe and dispense these medications to seniors to keep in mind. This is also something we urge patients, caregivers and family members to consider.
Is your loved one or family member taking a benzodiazepine long-term? Consider talking to your pharmacist or health care provider at your next encounter about whether it could be doing more harm than good.
Phil Emberley is the director of practice advancement and research for the Canadian Pharmacists Association (CPhA). He has been a practising pharmacist for almost 30 years.
Dr. Wendy Levinson is the Chair of Choosing Wisely Canada, an expert advisor with EvidenceNetwork.ca and a Professor of Medicine at University of Toronto.
