BENZODIAZEPINE(and similarly acting substances) REDUCTION PROGRAM Seniors Wellness Group, P.C. May, 2017

BENZODIAZEPINE (and similarly acting substances) REDUCTION PROGRAM QUIZ Benzodiazepines more than double the risk of falls and hip fractures in the elderly T / F List 3 risks of using sedative hypnotic drugs: ____________________________________ List 3 reasons why sedative hypnotic drugs are initially used: _____________________________________ There really are no better long term treatment options than sedative hypnotic drugs. T /F Sedative Hypnotic Medication has now been added to the _______________________ List 3 better treatment options for insomnia and anxiety: _______________________________________ ______________________________________   NAME______________________________________________

The Problem It is now well recognized that the long-term use of hypnotics and anxiolytics (including both, benzodiazepines and “Z” drugs) by the majority of patients in general practice is not appropriate. Clinical practice guidelines from various medical associations and expert consensus statements have cautioned against benzodiazepine use for longer periods and especially in older populations due to the significant risks associated with the use of these drugs. Despite this, usage has continued to increase, especially among older adults and even more so among females than males. Most prescriptions are written by non-psychiatrists or primary care/family practitioners.

Despite risks, benzodiazepine use highest in older people National Institute of Health-supported study examining prescribing patterns. December, 2014

Despite risks, benzodiazepine use highest in older people National Institute of Health-supported study examining prescribing patterns. December, 2014 “These new data reveal worrisome patterns in the prescribing of benzodiazepines for older adults, and women in particular … This analysis suggests that prescriptions for benzodiazepines in older Americans exceed what research suggests is appropriate and safe.” Thomas Insel, M.D., director of the National Institute of Mental Health (NIMH). “The safety risks associated with benzodiazepine use in the elderly are considerable and include potentially life-threatening events… As a result, there is a pressing public health need to increase access to safer alternative nonpharmacological interventions for insomnia and anxiety in older adults.” Mark Olfson, MD, MPH, professor of psychiatry at Columbia University Medical Center and the lead author of a study of benzodiazepine use in the U.S. “. . . extensive evidence suggests that benzodiazepines and other sedative– hypnotic medications (including the newer Z-compounds - zolpidem, eszopiclone, and zaleplon) more than double the risk of falls and hip fractures leading to hospitalization and death in older adults.” American Geriatrics Society, 2012

Benzodiazepines (Anxiolytics) Hypnotics (“Z” drugs) alprazolam (Xanax) chlordiazepoxide (Librium) clonazepam (Klonopin) clorazepate (Tranxene) diazepam (Valium) estazolam (ProSom) flurazepam (Dalmane) lorazepam (Ativan) oxazepam (Serax) temazepam (Restoril) triazolam (Halcion) quazepam (Doral) Hypnotics (“Z” drugs) eszoplicone (Lunesta) zaleplon (Sonata) zolpidem (Ambien) Benzodiazepines (Anxiolytics) Hypnotics (“Z” drugs)

Risks Cognitive Impairment Sedation Delirium Psychomotor Impairment Falls Fractures Motor Vehicle Accidents Disinhibition Depression Tolerance Withdrawal Dependence/Addiction Misuse Sub-Populations Stroke (Dementia) Pneumonia (Dementia) Death (e.g., Schizophrenia)

Benefits/Indications Rapid, short-term relief of acute anxiety and related symptoms Rapid, short-term relief of acute insomnia Urgent treatment of acute psychosis or acute mania Single-dose treatment of phobias (e.g., fear of flying) Short-term management of alcohol withdrawal symptoms Short-term seizure management Relief of muscle discomfort associated with acute injuries or acute exacerbations of chronic musculoskeletal pain

Contraindications Use beyond 4-6 weeks in the general population, but for exceptional circumstances (e.g., terminally ill patients) Use beyond 4 weeks for persons 65 years and older There is no evidence to support long-term use of these drugs for insomnia, anxiety, agitation associated with dementia, delirium or any mental health condition.

Problem of Tolerance, Dependence and Withdrawal Not all people who use benzodiazepines or Z-drugs become dependent on them (because of appropriate short-term use, or the absence of regular use) Among those who do, it can be extremely difficult to withdraw and we must keep in mind that the medications were given to help the patient in the first place, not to cause problems of dependency, adverse medical reactions and events or lowered quality of life, as the drugs end up doing in many instances.

Tolerance For the main indications of anxiety and insomnia, benzodiazepines and Z-drugs fare little better than placebo after a few weeks of treatment. After an initial improvement, the effects of either of these drugs tend to wear off and disappear, making a higher dose necessary for it to work. In time, the higher dose does not work, and so an even higher dose is needed, and so on.

Dependence (addiction) Once tolerance has developed, when the effects of the drug start to wear off or if the patient tries to stop taking the drug, she will experience withdrawal anxiety and insomnia. The usual conclusion by the patient is, “you see, the drug works. When they wear off or I stop them, I get worse.” In actuality though, the patient at this point is in effect just taking them to feel “normal.”

Signs and Symptoms of Withdrawal Acute - The majority of acute withdrawal symptoms are anxiety- related, and include restlessness, agitation, tremors, dizziness, panic attacks, palpitations, shortness of breath, sweating, flushing, shakiness, difficulty swallowing, poor sleep, sensation of choking, and chest pain. Additional symptoms of acute withdrawal include seizures, bowel/bladder problems, changes in appetite, tiredness, faintness, poor concentration, and many others. Long-term - Long-term withdrawal symptoms may take months or years to resolve and include anxiety, confusion, depression, depersonalization, psychosis, paranoid delusions, rebound insomnia, poor memory and cognition, motor symptoms (pain, weakness, muscle twitches, jerks, seizures), and abnormal perception of movement.

Better Treatment Options Cognitive behavior therapy (CBT) for insomnia and most anxiety disorders Sleep hygiene and relaxation approaches for insomnia Newer generation anti-depressants (e.g., SSRI’s) for chronic conditions of anxiety and anxiety symptoms associated with other primary psychiatric conditions (e.g., Major Depression) Non-pharmacological approaches for management of BPSD

Additional Considerations Citations during state’s survey Negative effects on 5-star rating Increased incidence of falls and fractures Increased incidence of re-hospitalizations and/or unnecessary hospitalizations secondary to adverse medical events Reduced mobility secondary to sedation with potential consequences of new or worsened bed sores and unnecessary loss of independence and functionality

Quality of Life of Resident MRS. ROBINSON’S STORY - She has been taking Lorazepam (Ativan), a commonly used benzodiazepine or sedative-hypnotic drug. “I am 65 years old and took Lorazepam for 10 years. A few months ago, I fell in the middle of the night on my way to the bathroom and had to go to the hospital. I was lucky and, except for some bruises, I did not hurt myself. I read that Lorazepam puts me at risk for falls. I did not know if I could live without Lorazepam as I always have trouble falling asleep and sometimes wake up in the middle of the night. I discussed the matter with my doctor who also told me more about the side effects of the drug. She also said that my body needs less sleep at my age – 6 hours of sleep per night is enough. So that’s when I decided to try to taper off the Lorazepam as my doctor recommended. She started a step-by- step tapering program that was slow and adjusted to the right pace in order to prevent withdrawal symptoms. I also applied some new sleeping habits that I had discussed with my doctor. First, I stopped drinking coffee after dinner in the evening. I also stopped exercising before bed, as well as reading in bed and finally, I got out of bed every morning at the same time whether or not I had a good night’s sleep. Over time, I succeeded in getting off Lorazepam. I now realize that for the past 10 years I had not been living to my full potential. Stopping Lorazepam has lifted a veil, like I had been semi-sleeping my life. I have more energy and I don’t have so many ups and downs anymore. I am more alert: I don’t always sleep well at night, but I don’t feel as groggy in the morning. It was my decision! I am so proud of what I have accomplished. If I can do it, so can you!’’

The Program Primary goals – avoid, contain, reduce the use of benzodiazepines and Z-drugs for the management of conditions/symptoms of anxiety, agitation, delirium and insomnia. Primary intervention – Education – resident, family members, provider and caregiver community

Main points of education Review Risks and benefits of usage showing that risks outweigh benefits Clarify that long-term use of benzodiazepines and Z-drugs is rarely, if ever, indicated consistent with R & B considerations Include focused explanation of process of developing tolerance, dependence and withdrawal Review of clinical indications for short-term prescribing Review of alternative and better (e.g., lower risk) treatment options

Desired Effects of education Resident – agrees to follow Rx for short-term use of a BENZ or Z- drug if Rx or agrees to Rx to taper and D/C if already using one or both drugs Family members – same as for the resident and otherwise reinforces these principles and goals on behalf of the resident PCP – avoids long-term use of BENZ or Z-drugs (i.e., greater than 4 weeks) or otherwise reinforces the above principles through the continuing course of care and reliably refers to psychiatric consultant for management of existing regimens of these drugs or management of conditions/symptoms of anxiety, agitation and insomnia Pharmacist – supports and reinforces principles of proper use of BENZ’s and Z-drugs with the resident and any/all other interested parties

Desired Effects of education(cont.) Nurses, Social Workers, Other Caregivers – avoid requesting BENZ’s and Z-drugs for patient care, reinforces principles of proper use of BENZ’s and Z-drugs with the resident and any/all other interested parties, seek and implement alternative non- pharmacological interventions to manage symptoms of anxiety, agitation, delirium and insomnia All Interested Parties – consistent application of the principles learned whenever confronting these issues in relation to patient care along with consistent support of SWG’s psychiatric consultant in realizing the aforementioned Primary Goals of avoiding, containing and reducing the use of BENZ’s and Z- drugs through the course of patient care

Benzodiazepine Reduction Flow Chart

BENZODIAZEPINE (and similarly acting substances) REDUCTION PROGRAM QUIZ Benzodiazepines more than double the risk of falls and hip fractures in the elderly T / F List 3 risks of using sedative hypnotic drugs: ___Falls____________________________ ___Stroke__________________________ ___Death__________________________ List 3 reasons why sedative hypnotic drugs are initially used: ___Anxiety_________________________ ___Insomnia________________________ ___Agitation________________________ There really are no better long term treatment options than sedative hypnotic drugs. Sedative Hypnotic Medication has now been added to the ___Quality Indicators___ List 3 better treatment options for insomnia and anxiety: ___Cognitive Behavioral Therapy_________________________ ___Patient Centered, Non Pharmacological Interventions__ ___Newer generation antidepressants (e.g. SSRI’s)_________   NAME______________________________________________