Prescribing drugs of dependence in general practice

Part B - Benzodiazepines - Chapter 4

Duration of benzodiazepine therapy

Last revised: 06 Nov 2019

Overview

Optimal duration of therapy

Guidelines and formularies typically give durations of 1–4 weeks for benzodiazepine therapy, depending on the indication. Short-term therapy is generally advised to reduce the risk of dependence and withdrawal, as well as other potential harm such as cognitive impairment. Short-term therapy does not reduce the risk of accidents or falls.

Dependence is recognised as a risk in some patients who receive treatment for longer than 1 month, and health professionals should be conscious of this when considering the relative benefits and risks of treatment.25

The 1–4 week time frame is not based on risk–benefit data; rather that no substantive placebo-controlled trials of hypnotics have been carried out for longer than a few weeks. The available evidence does not suggest there is an unfavourable risk–benefit transition at 3–4 weeks for any agent.101

Patients who are prescribed benzodiazepines for problems relating to anxiety or sleep usually do not escalate their doses even over a lengthy period of use.185 A 2013 study found most patients use benzodiazepines according to guidelines, and only 0.9% ended up as excessive users after 3 years.76 Excessive use occurred mostly in individuals with alcohol and drug histories.

Lacking the means to determine the optimal duration of therapy, a rational approach is to allow the duration of treatment to be determined by a series of risk–benefit decisions and shared decision making, with periodic trials of tapering and discontinuing medication to determine whether continued therapy is indicated.101,186 This approach provides an ‘exit strategy’ and thereby addresses concerns that once started, hypnotic therapy could be unending.101

Clinical discipline and accountable prescribing are essential when considering long-term benzodiazepine therapy.

While the optimum duration of therapy is not clear from the evidence, there are very few specific indications for the chronic use of benzodiazepines. The decision to prescribe benzodiazepines longer term should be uncommon and made with caution. Assume that all patients are at risk of dependence.

Benzodiazepines may be used for longer than 4 weeks in selected cases. Patients who are terminally ill or severely handicapped, where it is clear that the benefits outweigh the risks and side effects, or where a detailed individual assessment has been made with a patient and their family or carers.

Benzodiazepines may also be indicated in certain neurological disorders (eg stiff person syndrome) and in neuromuscular conditions where spasticity is problematic. Increasingly, benzodiazepines are being used off-label for indications (eg drug-induced movement disorders, restless legs syndrome, acute psychotic agitation, terminal agitation, nausea and vomiting, intractable pruritus and intractable hiccup).187

Recommendations supporting the long-term use of benzodiazepines for any mental illness or chronic sleep disorder come from evidence limited to shorter time frames. Hence, longer duration of prescribing should occur in conjunction with heightened clinical surveillance.

The principles of universal precautions apply. Ensure a clear diagnosis is formed, comprehensive assessment is undertaken, clear treatment plan is discussed with the patient and information is provided to the patient to enable informed consent. The negotiated treatment plan will have clearly defined time limit and goals of treatment.

Benzodiazepines are generally regarded by clinical practice guidelines as a short-term therapeutic option. Long-term use, beyond 4 weeks, is not generally advocated by clinical practice guidelines, hence long-term therapy should be should be uncommon and made with caution.

Prescribing benzodiazepines, like other aspects of clinical practice, should be based on thoughtful consideration of the likely risks and benefits, and the risks and benefits of alternative interventions. This decision should be made in conjunction with the patient and their carers, where appropriate.100 Benzodiazepines may be prescribed longer term where:

  • patients do not respond to, or cannot tolerate, numerous first-line therapies130,188
  • use is intermittent
  • specialists make a recommendation and are able to provide a rationale of therapy.

For some patients, benzodiazepine alternatives fail, have limited benefit, are unavailable or clinically inappropriate. If there is no history of drug dependence, positive indicative ‘lifestyle’ factors are present and a clinical decision for benzodiazepine treatment can be justified, then long-term therapy should not necessarily be regarded as a deviation from good clinical practice.25 Supervised benzodiazepine treatment may remain an acceptable long-term therapeutic option for some patients.

Many patients are able to safely take short courses of benzodiazepines, or to use them intermittently longer term, on a ‘as required’ basis and to stop them when no longer needed.25,113

In a situation where the clinical decision is that the ongoing use of a benzodiazepine is the most appropriate management, this requires ongoing monitoring of health outcomes and continuing vigilance for potential hazards throughout treatment.25

The responsible specialist or GP should clearly outline a prescribing plan that should be documented in the patients’ notes or management plan.

The prescribing plan may include instructions that:

  • regular prescription reviews take place
  • no repeat prescriptions will be made without face-to-face contact
  • all prescriptions will be made by one doctor within a single practice
  • one pharmacy will dispense all medication.

Benzodiazepine prescriptions should be at the lowest effective dose and given intermittently, with regular reviews of the treatment plans and regular attempts at withdrawal.

At the time of benzodiazepine prescription renewal or medication review, GPs should continue to discuss the risks of long-term benzodiazepines and the benefits of discontinuation (eg cognition, mood, sleep and energy level) and advise the patient to reduce or discontinue the benzodiazepines if there are issues. GPs should document this communication.

Patients should be monitored closely for problematic use or any therapeutic dose dependence behaviour. Any escalation of dose or inappropriate use would lead to a complete review of prescribing and attempted withdrawal of benzodiazepine, along with a review of alternative therapy.

Refer to Resource E.2 in the PDF version for an example of a prescription plan/agreement.

All GPs should develop strategies to manage inappropriate requests for benzodiazepines.

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