Benzodiazepines are an effective pharmacological intervention for the management of insomnia and anxiety, and also the prevention and treatment of epileptic seizures.1,2 While benzodiazepines are indicated for the short-term management of such conditions, their use may become prolonged, leading to drug dependence in an individual.3 Individuals may deliberately abuse benzodiazepines, or inadvertently become dependent, physically and/or psychologically.2 Prescribers are, at present, encouraged to provide the lowest effective dose to individuals, limit prescribing benzodiazepines to 4 weeks of use or less and to consider the risks of dependency in the individual being prescribed for.1

Individuals who become dependent, chronic users of benzodiazepines may experience physical symptoms such as flu-like illness and muscular cramps, and also psychological symptoms such as irritability and insomnia. Often, the symptoms of withdrawal mimic the symptoms of the original complaint that the benzodiazepines were prescribed for, leading to an exaggerated effect of rebound symptoms. This complicates the discontinuation of benzodiazepines as individuals mistakenly believe there is a need for continued prescription.2 To assist individuals with discontinuing long-term use of benzodiazepines, gradual withdrawal, psychological support and pharmacological intervention are recommended.1

The Cochrane review aims to assess the benefits and harms of pharmacological interventions to facilitate discontinuation of chronic benzodiazepine use.

The authors of this review examined whether pharmacological interventions may facilitate the discontinuation of benzodiazepines. Pharmacological interventions are centred on the symptomatic management of withdrawal; however, no drugs are, at present, recommended or approved for this purpose. The authors found that a previous systematic review provided inconclusive results on current pharmacological intervention approaches in general practice4; however, due to new studies having been performed in this area, a new review is warranted.

The review included 38 randomized controlled trials (RCTs), involving 2543 participants aged 18 years or older, who had been using benzodiazepines daily for a minimum of 2 months. Participants had an average age of 50 years, and most participants were women. All individuals with a diagnosed benzodiazepine dependence under any criteria (e.g. ICD-10, DSM-V) were included, and also individuals with somatic or psychological comorbidities. The experimental intervention was any drug administered in any setting to facilitate benzodiazepine withdrawal. The control intervention was treatment as usual, placebo or an active pharmacological comparator. Primary outcomes were measured by the authors and were benzodiazepine discontinuation, withdrawal symptoms and any serious adverse events resulting in death, life-threatening illness, hospitalization, prolonged hospital stay, persistent or significant disability or congenital anomaly/birth defects. Secondary outcomes included insomnia, anxiety and comorbid substance abuse.

The authors of this review could not find any pharmacological intervention to facilitate the withdrawal process from benzodiazepines. The quality of evidence found was low or very low due to risk of bias, study design and low number of participants, along with the financial involvement of the pharmaceutical industry. Drugs assessed included valproate, pregabalin, captodiame, paroxetine, tricyclic antidepressants, flumazenil and carbamazepine. The authors could not be certain if chances of benzodiazepine cessation were improved, if withdrawal symptoms were reduced, or if symptoms of anxiety were reduced in patients. Tolerability and safety were poorly reported across all studies, which, along with overestimated benefits and underestimated harms, led the authors to conclude that no conclusions could be made about the effectiveness of the interventions.

There are several implications for nursing practice when working with individuals discontinuing long-term benzodiazepine use. Pharmacological interventions may be prescribed by a medical practitioner; however, education of the individual on the use of these interventions and what to expect from these therapies is an important role the nurse may play. Assisting individuals to understand the effects of benzodiazepine withdrawal play a role in reducing the drive to seek further prescriptions for rebound symptoms. Providing psychological support and tools such as relaxation therapy and aforementioned education have been shown to be superior to dose reduction alone in primary care settings.4 Nursing education on good sleep hygiene practices may also assist with benzodiazepine discontinuation.

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