Benzodiazepine receptor agonist deprescribing principles for long-term use and dependence: modified Delphi recommendations from a multi-disciplinary expert panel

Abstract

Background: Benzodiazepine receptor agonists (BZRA) are frequently tapered because of risk of dependence and hazards of use in ageing. Standard tapering protocols may fail or result in harm from improper utilization of pharmacologic principles, lack of recognition of withdrawal and/or failures in shared decision-making. Objective: The aim of this work was to derive principles from experts to optimize deprescribing success while minimizing withdrawal among patients who use BZRA medication long-term. Design: Modified Delphi consensus study among experts from two not-for-profit organizations dedicated to BZRA use issues. Methods: Three stages of anonymized voting were conducted among clinical experts and patient representatives. An 80% agreement (‘agree’ or ‘strongly agree’ on a five item Likert-type scale) was required for consensus. Recommendations which failed to reach initial consensus, were modified from feedback and downgraded to ‘moderate’ (>80% agreement) or ‘weak’ consensus (50%–80% agreement) in the subsequent rounds. Results: A total of 35 of 48 invitees participated (73% response rate) which included seven family physicians, nine psychiatrists, five pharmacists, six patient advocates, two nurse practitioners, two licensed clinical social workers, two health service policy researchers, a physician assistant and a psychotherapist. A total of 31 of 35 participants were from the United States, with the remaining representatives from Canada, the UK and Ireland. Strong consensus was achieved for attaining informed consent prior to deprescribing (recommendation 1), using a flexible and gradual tapering approach (recommendation 2) characterized by shared decision-making (recommendation 3) with hyperbolic dose reductions (recommendation 4) facilitated via novel preparation techniques or compounded pharmaceutical formulations (recommendation 7). Reversion to previous doses may occur if necessary to reduce the incidence of withdrawal (recommendation 6). Strong consensus was also reached for adjunctive psychosocial interventions (recommendation 8) and/or peer-support resources (recommendation 9). Moderate and weak consensus was achieved, respectively, for step-wise conversion to a longer-acting BZRA (recommendation 5) and the avoidance of adjunctive non-BZRA pharmacotherapy (recommendation 10). Conclusion: This consensus guidance document for primary care providers, mental health clinicians and long-term users of BZRA outlines ten principles/recommendations intended for improving deprescribing outcomes with an emphasis on minimizing withdrawal risk.