W.J.M.J. Gorgels

Predictors of long-term benzodiazepine abstinence in participants of a randomized controlled benzodiazepine withdrawal program

Objective: To identify predictors of resumed benzodiazepine use after participation in a benzodiazepine discontinuation trial. Method: We performed multiple Cox regression analyses to predict the long-term outcome of a 3-condition, randomized, controlled benzodiazepine discontinuation trial in general practice. Results: Of 180 patients, we completed follow-up for 170 (94%). Of these, 50 (29%) achieved long-term success, defined as no use of benzodiazepines during follow-up. Independent predictors of success were as follows: offering a taper-off program with group therapy (hazard ratio [HR] 2.4; 95% confidence interval [CI], 1.5 to 3.9) or without group therapy (HR 2.9; 95%CI, 1.8 to 4.8); a lower daily benzodiazepine dosage at the start of tapering off (HR 1.5; 95%CI, 1.2 to 1.9); a substantial dosage reduction by patients themselves just before the start of tapering off (HR 2.1; 95%CI, 1.4 to 3.3); less severe benzodiazepine dependence, as measured by the Benzodiazepine Dependence Self-Report Questionnaire Lack of Compliance subscale (HR 2.4; 95%CI, 1.1 to 5.2); and no use of alcohol (HR 1.7; 95%CI, 1.2 to 2.5). Patients who used over 10 mg of diazepam equivalent, who had a score of 3 or more on the Lack of Compliance subscale, or who drank more than 2 units of alcohol daily failed to achieve long-term abstinence. Conclusions: Benzodiazepine dependence severity affects long-term taper outcome independent of treatment modality, benzodiazepine dosage, psychopathology, and personality characteristics. An identifiable subgroup needs referral to specialized care.

Tapering Off Benzodiazepines in Long-Term Users: An Economic Evaluation

AbstractBackground: Discontinuation of benzodiazepine usage has never been evaluated in economic terms. This study aimed to compare the relative costs and outcomes of tapering off long-term benzodiazepine use combined with group cognitive behavioural therapy (TO+CBT), tapering off alone (TOA) and usual care. Method: A randomised controlled trial was conducted, incorporating a costeffectiveness analysis from a societal as well as a pharmaceutical perspective.The cost of intervention treatment, prescribed drugs, healthcare services, productivity loss, and patients’ costs were measured using drug prescription data and cost diaries. Costs were indexed at 2001 prices. The principal outcome was the proportion of patients able to discontinue benzodiazepine use during the 18-month follow-up. A secondary outcome measure was quality of life (Health Utility Index Mark III [HUI-3] and the Medical Outcomes Study 36-item Short-Form Health Survey [SF-36]). Results: A total of 180 patients were randomised to one of TO+CBT (n = 73), TOA (n = 73) or usual care (n = 34). Intervention treatment costs were an average of €172.99 per patient for TO+CBT and €69.50 per patient for TOA. Both treatment conditions significantly reduced benzodiazepine costs during follow-up compared with usual care. The incremental cost-effectiveness ratios (ICERs) showed that, for each incremental 1% successful benzodiazepine discontinuation, TO+CBT cost €10.30–62.53 versus usual care, depending on the study perspective. However, TO+CBT was extendedly dominated or was dominated by TOA. This resulted in ICERs of €0.57, €10.21 and €48.92 for TOA versus usual care from the limited pharmaceutical, comprehensive pharmaceutical and societal perspective, respectively. Conclusions: TO+CBT and TOA both led to a reduction in benzodiazepine costs. However, it remains uncertain which healthcare utilisation has a causal relationship with long-term benzodiazepine consumption or its treatment. Although the ICERs indicated better cost effectiveness for TOA than for TO+CBT, the differences were relatively small. The addition of group CBT to tapering off had no clinical or economic advantages. Extrapolation of our data showed that the investment in TOA was paid back after 19 months when corrected for treatment gain with usual care.

Tolerance to benzodiazepines among long-term users in primary care

BACKGROUND Tolerance towards the effects of benzodiazepines is observed in various animal and human studies. Therefore, it is assumed that patients who use benzodiazepines for a longer period of time need to increase their dose over time to experience the same effect. OBJECTIVE To observe whether long-term benzodiazepine users increase their dose over time. METHODS From the Dutch National Information Network of Family Practices, a group of long-term benzodiazepine users was identified. This group was divided into an incident long-term benzodiazepine users group (N = 113) and a prevalent long-term benzodiazepine users group (N = 992). Long-term use of benzodiazepines was defined as usage for at least 6 months. The main outcome was a change in prescribed dose from baseline until 24 months after baseline. Linear regression analysis was performed to evaluate dose change. RESULTS Neither incident long-term benzodiazepine users nor prevalent long-term benzodiazepine users were prescribed increasing dosages during follow-up. CONCLUSION There is no increase in prescribed dose among long-term users, as might be expected due to the development of tolerance to the effects of benzodiazepines.

A benzodiazepine discontinuation programme does not increase the frequency of contacts with the family practice

Objective. The efficacy of programmes to reduce long-term benzodiazepine use could be compromised by subsequent increases in contacts with the family practice. In this study the hypothesis was tested as to whether participation in a benzodiazepine discontinuation programme affects the frequency of contacts with the family practice. Design. A controlled stepped-care intervention programme to decrease long-term benzodiazepine use. Setting. Family practices in the Netherlands. Subjects. The experimental group consisted of 996 long-term benzodiazepine users and a control group of 883 long-term benzodiazepine users. Main outcome measures. Practice contacts before and up to 12 months after the start of the programme. Results. There was a general tendency visible for contacts to decrease during the follow-up time. The course of the number of contacts during the follow-up was not different for the experimental and control groups (p=0.45). The level of non-benzodiazepine prescriptions was generally not altered. The number of non-benzodiazepine prescriptions decreased in benzodiazepine quitters during the follow-up of the programme. Conclusion. No clinically important differences in practice contacts were observed when the course of the number of contacts and non-benzodiazepine prescriptions were compared between the experimental and control groups. Family practitioners do not have to anticipate an increased workload associated with participation in such a benzodiazepine discontinuation programme.

General practitioners' opinions of a stepped-care benzodiazepine discontinuation programme.

Department Primary Care, Centre of Evidence Based Medicine (EBP), and Department of Psychiatry, Radboud University Nijmegen Medical Centre, the Netherlands, Department of Psychiatry and Institute for Research in Extramural Medicine, VU University Medical Centre, Amsterdam, the Netherlands, Department of Clinical Psychology, Radboud University, Nijmegen, the Netherlands, and Department of Psychiatry, Leiden University Medical Centre, Leiden, the Netherlands