Plan ahead to avoid long-term use of sleeping pills

Sleep doesn’t come easy as we age. Take Ilsa, a 78-year-old widow. Since her husband died, Ilsa has slept poorly. A recent hospitalization and the disorienting lights and noises of the in-patient ward made her irritated and exhausted. She was given a shortterm benzodiazepine to help her sleep.

A few weeks after being discharged, her family doctor suggested she stop taking the benzodiazepine, which she did cold turkey. Ilsa experienced significant rebound insomnia and felt horrible. Within a few days, she was back on the medication. One year later, she is still hooked. Ilsa isn’t alone in her dependence on these powerful drugs for sleep or anxiety. The Canadian Institute for Health Information recently released data showing more than one in 10 seniors regularly take these highly addictive medications. In Newfoundland and New Brunswick, that number is nearly one in four.

At one time, benzodiazepines such as alprazolam, diazepam and lorazepam were assumed to be safer than alternatives and were prescribed quite freely, particularly among seniors. While these drugs are now frequently abused and misused across all ages, long-term use is especially harmful. The shortterm assistance of helping Ilsa get some sleep during a stressful period is outweighed by the risks of long-term use. Side-effects include impaired thinking, reduced mobility and increased risk of injury from falls or car accidents.

As health-care providers, we commonly prescribe and dispense these medications. But in addition to providing a prescription, increasingly we are offering advice and talking to patients about the harms of longterm use and how they can avoid getting hooked on these medications.

We know seniors especially need support on how to taper medications.

It isn’t enough to tell a patient they should stop taking a pill, they need support and tools to safely wean themselves from these powerful medications. In fact, seniors often ask us about whether these medications can be addictive. This is an excellent time to discuss the potential pitfalls of long-term benzodiazepine use.

A groundbreaking study from researchers at the University of Montreal tested whether community pharmacists could help seniors taper benzodiazepine use. The study tested this by providing education to pharmacists on how to do this safely. Alongside health-professional education were materials developed specifically for patients on the harms of benzodiazepines and safer alternatives.

The study found that when provided with information and tools, a significant number of patients were able to safely taper and ultimately stop taking benzodiazepine. This is an important finding because both too fast and too slow tapers can ultimately fail, resulting in seniors continuing to take the medication.

Pharmacists have the knowledge and tools to help patients succeed.

As part of the national Choosing Wisely Canada campaign, the Canadian Pharmacists Association is informing 42,000 pharmacists to dispense not only prescriptions, but information on how to stop dangerous medications. Research shows that starting the conversation with patients about stopping or tapering dangerous medications like benzodiazepines can help curb long-term use and dependence.

Pharmacists can also reinforce other options to address sleep disturbances and anxiety, as well as help coach patients as they try these other options.

Last month, the association, along with the Choosing Wisely Canada campaign, released Six Things Pharmacists and Patients Should Question. One of the recommendations on the list, being distributed across Canada is, “Don’t prescribe or dispense benzodiazepines without building a discontinuation strategy into the patient’s treatment plan.”

This recommendation is something we urge all clinicians who prescribe and dispense these medications to seniors to keep in mind. This is also something we urge patients, caregivers and family members to consider.

Is your loved one or family member taking a benzodiazepine long-term? Consider talking to your pharmacist or health-care provider at your next encounter about whether it could be doing more harm than good.

Phil Emberley is the director of practice advancement and research for the Canadian Pharmacists Association. Dr. Wendy Levinson is the chair of Choosing Wisely Canada, an expert adviser with EvidenceNetwork.ca and a professor of medicine at the University of Toronto.