Following the recent publication of the WOREL guideline on a multimodal approach to sleep disorders and insomnia, the FAMHP wants to remind patients and healthcare professionals of the importance of the rational use of benzodiazepines and related medicines.
The primary care guideline on sleep disorders and insomnia from 2017 has recently been updated under the title ‘Multimodal management of sleep disorders and insomnia’. This revised guideline no longer targets general practitioners (GPs) alone. It now focuses on broad primary care, including GPs, pharmacists, psychologists, nurses, physiotherapists and occupational therapists. The guideline applies to adults, with a particular focus on senior citizens. The WOREL guideline also includes some practical tools, such as patient leaflets, a sleep diary and the sleep circle.
Benzodiazepines and related medicines are often prescribed for insomnia. Although these medicines are not considered first-line treatment for insomnia, they may be effective when used rationally, at the lowest possible dose and for a limited period. However, many patients use them long term. Benzodiazepines and related medicines are associated with numerous adverse effects, including cognitive impairment, an increased risk of falls and daytime drowsiness. Prolonged use beyond one or two weeks reduces efficacy due to the development of tolerance and may result in physical and psychological dependence. The risk of dependence increases with the dose and the duration of treatment.
How can misuse and dependence be prevented?
The best form of prevention is to avoid initiating treatment with benzodiazepines and related medicines when there is no clinical need.
Whenever healthcare professionals consider prescribing benzodiazepines or related medicines, the FAMHP encourages them to discuss the expected benefits, risks and limited duration of effectiveness with their patients before initiating treatment. The WOREL guideline recommends that benzodiazepines and related medicines be used only at the lowest possible dose and for a maximum duration of one week. The guideline also recommends that healthcare professionals discuss a discontinuation strategy at the start of treatment and schedule a follow-up consultation after approximately one week, where clinically indicated.
By prescribing the smallest appropriate package size, doctors can encourage patients to return for a follow-up consultation if symptoms persist, thereby reducing the risk of long-term use.
How can benzodiazepines be tapered safely?
Tapering off benzodiazepines and related medicines should be considered for all long-term users, particularly older patients, because of their increased risk of falls and other adverse effects. Discontinuation may cause withdrawal symptoms and a temporary recurrence or worsening of the original symptoms (rebound effects). Therefore, medically supervised tapering is strongly recommended.
Doctors and pharmacists can find practical information on tapering in a guide commissioned by the FPS Public Health. In addition, the non-profit organisation BCPI offers an e-learning course providing a range of tools and practical tips to support successful tapering.
Certain outpatients may be eligible to participate in the benzodiazepine tapering programme established by the NIHDI. This programme uses magistral preparations that allow a gradual dose reduction over a period of 50 to 360 days, depending on the selected tapering schedule.
Further information on psychotropic medicinal product
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