A recent study by Lynch et al. (2020) explored the effectiveness of primary care interventions on reducing or discontinuing benzodiazepine/Z-drug use compared with usual care.1 Benzodiazepines are often indicated in the clinical treatment of anxiety and insomnia. Z-drugs (zopiclone and zolpidem) behave similar to benzodiazepines but are not classed as such. Z-drugs and benzodiazepines can however be grouped as benzodiazepine receptor agonists (BZRA). Treatment recommendations include restricting use to short time periods due to the implications of addiction and withdrawal. However, treatment guidelines are often not adhered to, resulting in long-term BZRA use persisting worldwide. Prevalence rates of BZRA consumption is highest among older people (65+ years), making them particularly vulnerable to adverse physical and cognitive effects of BZRA use.

Much of the research on interventions has focused on benzodiazepines, with Z-drugs receiving less attention. A critique of the research into these interventions is the absence of theoretical underpinnings, limiting the understanding of the mechanisms of change impacting outcomes. To account for this, the study authors applied the theoretical domains framework (TDF) to understand the barriers and facilitators to behaviour change necessary for effective interventions.

Methods

A systematic review of randomised controlled trials of brief interventions in primary care settings aimed at BZRA reduction or cessation in adults with BZRA use of three months or more was carried out. The review was conducted across four databases: PubMed, EMBASE, PsycINFO, and CENTRAL. Findings were interpreted through TDF to identify the behavioural determinants targeted by interventions.

The review aimed to evaluate the evidence base for brief interventions targeting BZRA use in primary care settings. Interventions were defined as ‘an intervention comprising oral or written communication that involved discussion, negotiation or encouragement for reduction or discontinuation of long-term BZRA use, with or without additional support or follow-up‘ (p. 1620). ‘Long-term’ BZRA use was defined as three months or more. BZRA reduction was considered a reduction of 25% or more.

Key findings and discussion

The literature search identified eight studies comparing brief interventions with usual care. Some 2,071 patients aged 59–75 years, 71.2% of whom were female, were involved in the eight studies of the review. Interventions most commonly involved written letters suggesting BZRA reduction or discontinuation or short consultations containing recommendations for BZRA reduction or discontinuation. Others developed educational resources in the form of personalised booklets for patients. All interventions advocated a gradual dose reduction approach to BZRA reduction or discontinuation. Compared with control patients, intervention patients were more likely to have discontinued BZRA use at six months and 12 months post-intervention compared with usual care patients. This led the authors to conclude that brief interventions delivered in primary care settings are more effective than usual care at reducing and discontinuing BZRA use.

TDF analysis identified the behavioural determinants targeted by interventions to effect change. Constructs such as ‘knowledge’, ‘skills’, and ‘beliefs about consequences’ were coded frequently, with ‘beliefs about consequences’ existing across all interventions. Educating patients about the risks inherent in long-term BZRA use as well as providing them with the tools to practise gradual dose reduction may be effective areas for interventions to target. The absence of constructs related to emotions suggests to the authors that targeting emotions such as optimism may be effective at reducing BZRA consumption.

A gradual dose reduction approach must be specific to the individual to prevent rapid dose reduction, which has implications for withdrawal and can hinder patient success. Being flexible in reducing dosage and developing a personalised approach can prevent this. Involving other healthcare providers such as pharmacists is suggested to be a cost-effective way of delivering interventions.

Conclusion

More research is warranted to understand which interventions are most effective for reducing or discontinuing BZRA use.