Benzodiazepine Receptor Agonist Use Disorder Among Older Adults

Publication Date: January 1, 2020
Last Updated: November 30, 2023

RECOMMENDATIONS

1: Long-term use of benzodiazepine receptor agonists (BZRAs) (> 4 weeks) in older adults should be avoided for most indications because of their minimal efficacy and risk of harm. Older adults have increased sensitivity to BZRAs and decreased ability to metabolize some longer-acting agents, such as diazepam. All BZRAs increase the risk of cognitive impairment, delirium, falls, fractures, hospitalizations, and motor vehicle crashes. Alternative management strategies for insomnia, anxiety disorders, and the behavioural and psychological symptoms of dementia (BPSD) are recommended. (Moderate, Strong)
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2: Appropriate first-line non-pharmacological options for the treatment of insomnia and anxiety disorders include cognitive behaviour therapies (CBTs) provided in various formats. (Moderate, Strong)
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3: A BZRA should only be considered in the management of insomnia or anxiety after failing adequate trials of non-pharmacological interventions or safer pharmacological alternatives OR for shortterm bridging until more appropriate treatment becomes effective. (Moderate, Strong)
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4: An assessment of risk for BZRA use disorder and other potential adverse effects from these agents should be done prior to prescribing a BZRA. (, )
[Consensus]
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5: If a BZRA is being considered, the older adult should be informed of both the limited benefits and risks associated with use, as well as alternatives, prior to deciding on a management plan. (, )
[Consensus]
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6: Initiating treatment with a BZRA should be a shared decision between the prescriber and the older adult (or their substitute decision-maker). There should be agreement and understanding on how the BZRA is to be used (including planned duration of no more than 2 to 4 weeks) and monitored. (, )
[Consensus]
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7: Older adults who are receiving a BZRA should be:
a. Educated and provided the opportunity to discuss the ongoing risks of taking BZRAs.
(Moderate, Strong)
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b. Encouraged to only take the BZRA for a short period of time (2 to 4 weeks or less) at the minimally effective dose.
(Moderate, Strong)
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c. Monitored during the course of their prescription for evidence of treatment response and effectiveness, current and potential adverse effects, concordance with the treatment plan, and/or the development of a BZRA use disorder.
(, )
[Consensus]
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d. Supported in stopping the drug, which may require a gradual reduction until discontinued.
(Moderate, Strong)
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8: Health care providers and organizations should consider implementing interventions to decrease inappropriate use of BZRAs in their practice settings. These include medication reviews, prescribing feedback, audits and alerts, multidisciplinary case conferences, and brief educational sessions. Regulators, health authorities, and professional organizations should consult with clinical leaders and older adults to develop and implement policies that aim to minimize inappropriate use of BZRAs. (Low, Strong)
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9: Health care institutions, including acute care hospitals and longterm care facilities, should implement protocols that minimize new prescriptions for BZRAs because of the potential for harm and the risk of this leading to long-term use following discharge to the community or other transitions in care. (Low, Strong)
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10: Health care practitioners, older adults, and their families should advocate for adequate access and funding of effective nonpharmacological alternatives for the management of insomnia, anxiety disorders, and BPSD. (Low, Strong)
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11: Clinicians should be aware that BZRAs are prescribed more frequently to women and the potential implicit bias that may lead to inappropriate use. (Low, Weak)
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12: All older adults should be asked about current and past consumption of substances that might lead to substance use disorders, including BZRAs, during periodic health examinations, admissions to facilities or services, perioperative assessments, when considering the prescription of a BZRA, and at transitions in care. (, )
[Consensus]
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13: Health care practitioners should be aware of and vigilant to the symptoms and signs of substance use disorders, including BZRA use disorder. Particular attention should be paid to this possibility when assessing common conditions encountered in older adults, such as falls and cognitive impairment. (, )
[Consensus]
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14: Assessment of older adults suspected of having a BZRA use disorder should include indication, dose, duration, features indicative of BZRA use disorder, readiness to change, and presence of both medical and psychiatric comorbidities, including any other past or current substance use or misuse. (, )
[Consensus]
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15:

a. Multiple substance use is common and should be considered and inquired about in all older adults with a BZRA use disorder.
(Moderate, Strong)
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b. Health care practitioners should avoid prescribing BZRAs concurrently with opioids whenever possible.
(Moderate, Strong)
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c. The combination of a BZRA with alcohol should be avoided.
(Low, Weak)
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16: A person-centred, stepped-care approach to enable the gradual withdrawal and discontinuation of BZRAs should be used. Clinicians and patients should share in:
a) planning and applying a gradual dose reduction scheme supported by appropriate education of the patient;
b) identifying and optimizing alternatives to manage the underlying health issue(s) that initiated or perpetuated the use of BZRAs;
c) developing strategies to minimize acute withdrawal and managing rebound symptoms as needed; and
d) establishing a schedule of visits for reviewing progress.
(Moderate, Strong)
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17: Abrupt discontinuation of a BZRA after intermediate to long-term use (> 4 weeks) in individuals with BZRA use disorder should be avoided due to the risk of withdrawal symptoms, substance dependence reinforcement, rebound phenomena, and/or higher likelihood of relapse with resumption of BZRA use. (Moderate, Strong)
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18: Management of acute BZRA withdrawal symptoms should be monitored carefully and can be guided by a validated tool [e.g. Benzodiazepine Withdrawal Symptom Questionnaire, Clinical Institute Withdrawal Assessment-Benzodiazepine (CIWA-B)] and managed with symptom-driven judicious use of an appropriate BZRA. (Low, Weak)
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19: Regimens involving multiple BZRAs should be simplified and converted to a single BZRA. (, )
[Consensus]
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20: The routine switching of a short half-life BZRA with one having a long half-life to aid in withdrawing BZRAs is not generally recommended in older adults. Switching may have a role in certain situations, such as when withdrawal is being hindered by a limited number of available BZRA pill strengths or when alprazolam is the agent of dependence or misuse. (Moderate, Strong)
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21: Psychological interventions such as CBT should be considered during efforts to withdraw BZRAs as they can improve the older adult’s experiences and increase the likelihood of stopping the BZRA. (High, Strong)
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22: Substituting a pharmacologically different drug as a specific intervention to mitigate BZRA withdrawal symptoms during gradual dose reduction is not routinely recommended. (Moderate, Strong)
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23: Older adults with a BZRA use disorder whose drug use is escalating in spite of medical supervision, have failed prior efforts to withdraw their BZRA, are at high risk for relapse or harm, and/or suffer from significant psychopathology should be considered for referral to a specialty addiction or mental health service. (, )
[Consensus]
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Recommendation Grading

Disclaimer

Overview

Title

Benzodiazepine Receptor Agonist Use Disorder Among Older Adults

Authoring Organization

Publication Month/Year

January 1, 2020

Last Updated Month/Year

November 30, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Correctional facility, Hospital

Intended Users

Psychologist, addiction treatment specialist, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D019966 - Substance-Related Disorders, D001569 - Benzodiazepines

Keywords

Benzodiazepine Receptor, Use Disorder, BZRA

Source Citation

Conn DK, Hogan DB, Amdam L, Cassidy KL, Cordell P, Frank C, Gardner D, Goldhar M, Ho JM, Kitamura C, Vasil N. Canadian Guidelines on Benzodiazepine Receptor Agonist Use Disorder Among Older Adults Title. Can Geriatr J. 2020 Mar 30;23(1):116-122. doi: 10.5770/cgj.23.419. PMID: 32226570; PMCID: PMC7067147.

Supplemental Methodology Resources

Methodology Supplement