Providing brochures that contain information on benzodiazepine risks and ways to safely taper off of them can help older adults reduce their use of these medications, according to a new study.
Benzodiazepines are medications that slow down activity in the brain and nervous system and are often used to treat anxiety, seizure disorders, and insomnia; well-known brand names in this class of medications include Valium, Ativan, and Xanax. However, long-term use can result in dependence, and older adults are also at higher risk for suffering falls and other accidents when taking the sedating drugs.
“Benzodiazepines are high-risk medications for older adults given the risks of falls, fractures, motor vehicle accidents, and mortality,” said senior author Michelle Keller, assistant professor of gerontology and holder of the Leonard and Sophie Davis Early Career Endowed Chair in Minority Aging at the USC Leonard Davis School of Gerontology. “Even for younger adults, they have a high risk of dependence and the potential for accidental overdose when combined with other sedatives, such as opioids.”
The study adapted the Eliminating Medications Through Patient Ownership of End Results (EMPOWER) materials, originally used in a 2014 intervention in Canada, for a population of older patients of 22 primary care providers in the Cedars-Sinai Medical Group in Los Angeles County. 308 patients received the EMPOWER materials in the mail, while 291 patients received standard care.
“Many physicians assume that patients are already aware of the risks of benzodiazepines, but our study found that patients may not know these risks. These medications may have been initially prescribed decades ago – before we knew all of the risks of benzodiazepines or when the person was younger and had a lower risk of falls, fractures, etc.,” Keller explained. “We found that several patients reached out to their physicians using the patient portal and expressed surprise that these medications had serious risks such as increased risk of falls, fractures, motor vehicle accidents, and accidental overdose. That was really illuminating and increases our motivation to make sure that people know that these medications aren’t without risks.”
The EMPOWER materials not only illustrate the risks of benzodiazepines but also offer alternative strategies for managing symptoms and provide an example tapering schedule for gradually reducing medication use, all within a short brochure. The materials also aim to encourage patients to discuss benzodiazepine cessation strategies with their doctor.
Keller said the EMPOWER brochure was developed using social cognitive theory, a psychological theory which states that people learn by watching others. It provides a quiz about the risks of benzodiazepines and a short narrative about an older adult who has successfully stopped taking the medication.
“Imagine you’re learning to cook by watching a cooking show. You see the chef chop onions and sauté them, then you try it yourself. That’s social cognitive theory in action – learning by observing others and then imitating their actions,” she explained. “It’s not just about copying, though; it also involves things like paying attention, remembering what you saw, and being motivated to do it yourself. So, it’s all about how we learn from the world around us, especially by watching other people.”
Another powerful part of the intervention was a letter from the patient’s primary care physician, which encouraged the patient to come in and talk to them about these medications, Keller added. “Many people have a trusted, strong relationship with their primary care physician and trust their opinion, so we felt that this approach would be a successful way to start the conversation,” she said.
Overall, 26% of patients who received the EMPOWER brochure had stopped benzodiazepine use completely, versus 17% of the control group, when assessed after nine months.
“We found that for every 10 brochures we sent – a very low cost intervention – one person completely stopped these medications [while] working closely with their doctor,” Keller said. “This is a neat intervention because it is so simple. All it requires is sending patient education materials to a patient via mail. Sometimes healthcare is so complicated that it is nice to see such a simple intervention work.”
Another important finding was that patients with a pain diagnosis were twice as likely to discontinue benzodiazepines versus those without a pain diagnosis. This could be because people with chronic pain may be taking other medications that increase their risk of a dangerous drug-drug interaction, Keller said.
“For example, the risk of accidental overdose is 10 times higher among patients taking benzodiazepines and opioids compared to patients only taking opioids,” she explained. “The EMPOWER intervention may have prompted important conversations about these risks.”
In the future, Keller and her colleagues hope to reach out to different populations with the brochures, which have been translated into multiple languages. Keller added that the next phase of this research will involve providing the EMPOWER materials to patients in the hospital who have experienced a serious event such as a fall or fracture.
“Sometimes patients do not make the connection between use of these drugs and serious events, and we want to prevent the next serious fall or fracture,” she said. “We call these events ‘sentinel events,’ and we think that healthcare professionals, patients, and patient’s family members should do a thorough review of the patient’s medications whenever something serious like this happens.”
The study, “Implementation of an intervention aimed at deprescribing benzodiazepines in a large US healthcare system using patient education materials: a pre/post-observational study with a control group,” first appeared in BMJ Open on April 3, 2024. Coauthors included Tammy Le of the UCLA David Geffen School of Medicine; Scott Campbell, Alexa Andraos, Pedro Ahlmark, and Caroline Goldzweig of the Cedars-Sinai Medical Care Foundation; Ha Hoang, Sean Isserman, and Allison Mays of Cedars-Sinai Medical Center; and Kristin Bradley of the University of North Carolina.
