Shorter benzodiazepine prescriptions could reduce long-term use

Shorter prescription durations for benzodiazepine could reduce long-term use and associated morbidity and mortality, a new study suggests.

Prescription duration was a significant factor influencing time to discontinuation, a Canadian researchers found in a study published in PLOS Medicine.

The study looked at how initial prescribing practices influence use and analysed data from 1.8 million adults in Ontario, Canada, who received new benzodiazepine prescriptions between 1 January, 2013 and 31 December, 2020.

The longer the duration the less likely the medication would be discontinued.  When compared with prescriptions of seven days or fewer, benzodiazepine prescriptions of eight to 14 days had about half the likelihood of discontinuation and prescriptions of 15 to 30 days had one-quarter the likelihood of discontinuation.

Patients given an initial prescription of more than 30 days, were around seven times less likely to stop treatment at any given point than those given a prescription of one week or less.

While benzodiazepines are known to provide effective short-term relief from anxiety, insomnia, and other health issues, long-term use is generally not recommended due to the risk of addiction, overdose, and death.

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Lead researcher and associate scientist in the addictions division at the University of Toronto, Dr Nikki Bozinoff, said the findings could help reduce long-term use of these medications.

‘A lot of changes have been made to opioid prescribing in response to research that demonstrated shorter initial prescriptions reduce the risk of prolonged opioid use.

‘Our findings suggest the same is true for benzodiazepines – limiting the prescription to less than seven days may be the safest approach if clinically appropriate,’ she said.

The researchers examined how four characteristics of the initial prescription – prescription duration, whether the drug was short-acting or long-acting, the number of different benzodiazepines dispensed, and the mean daily dose in diazepam milligram equivalents – influenced treatment discontinuation.

In addition to prescription duration influencing medication use, the researchers also found that being prescribed two or more benzodiazepines rather than one was associated with a reduced likelihood of discontinuation.

Moreover, being prescribed long-acting benzodiazepines or a combination of short-acting and long-acting agents was associated with reduced likelihood of discontinuation compared with just short-acting agents.

The researchers, therefore, recommend limiting initial prescriptions of benzodiazepines to less than seven days and choosing a single, short-acting agent. They suggest that this could reduce prolonged benzodiazepine use and its associated morbidity and mortality.

Professor Amira Guirguis, chief scientist at the Royal College of Pharmacy, said that these findings may support greater attention to the first prescription.

‘Although the study is observational and cannot prove causation, it supports a clear safety principle: when benzodiazepines are clinically needed, they should be prescribed for the shortest appropriate duration, with a clear review and stopping plan from the outset.

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‘It also reinforces the role of pharmacists in identifying ongoing use and supporting safe deprescribing conversations.’

The authors note that current guidance from the National Institute for Health and Care Excellence recommending prescriptions of two to four weeks may be too permissive, given that risk of sustained use appears to rise with prescriptions longer than just seven days.

The study had several limitations. It relied on pharmacy dispensing records rather than confirmed medication use and, therefore, could not confirm whether patients took medications as prescribed.

Because the study was observational, some medications, including z-drugs and certain psychiatric medications, were not fully captured in the analysis. Furthermore, it could not account for disease severity, non-prescribed benzodiazepine use, social stability, or other unmeasured factors.

Professor Guirguis, added: ‘The study should not be interpreted as meaning that benzodiazepines have no clinical role. They remain useful medicines when prescribed appropriately.

‘The key is careful initiation, patient counselling, regular review and safe withdrawal support where needed.

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‘Pharmacists are well placed to help identify prolonged use, counsel patients on risks such as sedation, falls, dependence and interactions with other sedatives

‘Patients should not stop regular benzodiazepine treatment abruptly without professional advice.’

Between 2017 and 2018, 1.4 million adults received a prescription for benzodiazepines in England. In 2021, there were 538 deaths involving benzodiazepines in England and Wales compared with 476 the previous year — an increase of 13%.