Current Drug Therapy

Reducing the risks when using benzodiazepines to treat insomnia: A public health approach

Vania Modesto-Lowe, MD, MPH, Margaret M. Chaplin, MD, Roberto León-Barriera, MD and Lakshit Jain, MD
Cleveland Clinic Journal of Medicine May 2024, 91 (5) 293-299; DOI: https://doi.org/10.3949/ccjm.91a.23061

Article Figures & Data

Tables

  • TABLE 1

    Alternatives to formal cognitive behavioral therapy for insomnia

    Online apps and self-help books
    Online resources include books patients can read on their own and apps that guide patients through cognitive behavioral therapy for insomnia
    Brief therapies for insomnia
    Abridged versions of cognitive behavioral therapy that emphasize behavioral aspects of sleep regulation
    Education is given on sleep hygiene, factors that affect sleep, and principles of sleep restriction (described below)
    After examining a sleep diary, primary care clinicians can inquire about the patient’s sleep habits and provide education on patient-specific factors that may be affecting sleep (eg, excess alcohol, using screens in bed, attempting to go to bed too early)
    Sleep-restriction therapy
    Aims to limit a patient’s time in bed to when asleep
    Patients are asked to limit their time in bed to their average sleep time, go to bed only when sleepy, get up if they cannot fall asleep, and return to bed only once sleepy: the idea is that most of the time spent in bed is sleeping
    Gradually the time spent in bed is increased as sleep duration and quality improve
    Stimulus control
    The idea is to extinguish the association between the bed and wakefulness
    Patients should be instructed to use the bed only for sleep and sex, establish a consistent bedtime and waking time, go to bed only when sleepy, get out of bed if unable to sleep, and refrain from daytime naps
    Relaxation therapies
    Includes exercises designed to decrease tension, eg, deep breathing, abdominal breathing, progressive muscle relaxation, and meditation
    A variety of applications can be used for guided meditation and relaxation

    • Based on information in references 5, 12, and 18.

  • TABLE 2

    Strategies and tips for tapering benzodiazepines

    Strategies
    Taper by 25% every 2 weeks
    If dosage forms do not allow for a 25% reduction, consider a 50% reduction
    Consider slowing to 12.5% for the final 2 weeks of the taper
    Consider alternate-day dosing for the final 2 weeks of the taper
    Tips
    Educate patients on what to expect and reassure them that symptoms will resolve
    Consider switching to a medication formulation with lower dose options
    Consider using a nonaddictive medication alternative
    Some patients may require an extremely slow taper—over months, not weeks

    • Based on information in reference 5.

  • TABLE 3

    Preventing harm from benzodiazepines

    Primary prevention15
    Educate the public about benzodiazepine harms
    Educate prescribers and patients about cognitive behavioral therapy for insomnia
    Educate patients about risks of falls, fractures, and addictive potential
    Limit use to a carefully selected population
    Set the stage for limiting use to less than 4 weeks
    Secondary prevention13,22
    Taper after 4 weeks
    Use behavioral interventions, letters, brochures, or face-to-face interventions to encourage patients resistant to intervention
    Educate prescribers about the need to discontinue benzodiazepines
    Tertiary prevention5,11
    Use motivational interviewing to evaluate the stage of change
    Use shared decision-making to discuss risks and benefits to help move the patient to the action level of change
    Optimize deprescribing by addressing rebound (through education), withdrawal (through gradual tapering), and relapse (through addition of psychological support)
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