A narrative review of strategies for discontinuing long-term benzodiazepine use and methodological recommendations: Is a success rate of only one in three patients sufficient?

Abstract

Benzodiazepines (BZs) are psychotropic medications mainly prescribed for insomnia and anxiety. They can cause dependence, leading to decades of use. As such, there is debate grounded in confusion between substance abuse and fear of dependence in some patients. Clinical practice and evidence-based reviews agree that BZ dependence is difficult to treat: without support, only 7% of misusers manage to stop taking them. Analyzing randomized control trials (RCTs), this review examines three main interventions for BZ withdrawal: brief intervention (BI), substitution medication (SM) and cognitive-behavioral therapy (CBT). Post-intervention abstinence rates suggest that BIs can be compared to a simple taper program (TP), requiring low patient involvement, and may enable one in three patients to discontinue BZ use. However, this strategy should be considered with caution: outcomes could be adversely affected by the presence of a psychiatric disorder, a factor not controlled in these studies, nor are long-term results evaluated. Furthermore, can we consider that treating one in three patients is sufficient? CBT proved highly effective, enabling three in four patients attempting to abstain to successfully discontinue use, including patients with insomnia or anxiety. The SM approach showed no superiority over placebo effects. Moreover, abstinence rates being only measured over the very short term, no recommendations can be made regarding their use. This review concludes that there is a major methodological discrepancy between these approaches, BI and SM studies presenting substantially lower methodological quality in comparison to CBT studies. The present article proposes methodological recommendations for the study of BZ withdrawal methods.