Bedtime without benzodiazepines and ‘ZZZ-drugs’

Case scenario

Harry, aged 79, regularly presents to collect his temazepam 10 mg prescription with directions ’10 mg nocte when required’. At his most recent visit, he mentions that he is regularly waking to use the bathroom due to increased bladder frequency (2–3 times per night) and wonders if he should increase his dose so that he stops waking so regularly. You confirm that Harry has been taking temazepam for 6 years and you ask how helpful this medicine has been since he started.

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction

Sleep complaints are common, with up to 60% of Australians experiencing difficulty falling asleep, maintaining sleep, or waking too early multiple times per week.¹

Insomnia that is acute or short term tends to resolve once the precipitating factor(s) subside.² However, when symptoms occur at least three nights per week (with adequate opportunity for good sleep) and are associated with significant daytime impairment (e.g. fatigue, difficulty concentrating) for longer than 3 months, it is termed ‘chronic insomnia’. ^3,4 Recent estimates suggest 10–15% of Australian adults experience chronic insomnia at any given time.^1,5–8

Treatment of insomnia

Cognitive behavioural therapy for insomnia (CBTi) is recommended as first-line treatment for insomnia, however most individuals (90%) attending primary care are prescribed a benzodiazepine or alternative pharmacotherapy such as a non-benzodiazepine hypnotic (zolpidem or zopiclone, known as the Z-drugs).^9–11 Benzodiazepines and these Z-drugs are referred to together as benzodiazepine receptor agonists (BZRAs).^12–14

While effective in the short term at improving sleep onset, BZRAs do not treat the underlying cause of insomnia, and are associated with a wide range of potential adverse effects and risks of harm.^15–17 These include both cognitive and physical effects such as fatigue, dizziness, risk of falls and fractures in older adults, cognitive deficits (i.e. memory problems), motor vehicle accidents, and worsening mood and sleep.^18,19

Importantly, BZRAs can cause tolerance and dependence, which can potentially produce significant withdrawal symptoms on cessation. Guidelines recommend BZRAs be used intermittently or short term only (not more than 4 weeks) at the lowest possible dose.^20,21 However, it is not unusual for people to be prescribed these medicines long term, with rates of dependence observed equally across different BZRAs in long-term users. ^22-26

A role for pharmacists

Pharmacists can play a variety of roles in the quality use of medicines for insomnia, such as BZRAs. Studies have shown positive results when pharmacists work collaboratively with general practitioners by conducting medication reviews and providing deprescribing recommendations for BZRAs, and studies even demonstrate that pharmacists can lead deprescribing efforts with additional training.^27–29

However, a recent review showed pharmacists might have the greatest impact through consumer education, as this process can also facilitate shared decision-making and create an open dialogue.³⁰ As a standalone intervention, education can see nearly half (45%)
of long-term BZRA patients reduce their medication.^31,32

Patient education is key

Creating motivation for change

Patient education is essential when initiating the deprescribing process. Research with long-term BZRA users found that one of the reasons they continue BZRAs is because the underlying issue persists.³³ This can lead to the belief that they need their medication to sleep and, for many, creates a preoccupation about the impacts of poor sleep if they stop.³⁴

Nonetheless, many adults who hold these beliefs also want to reduce their medication and don’t like having to rely on it to sleep.^33,35,36 This paradox between ‘needing’ a medication but not wanting to rely on it illustrates why many will require effective treatment for their insomnia before they can stop their BZRA.³⁴

Education around the risk of harm is key for motivating change. With long-term use, tolerance to the sedative effects of BZRAs can occur, and the risk of dependence increases.³⁷ This means that for many, the BZRA may simply be staving off withdrawal rather than providing any real therapeutic benefit.³³ By focusing on a patient’s concerns about ongoing BZRA use, pharmacists can draw attention to the incongruence between the patients beliefs and behaviour, an important step towards eliciting motivation to engage with interventions like CBTi.²⁴

Although tempting to problem-solve on the spot, research tells us that patients need time after receiving new information, and that education alone rarely leads to immediate behaviour change.³⁸ Pharmacists will be more successful if they resist the urge to recommend BZRA cessation before the patient is ready.^39,40

Delivering tailored education

In addition to information about the harms of long-term BZRA use, pharmacists should also provide more specific information regarding their use. For example, other risks such as the risk of worsening sleep quality (i.e. less time spent in deep and rapid eye movement (REM) sleep), daytime sleepiness and risk of motor vehicle accidents (particularly with new prescriptions and in older adults), and reported parasomnias (e.g. sleepwalking and bizarre sleep behaviours).^41–45 Planting the seed for BZRA cessation requires not only increasing the salience of the harms but also decreasing the perceived benefits of continued use. 

Guidance on carrying out a gradual dose reduction (GDR – see further information below) while supporting the development of skills necessary to navigate the tapering process is another important component of patient education.³¹

Before initiating a GDR, patients may require a period of stabilisation where they take a consistent dose at set times of the day. This process can help offset psychological dependence resulting from any ‘when necessary’ (PRN) use and provides a steady baseline from which to begin the taper.^17,46 Engaging with CBTi at this stage can be useful to build the patient’s self-efficacy for sleep. Evidence shows that those able to make positive changes to sleep habits before reducing their BZRA use are more likely to have success when they do reduce.⁴⁷ This is useful for patients not ready to change their BZRA use, as CBTi builds skills and confidence that will benefit them through withdrawal.      

Why CBTi?

CBTi is the first-line treatment for chronic insomnia. In the short term, it can be
as effective as BZRAs at improving sleep onset, but unlike BZRAs, there are few adverse effects, and the benefits are sustained long term. ^48–51

CBTi combines several components, including education on sleep and healthy sleep behaviour, stimulus control therapy (i.e. strengthening bed/bedroom cues for sleep), bedtime restriction therapy, cognitive restructuring (i.e. identifying and challenging of thoughts, feelings and behaviours which impact sleep) and relaxation therapy.

Sessions aim to identify and target the underlying causes of insomnia and can lead to large and sustained improvements in insomnia and associated mental/physical symptoms.⁵²

Accessing CBTi

Although individually delivered and face-to-face is arguably the most effective way to deliver CBTi, access via Medicare Benefits Schedule (MBS) referral is low (<1%), and cost and limited availability of trained clinicians may be the main barriers.^11,53,54 As such, online and digital formats are increasingly common, with a range of evidence-based self-managed CBTi apps and programs available that demonstrate similar reductions in insomnia severity (see: www.sleepprimarycareresources.org.au/insomnia/cbti/referral-to-digital-cbti-programs).^55,56

Regardless of the format, supporting consumer choice is important, as many individuals will engage with multiple modalities at the same time.⁵⁶

Withdrawal from long-term BZRA use

There will always be some degree of hesitation or fear about reducing BZRAs; however, with sufficient time, planning, and support, most patients (up to 88%) can successfully reduce or withdraw from their BZRA use.⁵⁷

Every conversation with a patient about their BZRA is potentially a step towards reducing use, and pharmacists should aim to routinely provide education in a supportive and non-judgemental manner when they dispense a BZRA.

Up to 30% of patients who take benzodiazepines for just 4–6 weeks will experience withdrawal symptoms when they stop, and after 6 months of regular use, up to 80% of patients will experience withdrawal.^15,58

While the withdrawal sequalae from nonbenzodiazepine hypnotics (i.e. zolpidem and zopiclone) is less understood, and often only associated with high doses used over longer periods of time, guidelines indicate they should still be treated with the same level of caution as benzodiazepines.^21,59,60

Many patients will hesitate to even consider reducing their BZRA for fear of discontinuation symptoms. While withdrawal symptoms are common, their severity varies greatly. Some patients experience little to no discomfort during their BZRA taper and require minimal support from healthcare professionals after receiving written or verbal prompts. For others, withdrawal is complicated by discontinuation syndromes, and for a small number (10–15%) withdrawal can become protracted, lasting many months or even years.⁶¹ In those experiencing complicated or protracted withdrawal, often this is precipitated by their medication being reduced too quickly.⁶¹    

A GDR can reduce the severity of withdrawal symptoms and, consequently, increase the likelihood of successful cessation. The recently released Maudsley Deprescribing Guidelines recommend that a GDR should be designed around a patient’s risk of withdrawal, with reduction rates varying between 5–20% (depending on patient factors) of the total dose every 1–4 weeks, and stipulate that this should be guided by the patient’s experience.⁶² Pharmacists should refer to current, specialised references in regard to appropriate tapering and deprescribing of BZRAs.¹²

Withdrawal is not a linear process, and a GDR requires regular review and adjustment based on how the patient is managing their symptoms.⁶³ By normalising the need to pause or even reinstate a previous dose, pharmacists can reduce the likelihood that patients will interpret these setbacks as evidence that they cannot stop their BZRA. Pharmacists can provide ongoing support to patients tapering their medication by understanding the need for an individualised approach and advocating for flexible tapering plans with their prescriber.

Pharmacists’ skills and knowledge in compounding can also offer patients options when they get to lower doses or where proprietary formulations are limiting. In some cases, patients may also benefit from staged supply, such as when they are having difficulty regulating their own use.

Managing withdrawal symptoms 

While it is difficult to predict who will be successful and why, patients trying to reduce their BZRA are best equipped when they are properly educated about the deprescribing process and informed about potential withdrawal symptoms (see Table 1).

When reducing BZRAs, most patients will experience some degree of rebound insomnia, which involves the recurrence of their original symptoms at a greater intensity.^64,65 While longer duration of use and higher doses are typically associated with more severe withdrawal, these risk factors can often be mitigated by a slower reduction rate. Notably, older adults appear to tolerate withdrawal just as well as their younger counterparts.^66,67 The acute severity of withdrawal symptoms may be mitigated in older adults due to the protracted clearance of BZRAs in older age.⁶⁸

Through difficult periods, patients may seek means for symptom relief. Monitoring potential compensation with other over-the-counter sedatives (e.g. doxylamine) or increased alcohol use can help track how a patient is coping with their reduction. Most patients will benefit from reassurance that their symptoms will pass with time, however pharmacists need to strike the right balance between normalising the ups and downs of withdrawal and referring on for further investigation when necessary.⁶³

While recommended in some guidelines, switching to a long-acting BZRA is unlikely to improve the outcome, particularly when switching from a short-acting BZRA taken once at night for insomnia.^69,70

Currently no medication is approved in Australia to support BZRA withdrawal, therefore non-pharmacological strategies are key to managing symptoms (e.g. relaxation and mindfulness practice, a balanced diet, abstaining from alcohol, regular exercise, and support groups).⁷¹

There is good evidence, however, that CBTi leads to increased success with BZRA cessation.^72–74 It is proposed that as CBTi treats the underlying psychological and behavioural factors perpetuating insomnia, it can render the medication redundant, diminishing the psychological dependence and reducing the likelihood of relapse.⁷³

Knowledge to practice

Pharmacists routinely encounter patients taking long-term BZRAs for insomnia and are in an ideal position to identify potential tolerance (e.g. dose escalation) and dependence (e.g. what happens if they miss a night, drug-seeking behaviour). Pharmacists should explore the patient’s understanding of the risks associated with prolonged BZRA use and provide education on reduction and withdrawal where appropriate. Pharmacists also play an important role in providing education on evidence-based treatment for insomnia (i.e. CBTi). Pharmacists should be aware of referral options to access CBTi and BZRA dependence support so these can be provided to patients where necessary. Please see ‘Further information and resources’ located with the references (via QR code) for resources for deprescribing, evidence-based treatment of insomnia, CBTi, and health professional and patient support services.

Conclusion

Pharmacists play a pivotal role in sleep health education for all patients. Routinely engaging patients in conversations about their sleep and BZRA use not only opens a dialogue and builds rapport but also provides a stepwise approach for pharmacists to address an often-complex issue, and represents a patient-centred approach to quality use of medicines. Each interaction builds on previous conversations to facilitate collaborative and informed decision-making, laying the foundation to support patient choice and motivation to reduce BZRA use.

Key points

• BZRAs are routinely prescribed to manage insomnia.
• BZRAs should only be used short term or intermittently for insomnia (maximum 4 weeks) at the lowest possible dose but are often prescribed for longer periods. Dependence and tolerance can occur.
• CBTi is the first-line treatment for insomnia and is available in a range of formats to suit consumer preferences.
• Withdrawing from BZRAs requires an individualised approach, some patients can cease these easily while others will require many months (if not years).
• Pharmacists can support BZRA cessation through patient education and appropriate referral.

If you do get an enrolment error, please click here

References 

1. Reynolds A, Appleton S, Gill T, et al. Chronic insomnia disorder in Australia: A report to the Sleep Health Foundation. Sleep Health Foundation Special Report. 2019. At: https://www.sleephealthfoundation.org.au/special-sleep-reports/chronic-insomnia-disorder-in-australia 
2. Perlis ML, Vargas I, Ellis JG, et al. The natural history of insomnia: the incidence of acute insomnia and subsequent progression to chronic insomnia or recovery in good sleeper subjects. Sleep 2019;43(6). 
3. The American Academy of Sleep Medicine (AASM). International classification of sleep disorders (ICSD-3), diagnostic and coding manual. 3rd edn. AASM; 2014. 
4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edn. 2022. 
5. Appleton SL, Reynolds, AC, Gill TK, et al. Insomnia prevalence varies with symptom criteria used with implications for epidemiological studies: role of anthropometrics, sleep habit, and comorbidities. Nat Sci Sleep 2022;14:775–90.  
6. Cunnington D, Junge MF, Fernando AT. Insomnia: prevalence, consequences and effective treatment. Med J Aust 2013;199(8):S36–S40. 
7. Ng L, Cunningham D. Management of insomnia in primary care. Aust Prescr 2021;44:124–8. 
8. Ohayon M, Reynolds CF. Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the International Classification of Sleep Disorders (ICSD). Sleep Med 2009;10:952–60. 
9. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2021;17(2):255–62. 
10. Wilson S, Anderson K, Baldwin D, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias, and circadian rhythm disorders: An update. J Psychopharmacol 2019;33(8):923–47. 
11. Miller CB, Valen FL, Harrison CM, et. Al. Time trends in the family physician management of insomnia: the Australian experience (2000–2015). J Clin Sleep Med 2017;13(06):785–90.  
12. Pottie K, Thompson W, Davies S et al. Deprescribing benzodiazepine receptor agonists: evidence-based clinical practice guideline. Can Fam Physician 2018;64(5):339–51. 
13. Sibille FX, Spinewine A, Zerah L, et al. Current practice in benzodiazepine receptor agonists deprescribing on acute geriatric wards: a cohort study. BMC Geriatr 2022;22(1):88.   
14. Croke L. Deprescribing benzodiazepine receptor agonists for insomnia in adults. Am Fam Physician 2019;99(1):57–8. 
15. Lader M. Benzodiazepines revisited – will we ever learn? Addiction 2011;106: 2086–109.  
16. Glass J, Lanctot K L, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 2005;331:1169. 
17. Reconnexion. The benzodiazepine toolkit. 2018. At: www.reconnexion.org.au/health-professionals 
18. Brandt J, Leong C. Benzodiazepines and z-drugs: an updated review of major adverse outcomes reported on in epidemiologic research. Drugs R D 2017;17:493–507. 
19. Guina J, Merrill B. Benzodiazepines I: upping the care on downers: the evidence of risks, benefits and alternatives. J Clin Med 2018;7(2):17. 
20. Rossi S, ed. Drugs for anxiety and sleep disorders. Australian medicines handbook; Adelaide. Australian Medicines Handbook: 2024. At: https://amhonline.amh.net.au/chapters/psychotropic-drugs/drugs-anxiety-sleep-disorders 
21. Royal Australasian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice, Part B: Benzodiazepines. 2019. At: www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/drugs-of-dependence/part-b 
22. Brett J, Karanges EA, Daniels B, et al. Psychotropic medication use in Australia, 2007 to 2015: changes in annual incidence, prevalence and treatment exposure. Aust N Z J Psychiatry 2017;51(10):990–9. 
23. Begum M, Gonzalez-Chica D, Bernardo C, et al. Trends in the prescription of drugs used for insomnia: an open-cohort study in Australian general practice, 2011–2018. Br J Gen Pract 2021;71(712):e877–e886.  
24. Sake FT, Wong K, Bartlett DJ, et al. Benzodiazepine usage and patient preference for alternative therapies: a descriptive study. Health Sci Rep 2019;2(5):e116. 
25. Curado DF, de Barros VV, Noto AR, et al. Dependence on hypnotics: a comparative study between chronic users of benzodiazepines and z-drugs. Braz J Psychiatry 2022; 44(3):248–56. 
26. Guerlais M, Grall-Bronnec M, Feuillet F, et. Al. Dependence on prescription benzodiazepines and z-drugs among young to middle-aged patients in France. Subst Use Misuse 2015; 50(3),320–7. 
27. Melo TR, Bezerra CO, Fernandes BD, et al. Pharmacists’ contribution to benzodiazepine deprescribing in older outpatients: a systematic review and meta-analysis. Int J Clin Pharm 2023;45,1037–49. 
28. Lui E, Wintemute K, Muraca M, et al. Pharmacist-led sedative-hypnotic deprescribing in team-based primary care practice. Can Pharm J 2021;154(4):278–84. 
29. Gregorian T, Bradley K, Campbell S, et al. Design, implementation, and evaluation of a pharmacist-led outpatient benzodiazepine-tapering clinic. J Am Pharm Assoc 2023; 63(1):409–15. 
30. Ashkanani FZ, Rathbone AP, Lindsey L. The role of pharmacists in deprescribing benzodiazepines: a scoping review. Explor Res Clin Soc Pharm 2023;12(4):100328. 
31. Lynch T, Ryan C, Hughes C, et al. Brief interventions targeting long term benzodiazepine and z drug use in primary care: a systematic review and meta-analysis. Addic 2020;115(9):1618–39. 
32. Ng B, le Couteur D, Hilmer SN. Deprescribing benzodiazepines in older patients: impact of interventions targeting physicians, pharmacists, and patients. Drugs Aging 2018; 35(6):493–521. 
33. Oldenhof E, Mason T, Anderson-Wurf J et. Al. Role of the prescriber in supporting patients to discontinue benzodiazepines: a qualitative study. Br J Gen Pract 2021;71(708):e517–27. 
34. Kuntz J, Kouch L, Christian D, et al. Barriers and facilitators to the deprescribing of nonbenzodiazepine sedative medications among older adults. Perm J 2018;22:17–157. 
35. Tully IA, Kim JP, Simpson N, et al. Beliefs about prescription sleep medications and interest in reducing hypnotic use: an examination of middle-aged and older adults with insomnia disorder. J Clin Sleep Med 2023;19(7):1247–57. 
36. Swierzbiolek B, Oldenhof E, Byrne J, et al. “Let’s talk about sleep health”: patient perspectives on willingness to engage in psychological interventions for insomnia. Br J Gen Pract 2024. Epub 2024 Feb 14. 
37. Cheng T, Wallace D, Ponteri B, et al. Valium without dependence? Individual GABAA receptor subtype contribution toward benzodiazepine addiction, tolerance, and therapeutic effects. Neuropsychiatr Dis Treat 2019;14:1351–61. 
38. Arlinghaus KR, Johnston CA. Advocating for behavior change with education. Am J Lifestyle Med 2017;12(2):113–116. 
39. Heather N, Paton J. Ashton H. Predictors of response to brief intervention in general practice against long-term benzodiazepine use. Addict Res Theory 2011:19(6):519–27.   
40. Cook JM, Biyanova T, Masci C, et. Al. Older patient perspectives on long-term anxiolytic benzodiazepine use and discontinuation: a qualitative study. J Gen Intern Med 2007;22(8):1094–100. 
41. de Mendonça FMR, de Mendonça GPR, Souza LC, et al. CNS Neurol Disord Drug Targets 2023;22(2):172–9. 
42. Hansen RN, Boudreau DM, Ebel BE, et al. Sedative hypnotic medication use and the risk of motor vehicle crash. Am J Public Health 2015;105(8):e64–9. 
43. Gunja N. In the Zzz zone: the effects of z-drugs on human performance and driving. J Med Toxicol 2013;9(2):163–71. 
44. Olson L. Hypnotic hazards: adverse effects of zolpidem and other z-drugs. Aust Prescr 2008;31:146–9. 
45. Ben-Hamou M, Marshall NS, Grunstein RR, et al. Spontaneous adverse event reports associated with zolpidem in Australia 2001–2008. J Sleep Res 2011;20:559–68. 
46. Westra HA, Stewart SH. As-needed use of benzodiazepines in managing clinical anxiety: incidence and implications. Curr Pharm Des 2002;8(1):59–74. 
47. Edinger JD, Wamboldt FS, Johnson RL, et al. Adherence to behavioral recommendations of cognitive behavioral therapy for insomnia predicts medication use after a structured medication taper. J Clin Sleep Med 2023;19(8):1495–1503. 
48. Trauer JM, Qian MY, Doyle JS, et al. Cognitive behavioural therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med 2015;163(3):191–204.  
49. Mitchell MD, Gehrman P, Perlis M, et al. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract 2012;13(40):13–40. 
50. Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA 2006;295:2851–8. 
51. Wu R, Bao J, Zhang C, et al. Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia. Psychother Psychosom 2006;75(4):220–8. 
52. Australasian Sleep Association. Sleep heatlh primary care resource: chronic insomnia / insomnia disorder, cognitive behavioural therapy for insomnia (CBTi). 2021. At: www.sleephealthfoundation.org.au/sleep-disorders/cognitive-behavioural-therapy-for-insomnia-cbt-i 
53. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2021;17(2):255–62. 
54. Manber R, Simpson NS, Bootzin RR. A step towards stepped care: delivery of CBT-I with reduced clinician time. Sleep Med Rev2015;19:3–5. 
55. Espie CA, Henry AL. Disseminating cognitive behavioural therapy (CBT) for insomnia at scale: capitalising on the potential of digital CBT to deliver clinical guideline care. J Sleep Res 2023;32(6):e14025. 
56. Koffel E, Branson M, Amundson E, et al. Sign me up, I’m ready!”: helping patients prescribed sleeping medication engage with cognitive behavioral therapy for insomnia (CBT-I). Behavioral Sleep Medicine 2021;19(5):629–39. 
57. Wurf G, O’Neal, P. Community-based counselling for benzodiazepine withdrawal: a mixed-methods study of client outcomes. Couns Psychother Res 2022;22:773–83. 
58. Roy-Byrne PP, Hommer D. Benzodiazepine withdrawal: overview and implications for the treatment of anxiety. Am J Med 1988;84(6):1041–52. 
59. Yen CF, Yen CN, Ko CH, et. Al. Correlates of dependence and beliefs about the use of hypnotics among zolpidem and zopiclone users. Subst Use Misuse 2015; 50(3):350–7. 
60. Hajak G, Müller WE, Wittchen HU, et. al. Abuse and dependence potential for the non-benzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data. Addict 2003;98(10);1371–8. 
61. Ashton H. Protracted withdrawal from benzodiazepines: the post-withdrawal syndrome. Psychiatr Ann 1995;25:174–9. 
62. Horowitz M, Taylor, D. The Maudsley deprescribing guidelines: antidepressants, benzodiazepines, Gabapentoids and z-drugs. Wiley Blackwell; 2024. 
63. Ashton HC. Benzodiazepines. How they work and how to withdraw. University of Newcastle, UK. 2002. 
64. Dell’osso B, Lader M. Do benzodiazepines still deserve a major role in the treatment of psychiatric disorders? A critical reappraisal. Eur Psychiatry 2013;28(1):7–20.   
65. NSW Health. Management of withdrawal from alcohol and other drugs clinical guidance. 2022. At: www.health.nsw.gov.au/aod/professionals/Publications/clinical-guidance-withdrawal-alcohol-and-other-drugs.pdf 
66. Schweizer E, Case WG, Rickels K. Benzodiazepine dependence and withdrawal in elderly patients. Am J Psychiatry 1989;146(4):529–31. 
67. Gould RL, Coulson MC, Patel N, et al. Interventions for reducing benzodiazepine use in older people: meta-analysis of randomised controlled trials. B J Psych 2014;204(2):98–107. 
68. Griffin CE, Kaye AM, Bueno FR, et al. Benzodiazepine pharmacology and central nervous system-mediated effects. Ochsner J 2013;13(2):214–23. 
69. Lee JY, Farrell B, Holbrook AM. Deprescribing benzodiazepine receptor agonists taken for insomnia: a review and key messages from practice guidelines. Pol Arch Intern Med 2019;129:43–49.  
70. Hintze JP, Edinger JD. Hypnotic discontinuation in chronic insomnia. Sleep Med Clin 2020;15(2):147–54.  
71. Baandrup L, Ebdrup BH, Rasmussen JØ, et al. Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users. Cochrane Database of Systematic Reviews 2018;3(3). 
72. Soni A, Thiyagarajan A, Reeve J. Feasibility and effectiveness of deprescribing benzodiazepines and z-drugs: systematic review and meta-analysis. Addiction 2023;18(1):7–16. 
73. Sweetman A, Putland S, Lack L, et al. The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: a narrative review. Sleep Med Rev 2021;56.  
74. Takaesu Y, Utsumi T, Okajima I, et al. Psychosocial intervention for discontinuing benzodiazepine hypnotics in patients with chronic insomnia: a systematic review and meta‑analysis. Sleep Med Rev 2019;48. 
75. Cosci F, Chouinard G. Acute and persistent withdrawal syndromes following discontinuation of psychotropic medications. Psychother Psychosom 2020; 89(5):283–306. 
76. Schifano F, Chiappini S, Corkery JM, et. l. An insight into z-drug abuse and dependence: an examination of reports to the European medicines agency database of suspected adverse drug reactions. Int J Neuropsychopharmacol 2019;22(4):270–77.

Our authors

Dr Erin Oldenhof BA(Psych)(Hons), Doctor of Psychology (Clinical) (she/her)

Erin is a registered psychologist working as a Benzodiazepine Withdrawal Counsellor and Research Coordinator at Reconnexion. She has experience working long-term with individuals who have become dependent on their benzodiazepines and z-drugs, and her research focuses on improving the patient-centeredness of deprescribing.

Stacey Putland BPharm AACPA MPS (she/her)

Stacey is a credentialled pharmacist and project manager with the Australasian Sleep Association. She has experience collaborating with patients and prescribers to optimise medicines management in residential aged care, hospital and community settings.

Our reviewers

Hana Numan BPharm (NZ), PGDipClinPharm (NZ), MPS (NZ) (she/her)

QUALITY USE OF MEDICINES FOR INSOMNIA AND SLEEP HEALTH (QUMISH) STEERING COMMITTEE

Conflicts of interest

Dr Oldenhof is employed by Reconnexion to support individuals dependent on benzodiazepines and z-drugs to safely stop their medication.

Stacey Putland is employed by the Australasian Sleep Association to manage a grant project specifically focused on upskilling pharmacists on insomnia management and sleep health.