探花合集

Tricia Wright, MD, MS, FACOG, DFASAM

This week ASAM released the new Joint Clinical Practice Guideline on Benzodiazepine Tapering. This guideline was developed to help clinicians determine when the risks of continued BZD prescribing outweigh the benefits for a given patient and how to safely taper the medication when indicated.

Existing guidelines generally recommend limiting duration of BZD use to 2-4 weeks (except for limited conditions such as severe treatment-resistant generalized anxiety disorder, complex seizure disorders, spasticity, and sleep disorders involving abnormal movements). However, long-term BZD prescribing remains prevalent.

The challenges of BZD tapering are not specific to addiction medicine. Nearly all patients who take BZD regularly for more than a month will develop physical dependence, while only 1.5% will develop a BZD use disorder. As such, the Guideline is applicable to diverse clinical specialties and was developed by a coalition of medical and professional societies representing psychiatrists, neurologists, family practice providers, addiction medicine specialists, geriatricians, obstetricians, medical toxicologists, psychiatric pharmacists, and advanced practice providers, with funding provided by the US Food and Drug Administration (FDA). In performing a rigorous, systematic review of the evidence around tapering BZD, the guideline development committee was surprised by the paucity of research given that the need for BZD tapering is a relatively common clinical situation.

Many providers across disciplines struggle with helping patients taper or even broaching the subject. Tapering can be challenging, and the challenges are often unpredictable. One patient who has been taking BZDs for years may have little trouble tapering at a rate of 25% every 2-4 weeks. Another patient who has been taking BZD for less time may experience significant and persistent withdrawal symptoms even with a much slower taper. The Guideline emphasizes the importance of a patient-centered approach to tapering, starting slowly and adjusting the pace of the taper based on the patient’s response.

The Guideline also discusses considerations for patients with substance use disorder, emphasizing the importance of screening patients for non-prescription BZD misuse and BZD use disorder. For patients with SUD, the Guideline recommends:

Importantly, the Guideline emphasizes that residential or inpatient treatment may be necessary for patients with SUD who are unlikely to safely and effectively participate in outpatient tapering. It also emphasizes that BZD prescribing and tapering considerations should never be used as a reason to discontinue or disrupt a patient's medications for SUD treatment, including buprenorphine and methadone.

From the start of Guideline development, the guideline committee was aware of the potential for unintended consequences. As was seen with the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, . The committee was acutely aware of the risk for patient harm if BZD tapering is poorly managed, including risks for severe and protracted withdrawal, recurrence or exacerbation of underlying health conditions, and transition to the illicit drug market where patients risk encountering products contaminated by fentanyl and other high-potency synthetic opioids.

Careful implementation of the Guideline, including avoiding patient abandonment, will be critical for preventing harm. Health care systems, which are already overburdened, are likely to identify a large population of patients who would benefit from BZD tapering. It will be important for health care systems and policymakers to consider how to triage those at highest risk and leverage existing health care resources to meet the needs of the population. When measuring success it will be critical to measure patient-centered outcomes (eg, functionality, patient experience) as well as adverse events (eg, protracted withdrawal) instead of using reductions in BZD prescribing as the sole measure of success.

Addiction specialists, psychiatrists, and medical toxicologists have the specialty expertise to help our colleagues in primary care and other disciplines effectively support their patients through BZD tapering. As this Guideline is released and implemented, we hope that you will explore ways to help other clinicians in your community rise to this challenge.

探花合集 is offering a webinar series to explore guideline concepts in depth.