Table 1.
Educational Interventions to decrease benzodiazepine use
| Study | Location | Intervention design: Educational Letter Interventions Targeting Consumers |
Study Design and Size | Result | Follow up |
|---|---|---|---|---|---|
| Bashir et al, 1994 [57] | London | Letters sent long term users (> 1 year) with a request to visit their GP and allocated to: 1 = informed about the correct use of BZ + self help book. 2 = control (no advice) |
RCT 11 GP practices 109 patients. |
Sig increase in the number of patients' that reduced BZ prescriptions in intervention group (18%) compared to control (5%). | 6 months post intervention |
| Towle and Adams, 2006 [25] | Scotland | Letter sent to repeat BZ users by pharmacist to tell them that a step down program had been initiated and invited them to see their GP for a medication review + repeat BZ prescriptions were inactivated. Posters displayed in GP practice. | Convenience Sampling 1 practice, 206 patients. |
73% collected their step down program. Decreased number of tablets prescribed by 64%. Only 23% of 369 patients stayed on a repeat script. (No statistical analysis). | 3 years (end of the study) |
| Heather et al, 2004 [26] |
UK | Long term BZ users (> 6 months) were allocated to: 1 = letter from GP asking them to consider cutting down their BZs. 2 = letter inviting participants to a consultation + leaflet and self help sleep book. 3 = control. |
RCT 7 Practices, 299 patients. |
Sig reduction in letter group (24%) vs. control (16%) and sig reduction in consult (22%) vs. control (16%). No sig difference between consultation and letter group for BZ decrease. | 6 months post intervention |
| Cormack et al, 1989 [58] |
UK | Long term BZ users (> 1 year) were allocated to: 1 = letter from GP advising patients to cut down BZ use. 2 = invitation to see the GP about cutting down BZ use. 3 = control. | CT 5 practices, 75 patients. |
Sig reduction in BZ use in both the letter group and the consultation group compared to no change in control group (data not reported). | 6 months to 1 year post intervention |
| Cormack et al, 1994 [23] |
England | Long term BZ users (> 6 months) allocated to: 1 = letter from GP to recommending stopping BZs 2 = letter from GP + monthly advice sheets. 3 = control |
CT 3 practices 209 patients. |
30% reduction in BZ use by intervention groups (sig difference from control) No sig difference between interventions. | 6 months post intervention |
| Gorgels et al, 2005 [59] |
Netherlands | 1 = discontinuation letter to long term users then approximately 3 months after the letter, an invitation for GP evaluation of BZ use. 2 = control. | RCT 30 practices 1707 patients (intervention) and 1821 (control). |
Sig use reduction of BZ prescriptions in intervention group (24%) vs. control (5%). Sig reduction in BZ use in the intervention group for those who attended the GP evaluation (35%) vs. those who did not go (24%). | 21 months post intervention |
| Morrison, 1990 [60] |
UK | Long term BZ users (> 6 months) were informed that they should stop BZs by their GP. If agreed an individual plan (how to decrease and number of follow-up visits) was established. | Convenience Sampling 1 practice, 27/72 eligible patients agreed. |
No new long term users started during study. 37.5% quit 33.3% reduced dose by >50% and 15% remained same dose or <50% reduction. No-one increased their dose during the study period. | 1 year (end of study) |
| Onyett and Turpin, 1988 [28] | UK | Recruitment of long term users by notices. Asked to self-reduce BZs then all participants received a pamphlet and allocated to: 1 = group session. 2 = individual GP appointment. | Prospective cohort 18 patients. |
59% reduction in dose (group) and 69% reduction in dose (GP meeting) but no sig difference between groups. | 15 week post intervention |
| Brymer and Rusnell, 2000 [27] | Canada | Home assessment by nurse to determine if patients were substance dependent. Saw Geriatrician for medical review, who recommended a treatment plan (also sent to their GP). Were encouraged to join support/educational groups. | Observational study 55 elderly patients. |
Significant reduction of BZ use (59%) between pre and post intervention. | 6 months post intervention |
| Study | Location |
Intervention Design: Educational Interventions Targeting GPs |
Study Design and Size | Result | Follow up |
| Zwar et al, 2000 [61] |
Australia | 1 = face to face 20 min educational visit by a GP focusing on the management of long term users of BZs + guidelines + leaflets on relaxation techniques for patients. 2 = control. | RCT 157 GP registrars |
Sig decrease in overall BZs use in both groups (0.6 per 100 encounters for both group), however no difference between control and intervention groups. | 3 practice surveys - 6 monthly |
| Smith et al, 1998 [30] |
Washington, USA | 1 = mailed intervention package (guidelines, letter, prescriber-specific profile, patient profile) for prescribers of over users (1 tab per day >1 year) 2 = control. |
RCT GPs or pharmacist of 222 over users |
Sig decrease in BZ prescribing/dose for the intervention group (27.6%) compared to control (8.5%). | 3 months post intervention |
| Holm, 1990 [32] |
Aarhus, Denmark | 1 = invite to a meeting on correct use of hypnotics/sedatives + educational material given at the meeting. 2 = mailed information on correct use and feedback on their prescribing rate compared with others. 3 = control. | RCT 356 GPs (245 practices) |
Sig decrease (-53) in DDD/1000 pat/week between pre and post intervention. No difference between groups 1 and 2 but sig difference between groups 2 and 3 (2 prescribed more). | 1-2 months post intervention |
| De Burgh et al, 1995 [29] | NSW, Australia | 1 = 20 min educational visit to GPs. Educational material left (management guidelines, review cards for long term users). Offered access to sleep aids. Recommended to review 5 patients and received a follow-up phone call. 2 = control. | RCT 286 GPs |
An overall decrease in BZ prescribing (23.7%). No sig difference between intervention and control for reduction rate of BZ. Sig decrease between intervention (72% decrease) and control (13% decrease) for rate of new BZ scripts for insomnia. | Approx 6 months post intervention |
| Midlov et al, 2006 [62] | Skane, Sweden | 1 = two educational visits from pharmacist and GP focusing on effects of medium and long acting BZs in the elderly. 2 = control (received intervention after the study). | RCT 15 GPs (8 in intervention, 7 in control) |
Sig decreases in all BZ prescribing (26.63%) and 25.8% decrease of long and medium acting BZs vs. control. | 1 year post intervention |
| Berings et al, 1994 [31] | East and West Flanders, Belgium | 1 = educational advertisement like mailings (with slogan) + educational visit. 2 = mailings only 3 = control | RCT 128 physicians |
Sig decrease for whole sample pre to post intervention. Sig decrease in BZ prescriptions between intervention 1 (24%) and control (3%) and intervention 2 (14%) and control and intervention 1 and 2. | 4 weeks post intervention |
| Study | Location | Intervention Design: Educational Interventions Targeting LTC | Study Design and Size | Result | Follow up |
| Hagen et al, 2005 [63] | Alberta | 1 = Algorithm on non-pharmacological approaches for agitation. Education based on algorithm to nurses, pharmacists, or family members. 30 min education session for GP. 2 = Control | CT 24 LTC facilities, 12 (intervention) and 12 (control) |
BZ use in both the control and the intervention increased post intervention (Sig increase for control only). At 6 months post intervention total BZ use sig higher in control vs. intervention. | Every 2 months until 6 months post intervention |
| Avorn et al, 1992 [64] | Massachusetts | 1 = physicians received 3 × drug advertisement like summaries of literature about geriatric medicine, psychopharmacology + 3 face to face visits to each doc by pharmacist. 4 training sessions for nurses on alternatives to psychoactive drugs + ADRs. 2 = Control | MPR 12 LTC facilities 6 (intervention) and 6 (control) both groups were matched |
Sig difference in the % change to more appropriate BZs in intervention (64%) vs. control (4%). E.g. long acting to short acting. | 30 days post intervention |
| Schmidt et al, 1998 [65] | Sweden | 1 = Monthly meeting for 12 months led by pharmacist and included physician, and nurses. Each patient's medications were reviewed. 2 = Control | RCT 33 nursing homes (15 intervention, 18 control) |
Sig increase (from baseline) in prescribing of appropriate hypnotics (+70%) and anxiolytics (+ 50%) in intervention group. No sig difference in control group | 1 month post intervention |
| Gilbert et al, 1993 [36] | Adelaide, Australia | 1 = letter to residents inviting participation in relaxation groups (8 × 40 min) audio tape of relaxation for practice and information about sleep & anxiety medications. Nurses received a seminar on dealing with BZ withdrawal. Doctors received letter of progress. 2 = Control | Prospective cohort 2 LTC facilities |
There was a sig decrease in the % of BZs users' from baseline (70%) to post intervention (35%). No change in control | 12 weeks after baseline |
BZ = benzodiazepines, GP = General Practitioner, LTC = long term care, Sig = statistically significant (p < 0.05), tab = tablet, ADRs = Adverse Drug Reactions, DDD/1000 pats/week = the number of defined daily doses dispensed per 1000 patients per week, RCT = Randomized controlled trial, CT = Controlled trial, MPR = Matched pair randomization