Table 1.

Studies Evaluating Patient Education to Overcome Patient Barriers to Reduce SH Use in Community-Dwelling Adults.

Study description	Intervention	Results	Number needed to treat
Subcategory: patient education delivered by physician
Morgan et al (2002) 30 • Design: prospective pre-post intervention • Duration: 1 year preintervention, 1 year postintervention • Setting: 2 general medical practices in the United Kingdom, n = 242 patients • Target: BZD	• Educational letters sent to patients: ° explaining the problems associated with long-term BZD use and encouraged patients to gradually reduce their BZD intake ° containing sleep hygiene advice ° signed by patient’s physician	• 31% Of patients discussed drug use with their physician • 17% Reduced BZD use, and 5% discontinued prescriptions • Mean DDD decreased from 336.6 in the preintervention to 283.0 in the postintervention group (P < 0.001) • Patients discussing the letter with their physician (P = 0.008) and those with shorter durations of BZD use (P = 0.03) were more likely to reduce their usage	N/A
Baillargeon et al (2003) 31 • Design: RCT (randomization at patient level) • Duration: baseline, 3, and 12 months • Setting: community dwelling, Québec city, Canada • Target: BZD	• Intervention 1: gradual dose reduction during a weekly physician consultation for 8 weeks plus 90-minute sessions of group cognitive behavioral therapy for insomnia weekly for 8 weeks • Intervention 2: gradual dose reduction during a weekly physician consultation for 8 weeks	• Intervention group 1: 77%, 67%, 70% complete cessation at 0, 3, 12 months post–intervention completion • Intervention group 2: 38%, 34%, 24% complete cessation at 0, 3, 12 months post–intervention completion (P < 0.05) at all time points	NNT for cessation at 12 months: • 2.2 For intervention 1 compared to intervention 2
Heather et al (2004) 32 • Design: RCT (randomization at patient level) • Duration: 6 months preintervention, 6 months intervention • Setting: UK general practice • Target: BZD	Intervention 1: Patients were sent a letter from their GP inviting them for a medication review • GPs received training and written guidelines for patient communication and BZD tapering • Guidelines were attached to the notes of eligible patients • Patients provided with self-help booklets • Intervention 2: Patients received an educational letter signed by their GP • Control: Usual care	• Reduction in BZD use for both interventions compared to control at 6 months ° Intervention 1: 22% reduction ° Intervention 2: 24% reduction ° Control: 16% reduction • Both interventions produced a significant reduction compared to control (P = 0.042 and P = 0.012, respectively) • There was no significant difference between intervention 1 and 2 for dose reduction (P = 0.47) • Proportion of patients achieving ≥25% reduction in BZD use at 6 months ° Intervention 1: 37% ° Intervention 2: 41% ° Control: 24% • Intervention 2 was significantly different to control (P = 0.011), whereas intervention 1 was not (P = 0.076) • Cessation of BZD use at 6 months ° Intervention 1: 10.5% ° Intervention 2: 10.2% ° Control: 6.7% • There was no significant difference between intervention 1 or 2 and control for cessation (P = 0.37)	NNT for reduction in BZD use at 6 months: • Intervention 1: 16.7 • Intervention 2: 12.5 • NNT for ≥25% dose reduction at 6 months • Intervention 1: 26.3 • Intervention 2: 28.6 NNT for cessation at 6 months • Intervention 1: 26.3 • Intervention 2: 28.6
Gorgels et al (2005), 33 De Gier et al (2010) 34 • Design: prospective controlled intervention study • Duration: 21-month follow-up • Setting: 30 primary care practices in Netherlands, n = 3833 patients • Target: BZD	• Intervention: patients received letter from GP with advice to gradually discontinue (discontinuation letter); followed at 3 months with a written invitation to meet with GP to evaluate actual use (evaluation consultation) • Control: usual care	• At 4-6 months, reduction in BZDs was higher at 24% in intervention vs 5% in control group (difference in PDD = 14.2; 95% CI = 10.6-17.8) • At 21 months, results were sustained with difference in PDD = 12.5% (95% CI = 8.2-16.8) • Percentage of participants without a prescription (ie, cessation): ° At 6 months: 24% in intervention vs 12% in control group (RR = 2.1; 95% CI = 1.8-2.4) ° End of the study: 13% in intervention vs 5% in control group (RR = 2.6; 95% CI = 2.0-3.4) • No additional physician workload reported • 10-Year follow-up data (for a subset of patients) showed that 73% remained abstinent or showed minimal use over 10 years; 59% were completely BZD free during the 10th-year follow-up data collection	NNT for cessation at 6 months: • 8.3 NNT for cessation at 21 months • 12.5
Vicens et al (2014) 35 • Design: cluster RCT (randomization at practitioner level) • Duration: baseline and 12 months postintervention • Setting: 3 regions within Spain • Target: BZD	Patient education components: • Intervention 1: structured intervention with written instructions and follow up visits • Intervention 2: structured intervention with written instructions • Control: usual care GP Education components: All GPs received baseline education and training, with intervention GPs receiving an additional 3 hours	• Intervention 1: 45% discontinuation rate, RR = 3.01 (95% CI = 2.03-4.46) • Intervention 2: 45% discontinuation rate, RR = 3.00 (95% CI = 2.04-4.40) • Control: 15% discontinuation rate • No significant difference between intervention 1 and 2 (RR = 1.0; 95% CI = 0.78-1.28) • Most frequently reported withdrawal symptoms were insomnia, anxiety, and irritability	NNT for cessation at 12 months • Intervention 1: 3.3 • Intervention 2: 3.3
Vicens et al (2016) 36 • Design: cluster RCT (randomization at practitioner level) • Duration: baseline and 36 months postintervention • Setting: 3 regions within Spain • Target: BZD	Patient education components: • Intervention 1: structured intervention with follow-up visits • Intervention 2: structured intervention with written instructions • Control: usual care GP Education components: all GPs received baseline education and training, with intervention GPs receiving an additional 3 hours	• Intervention 1: 41% discontinuation rate, RR = 1.59 (95% CI = 1.15-2.19) • Intervention 2: 39% discontinuation rate, RR = 1.51 (95% CI = 1.10-2.05) • Control: 26% discontinuation rate • No significant difference between intervention 1 and 2 (P value not provided)	NNT for cessation at 36 months • Intervention 1: 6.7 • Intervention 2: 7.7
Subcategory: patient education delivered by nonphysician
Oude Voshaar et al (2003) 37 • Design: RCT (randomization at patient level) • Duration: 3 months • Setting: 30 general practice, Netherlands, 180 patients • Target: BZD	• Intervention 1: tapering off chronic BZDs (by converting to diazepam; 25% weekly reductions) alone • Intervention 2: tapering off chronic BZDs plus CBT (5 weekly 2-hour sessions) • Control: usual care	• For patients who completed the study: tapering off led to significantly higher proportion of successful discontinuations than usual care (62% taper only vs 58% taper + CBT vs 21% usual care, P = 0.002)	NNT for cessation at 3 months • Intervention 1: 2.4 • Intervention 2: 2.7
Lopez-Peig et al (2012) 38 • Design: pre-post pseudo-experimental • Duration: baseline compared to 6 and 12 months post intervention • Setting: GP practices in Spain • Target: chronic BZD	• Nurses provided patient education on gradual dose reduction to chronic users • Substitution with hydralazine or valerian allowed	• 80% Cessation of BZDs at 6 months and 64% cessation maintained at 12 months • An improvement in all parameters of the Goldberg scale for depression and anxiety (P < 0.05) and in the mental component of SF-12 at 3.3 points (P = 0.024), as well as in most components of the MOS scale, was observed in the group that had discontinued BZD. No significant differences in these scales before and after the intervention were observed in the group that had not discontinued	N/A
Tannenbaum et al (2014) 39 • Design: cluster RCT (randomization at the community pharmacy level) • Duration: 6 months, n = 303 • Setting: 30 community pharmacies in Québec, Canada • Target: BZD	• Direct to consumer education using patient education tool: “Eliminating Medications Through Patient Ownership of End Results (EMPOWER)” • Intervention: ° Self-assessment on risks of BZDs ° Evidence of BZD-induced harms, drug interactions ° Peer champion stories to augment self-efficacy ° Suggestions of equally or more effective therapies for insomnia and/or anxiety ° Stepwise tapering protocol (21-week visual chart) ° Encourage recipients to discuss deprescribing with their physician/pharmacists • Control: usual care	• 86% Of participants completed 6 months of follow-up • 27% Of intervention group completed cessation of BZD use at 6 months vs 5% of controls; OR = 8.1 (95% CI = 3.5%-18.5%) • Dose reduction of BZD occurred in another 11% (95% CI = 6%-16%) • NNT for any discontinuation or dose reduction = 3.7 • In multivariate subanalyses, age greater than 80 years, sex, duration of use, indication for use, dose, previous attempt to taper, and concomitant polypharmacy (≥10 prescriptions per day) were not associated with BZD therapy discontinuation	NNT for cessation at 6 months • 4.5
Martin et al (2018) 40 • Design: pragmatic cohort RCT (randomization at the community pharmacy level) • Duration: 6 months • Setting: 69 community pharmacies in Québec, Canada • Target: SH, NSAIDs, antihistamines, glyburide	• Intervention group: Pharmacists received lists of their patients aged ≥65 years who were chronic users of target medications ° Pharmacists provided patients with an educational brochure and physicians with an evidence-based pharmaceutical opinion • Control group: usual care	• 43% Of interventions ceased a target medication vs 12% of control group at 6 months (risk difference = 31% [95% CI = 23%-38%]); NNT to discontinue = 3 • 43.2% vs 9.0% Ceased an SH (risk difference = 34% [95% CI = 25-43])	NNT for cessation at 6 months • 3.0

Abbreviations: BZD, benzodiazepine; CBT, cognitive behavioral therapy; DDD, defined daily dose; GP, general practitioner; N/A, not applicable; NNT, number needed to treat; MOS, medical outcome study; NSAIDs, nonsteroidal anti-inflammatory drugs; OR, odds ratio; PPD, prescribed daily dose; RCT, randomized controlled trial; RR, risk ratio; RRR, relative risk ratio; SF-12, Short-Form 12; SH, sedative-hypnotic.