Patient-GP-Pharmacist cooperation towards individualized tapering schemes for long term benzodiazepine users

Abstract

Long-term use of benzodiazepines and Z-drugs is associated with multiple side effects, such as increased sedation, fall risk, and an elevated risk of dependency and abuse. Avoiding initiation of treatment, or stopping treatment after a few weeks, is definitely the best-case scenario. But for patients that are already using benzodiazepines for more than 3 months (up to 20 years or more), a deprescribing methodology should be deployed. Abrupt withdrawal, particularly if the individual has been taking the drug in high doses, can result in severe symptoms, including psychotic reactions. The recommendation is for slow withdrawal, tapering the dosage gradually over a period of several months.
 Pharmacy compounding of capsules has been a possibility for many years, and allows to prepare and dispense individualized dosages to patients. Medical practitioners such as GP’s have always had the possibility to prescribe dose reduction schemes for patients motivated to taper off. Unfortunately, as benzodiazepines are not reimbursed in Belgium, this came at a high cost for patients.
 In 2022, pharmacy associations together with health insurance funds and the National Institute for Health and Disability Insurance (NIHDI) worked on a reimbursement scheme that allowed tapering off benzodiazepines. The patient-GP-pharmacist triangle is at the core of the scheme:
 -Pharmacists raise awareness when dispensing prescribed benzodiazepines, and prepare and dispense individualized doses
 -GP’s motivate patients to consider tapering and prescribe the programme
 -Patients engage in a tapering path and are intensively followed by the GP and the pharmacist
 Apart from the roles and responsibilities of the 3 parties, there are some rules set out to increase the change of successful tapering whilst keeping expenditure under control. For instance, a maximum daily consumption of 3 DDD set out, there is choice between 3 tapering schemes (5, 7 or 10 steps), and the total duration of the programme should not exceed 360 days.
 Critical success factors of these programs are: intrinsic motivation of the patient, therapeutic contract with 3 parties concerned, absence of financial penalty for patients, and smooth communication between prescriber and preparer/dispenser.