educational program to decrease benzo use in elderly

one of the "choosing wisely" items of the american geriatric society is to avoid the use of benzodiazepines in people over 65 yo because of the associated increased risk of falls and hip fractures. of note, benzos comprise 20-25% of "inappropriate" scripts for elderly, with prevalence of use at 5-32% in community-dwelling elders. a study was done of direct-to-consumer advertising to see if that could decrease benzo usage in community-dwelling people >65yo on chronic benzos (see benzo education in elderly jama intmed 2014 in dropbox, or  doi:10.1001/jamainternmed.2014.949). in this study community pharmacies were randomly assigned to either intervention or control, with approx 150 patients aged 65-95 yo in each group. patients in the active arm of the trial got an 8-page booklet with a self-assessment component about benzo use, presentation of evidence of benzo harm, drug interactions, peer champion stories to augment self-efficacy, suggestions for alternative therapies for insomnia or anxiety, and specifics for stepwise taper. the patients were then urged to discuss this with their MD or pharmacist. they then measured benzo usage 6 months later. results:

    --indication for chronic benzos: 60% for insomnia and 48% for anxiety, mean duration 10 years and average daily dose = 1.3mg equivalents of lorazepam
    --86% of participants completed the 6-month follow-up
    --of those in the intervention group, 62% initiated conversation about benzo cessation with their medical provider and/or pharmacist
    --at 6 months, 27% in the intervention group and 5% in control group had discontinued the benzos, a highly significant difference, with NNT of 4.  dose reduction in an additional 11%
    --no interaction effect in subgroup analysis for age>80, sex, duration of use, indication for use, dose, prior attempts to taper, concomitant polypharmacy (>10 drugs/d)

so, pretty remarkable changes through direct patient education and empowerment. 27% of patients on reasonably high doses of benzos for 10 years were able to completely taper off benzos and additional 11% to cut back!! runs counter to the complacent attitude that "my patient is doing fine. stable. sleeping better. why change anything since he/she is having no problems/falls. and besides, he/she probably is addicted and will go through potentially traumatic withdrawal....."

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