The study was designed to show that a BZD withdrawal program, with nursing professionals as the key element, can be applicable within the Spanish Primary Care setting. The following points were considered in developing our program: a) In agreement with many authors, patients should not be forced to cease their treatment
]; b) The use of complementary medicines as co-adjuvant therapy. Numerous trials have been carried out using complementary medicines to control withdrawal symptoms while the patients are on BZD
]. These trials have highlighted the successful use of Hydroxyzine
] due to its good tolerance, low risk, and reduced cost; c) Tapered dose. Other studies have also focused on a progressive cessation of BZD
], which reveal a cost-effective alternative for BZD withdrawal; d) Pharmacological support. Although cognitive behavioural therapy is an effective adjuvant therapy in BZD withdrawal programs
] its implementation in daily practice can have significant cost and time implications. Several clinical trials have, therefore, focused instead on providing psychological support to patients during their withdrawal period, based on identifying the reason prescriptions were initiated and maintained, and patients’ information on dependence and withdrawal symptoms
]; and e) The use of Valerian for improving sleep. Whilst Valerian has a subjective improvement on sleep quality it does not reflect an improvement in sleep onset latency
After the level of commitment required to successfully complete the first stage of this programme (i.e. to attend at least six appointments with the nurse and to complete multiple assessment questionnaires) had been explained, 28 of the selected patients did not wish to participate. Most of these patients gave as their reason for refusal the fact of being in active employment and, therefore, limited in terms of time. It should also be noted that the study excluded young patients, which additionally reduced our patient sample. As a result, our sample group consisted predominantly of elderly and retired patients (particularly female pensioners with a low socio-economic level) with concomitant chronic diseases.
Their socio-demographic features matched those of patients defined as being at risk of chronic BZD use
Our sample size was large enough to show the beneficial effect of a BZD cessation programme and highlight the difference between the patients’ condition before and after the intervention programme. We recognize, however, that size was the main limitation of the study, and we were unable to obtain statistically significant differences between patients who successfully completed the cessation programme and those who did not. The latter comparison was not, however, a key objective although we consider it could become a useful starting point for further studies.
It should be pointed out that almost 20% of the patients consumed antidepressants, mostly from the Selective Serotonin Reuptake Inhibitor (SSRI) group. This highlights non-compliance with national guidelines based on previous studies
] which advise limiting the use of BZD to the onset of SSRI treatment. More than twenty years ago it was reported that the benefit of BZD was significantly reduced after fifteen days of use
]. Yet, as our results confirm, BZD continues to be prescribed without due consideration for this benefit/time restriction.
A comparison revealed that the average daily dose of BZD in the United Kingdom (equivalent to 5 mg of Diazepam)
] was lower than that in our study in Spain (equivalent to 10 mg of Diazepam). Nevertheless, the percentage of cessation at six months was the same in both countries. Results achieved in withdrawal programmes in both countries were not, therefore, influenced by the initial BZD dosage. In our study, patients taking a higher initial dose of BZD presented more sleeping problems in the baseline test than those taking lower doses; once, however, they had all completed the program, those who had initially consumed more BZD did not score higher on the sleeping problem scale. This finding helped to confirm that the consumption of a higher dose of BZD does not improve sleep quality
]. It is noteworthy, that 10% of the patients who were taking BZD (with its concomitant side effects)
] in excess of four years were unaware of the reason for its indication.
When analysing the SF-12 results before the initial intervention and at 24 weeks, we saw an improvement in the mental component but not in the physical one among the cessation group. These results are similar to those expected as consumption of BZD should not influence physical fitness.
In the analysis of the Goldberg scale, the cessation group showed a statistically significant gradual decrease in both the anxiety and depression components. These results are positive when compared with the study by Curran et al.
] which, whilst using a different parametric scale (the Geriatric Depression Scale), reported neither an improvement nor a deterioration of these symptoms for the cessation group.
The results of the sleep scale could be interpreted as being due to a heightened awareness of other underlying chronic diseases. In fact, a quarter of the patients had Chronic Obstructive Pulmonary Disease (COPD) and they should not have been taking BZD as a chronic treatment. Discontinuing BZD prevents severe symptoms being masked, and thus permits early action on potential complications. A 64.7% success rate (percentage of BZD cessation cases maintained for one year) shows that, after specific training, nurses in a Primary Care setting can implement a program with the objective of achieving the cessation of BZD intake in volunteer patients, with similar results to studies conducted by other professionals such as physicians or psychologists
]. Nevertheless, it must be conceded that our outcome could be partly attributed to an inaccurate diagnosis of insomnia, mistaking this, and the patient’s addiction due to tolerance
], for physiological sleep disturbances related to age, which are easy to treat through advice and sleep hygiene. Our results may provide another overview
] of the initial and medium term results of this withdrawal program and represent a starting point for further studies on effectiveness.