title: The effects of substituting zopiclone in withdrawal from chronic use of benzodiazepine hypnotics Cognitive-behavioural, pharmacological and psychosocial predictors of outcome during tapered discontinuation of benzodiazepine. Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care. Withdrawal from benzodiazepines by initially switching to zopiclone. Insomnia in young men and subsequent depression. The Johns Hopkins Precursors Study. Tapering off long-term benzodiazepine use with or without group cognitive-behavioural therapy: three-condition, randomised controlled trial. Gradual withdrawal from benzodiazepines in residents of homes for the elderly: experience and suggestions for future research Hypnotic taper with or without self-help treatment of insomnia: a randomized clinical trial. Older adults and withdrawal from benzodiazepine hypnotics in general practice: effects on cognitive function, sleep, mood and quality of life. Efficacy of an Internet-based behavioral intervention for adults with insomnia. Facilitation of benzodiazepine discontinuation by melatonin: a new clinical approach. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. Long-term therapeutic use of benzodiazepines. I. Effects of abrupt discontinuation. Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial. Long-term therapeutic use of benzodiazepines. II. Effects of gradual taper. Predictors of Long-Term Benzodiazepine Abstinence in Participants of a Randomized Controlled Benzodiazepine Withdrawal Program Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. Withdrawal reaction after long-term therapeutic use of benzodiazepines. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians.
abstract: Abstract Twenty-four volunteers ( 19 women and five men ) with insomnia and a history of chronic use of benzodiazepine hypnotics  participated in a r and omized , double blind , controlled clinical trial . The study was design ed to assess the effects of substituting zopiclone ( ZOP ) – as an hypnotic – among chronic users of flunitrazepam ( FLU )  , and to compare the subsequent withdrawal of ZOP with placebo controlled withdrawal of FLU . During the 5 weeks of a withdrawal protocol , sleep and physiological parameters were assessed by polysomnographic measures for 11 nights and by nightly actigraphic recordings for weeks 1 , 3 , and 5 . Subjective effects of the withdrawal process were evaluated with daily sleep diaries , and with various weekly self-report symptom checklists . Paired t-tests performed on differences in objective sleep parameters between baseline and the last weeks of the withdrawal program showed a significant decrease in sleep quality within the FLU group , but not in the ZOP group . Subjective sleep diaries consistently reflected the objective ly measured changes in sleep throughout the withdrawal program , indicating significant changes in sleep parameters only in the FLU group . The results obtained from the self report inventories aim ed at assessing withdrawal symptoms , however , revealed no differences between the baseline week and the termination week of the program in any of the groups . After completing the pharmacological withdrawal , all subjects received a short-term cognitive behavioral intervention focused on improving their coping strategies with symptoms of insomnia ; they were evaluated immediately after concluding the intervention , and at 3 and 12 month follow-ups Eighty-six participants wishing to stop benzodiazepine and who met DSM-IV ( Diagnostic and Statistical Manual of Mental Disorders , 4th ed . American Psychological Association , 1994 ) criteria for anxiety disorder or insomnia were assessed pre- and post-taper on clinical , pharmacological and psychosocial measures . An initial cohort of 41 participants received treatment as usual ( taper only ) plus physician counselling in the same clinic setting . A second cohort of 45 participants were r and omly allocated to group cognitive-behavioural therapy ( CBT ) plus taper , or group support ( GS ) plus taper . At 3 months follow-up , the outcomes in both the CBT and the GS subgroups were equivalent . Intention to treat analysis revealed a slight advantage to the CBT over the GS group and the CBT group showed higher self-efficacy post-taper . Over all 86 participants , a high-baseline level of psychological distress , anxiety and dosage predicted a poor outcome , but increase in self-efficacy contributed to a successful outcome particularly in those with initially poor baseline predictors . Although there was a decrease in positive affect during preliminary stages of tapered discontinuation compared to baseline , there was no significant overall increase in negative affect BACKGROUND Benzodiazepines are extensively used in primary care , but their long-term use is associated with adverse health outcomes and dependence . AIMS To analyse the efficacy of two structured interventions in primary care to enable patients to discontinue long-term benzodiazepine use . METHOD A multicentre three-arm cluster r and omised controlled trial was conducted , with r and omisation at general practitioner level ( trial registration IS RCT N13024375 ) . A total of 532 patients taking benzodiazepines for at least 6 months participated . After all patients were included , general practitioners were r and omly allocated ( 1:1:1 ) to usual care , a structured intervention with follow-up visits ( SIF ) or a structured intervention with written instructions ( SIW ) . The primary end-point was the last month self-declared benzodiazepine discontinuation confirmed by prescription cl aims at 12 months . RESULTS At 12 months , 76 of 168 ( 45 % ) patients in the SIW group and 86 of 191 ( 45 % ) in the SIF group had discontinued benzodiazepine use compared with 26 of 173 ( 15 % ) in the control group . After adjusting by cluster , the relative risks for benzodiazepine discontinuation were 3.01 ( 95 % CI 2.03 - 4.46 , P<0.0001 ) in the SIW and 3.00 ( 95 % CI 2.04 - 4.40 , P<0.0001 ) in the SIF group . The most frequently reported withdrawal symptoms were insomnia , anxiety and irritability . CONCLUSIONS Both interventions led to significant reductions in long-term benzodiazepine use in patients without severe comorbidity . A structured intervention with a written individualised stepped-dose reduction is less time-consuming and as effective in primary care as a more complex intervention involving follow-up visits Withdrawal from hypnotics can produce a variety of problems , especially sleep difficulties , some of which may arise from the multiple actions of most hypnotics , thus producing a range of rebound effects . This study examined whether switching patients to a hypnotic with a narrower range of action and of a different class would reduce these problems . One hundred and thirty-four patients participated ; they were r and omly allocated to one of three methods of switching from " previous hypnotic " to zopiclone ( a cyclopyrrolone ) . The methods were gap ( an interval between taking the two drugs ) ; abuttal ( taking zopiclone immediately on stopping previous drug ) ; and overlap ( gradually reducing previous drug after starting zopiclone ) . The main findings were that zopiclone was associated with better sleep and increased alertness ; the abuttal method was the best method of switching ; and no serious side effects from zopiclone were reported . It was concluded that zopiclone has a useful role in benzodiazepine withdrawal , and that immediate substitution is the best method The Johns Hopkins Precursors Study , a long-term prospect i ve study , was used to study the relation between self-reported sleep disturbances  and subsequent clinical depression and psychiatric distress .  A total of 1,053 men provided information on sleep habits during medical school at The Johns Hopkins University ( classes of 1948 - 1964 ) and have been followed since graduation . During a median follow-up period of 34 years ( range 1 - 45 ) , 101 men developed clinical depression  ( cumulative incidence at 40 years , 12.2 % ) , including 13 suicides . In Cox proportional hazards analysis adjusted for age at graduation , class year , parental history of clinical depression , coffee drinking , and measures of temperament , the relative risk of clinical depression was greater in those who reported insomnia in medical school ( relative risk ( RR ) 2.0 , 95 % confidence interval ( CI ) 1.2 - 3.3 ) compared with those who did not and greater in those with difficulty sleeping under stress in medical school ( RR 1.8 , 95 % CI 1.2 - 2.7 ) compared with those who did not report difficulty . There were weaker associations for those who reported poor quality of sleep ( RR 1.6 , 95 % CI 0.9 - 2.9 ) and sleep duration of 7 hours or less ( RR 1.5 , 95 % CI 0.9 - 2.3 ) with development of clinical depression . Similar associations were observed between reports of sleep disturbances in medical school and psychiatric distress assessed in 1988 by the General Health Question naire . These findings suggest that insomnia in young men is indicative of a greater risk for subsequent clinical depression and psychiatric distress that persists for at least 30 years BACKGROUND Benzodiazepine withdrawal programmes have never been experimentally compared with a nonintervention control condition . AIMS To evaluate the efficacy and feasibility of tapering off long-term benzodiazepine use in general practice , and to evaluate the value of additional group cognitive-behavioural therapy ( CBT ) . METHOD A 3-month r and omised , 3-month controlled trial was conducted in which 180 people attempting to discontinue long-term benzodiazepine use were assigned to tapering off plus group CBT , tapering off alone or usual care . RESULTS Tapering off led to a significantly higher proportion of successful discontinuations than usual care ( 62 % nu . 21 % ) . Adding group CBT did not increase the success rate ( 58 % v. 62 % ) . Neither successful discontinuation nor intervention type affected psychological functioning . Both tapering strategies showed good feasibilityin general practice . CONCLUSIONS Tapering off is a feasible and effective way of discontinuing long-term benzodiazepine use in general practice . The addition of group CBT is of limited value Objective A r and omised , controlled clinical trial was performed to study the long-term effect of gradual withdrawal from benzodiazepines on the daily functioning of residents of homes for the elderly . The planned sample size was not achieved due to recruitment and follow-up problems . Results The results in this small sample nevertheless suggest that gradual withdrawal from benzodiazepines is possible in residents of homes for the elderly , and that it can have a positive effect on their daily functioning . No major withdrawal symptoms were observed , although there was a decrease in sleep quality during withdrawal . Conclusion The findings are promising for further research , but research ers should anticipate the problems inherent in executing a trial with institutionalised elderly subjects This study aim ed to assess the efficacy of a minimal intervention focusing on hypnotic discontinuation and cognitive-behavioral treatment ( CBT ) for  insomnia . Fifty-three adult chronic users of hypnotics were r and omly assigned to an 8-week hypnotic taper program , used alone or combined with a self-help CBT .  Weekly hypnotic use decreased in both conditions , from a nearly nightly use at baseline to less than once a week at posttreatment . Nightly dosage ( in lorazepam equivalent ) decreased from 1.67 mg to 0.12 mg . Participants who received CBT improved their sleep efficiency by 8 % , whereas those who did not remained stable . Total wake time decreased by 52 min among CBT participants and increased by 13 min among those receiving the taper schedule alone . Total sleep time remained stable throughout withdrawal in both CBT and taper conditions . The present findings suggest that a systematic withdrawal schedule might be sufficient in helping chronic users stop their hypnotic medication . The addition of a self-help treatment focusing on insomnia , a readily available and cost-effective alternative to individual psychotherapy , produced greater sleep improvement BACKGROUND Older adults are the main recipients of repeat prescriptions for benzodiazepine ( BZD ) hypnotics . BZDs can impair cognitive function and may not aid sleep when taken continuously for years . This study therefore aim ed to determine if withdrawing from BZDs leads to changes in patients ' cognitive function , quality of life , mood and sleep . METHOD One hundred and ninety-two long-term users of BZD hypnotics , aged > or = 65 years , were identified in 25 general practice s. One hundred and four who wished to withdraw were r and omly allocated to one of two groups under double-blind , placebo controlled conditions : group A 's BZD dose was tapered from week 1 of the trial ; group B were given their usual dose for 12 weeks and then it was tapered . An additional group ( C ) of 35 patients who did not wish to withdraw from BZDs participated as ' continuers ' . All patients were assessed at 0 , 12 and 24 weeks and 50 % were reassessed at 52 weeks . RESULTS Sixty per cent of patients had taken BZDs continuously for > 10 years ; 27 % for > 20 years . Of all patients beginning the trial , 80 % had successfully withdrawn 6 months later . There was little difference between groups A and B , but these groups differed from continuers ( C ) in that the performance of the withdrawers on several cognitive/psychomotor tasks showed relative improvements at 24 or 52 weeks . Withdrawers and continuers did not differ in sleep or BZD withdrawal symptoms . CONCLUSIONS These results have clear implication s for clinical practice . Withdrawal from BZDs produces some subtle cognitive advantages for older people , yet little in the way of withdrawal symptoms or emergent sleep difficulties . These findings also suggest that , taken long-term , BZDs do not aid sleep CONTEXT Insomnia is a major health problem with significant psychological , health , and economic consequences . However , availability of one of the most effective insomnia treatments , cognitive behavioral therapy , is significantly limited . The Internet may be a key conduit for delivering this intervention . OBJECTIVE To evaluate the efficacy of a structured behavioral Internet intervention for adults with insomnia . DESIGN , SETTING , AND PARTICIPANTS Forty-five adults were r and omly assigned to an Internet intervention  ( n = 22 ) or wait-list control group  ( n = 23 ) . Forty-four eligible participants ( mean [ SD ] age , 44.86 [ 11.03 ] years ; 34 women ) who had a history of sleep difficulties longer than 10 years on average ( mean [ SD ] , 10.59 [ 8.89 ] years ) were included in the analyses . INTERVENTION The Internet intervention is based on well-established face-to-face cognitive behavioral therapy incorporating the primary components of sleep restriction , stimulus control , sleep hygiene , cognitive restructuring , and relapse prevention . MAIN OUTCOME MEASURES The Insomnia Severity Index and daily sleep diary data were used to determine changes in insomnia severity and the main sleep variables , including wake after sleep onset and sleep efficiency . RESULTS Intention-to-treat analyses showed that scores on the Insomnia Severity Index significantly improved from 15.73 ( 95 % confidence interval [ CI ] , 14.07 to 17.39 ) to 6.59 ( 95 % CI , 4.73 to 8.45 ) for the Internet group but did not change for the control group ( 16.27 [ 95 % CI , 14.61 to 17.94 ] to 15.50 [ 95 % CI , 13.64 to 17.36 ] ) ( F(1,42 ) = 29.64 ; P < .001 ) . The Internet group maintained their gains at the 6-month follow-up . Internet participants also achieved significant decreases in wake after sleep onset ( 55 % [ 95 % CI , 34 % to 76 % ] ) and increases in sleep efficiency ( 16 % [ 95 % CI , 9 % to 22 % ] ) compared with the nonsignificant control group changes of wake after sleep onset ( 8 % [ 95 % CI , -17 % to 33 % ) and sleep efficiency ( 3 % ; 95 % CI , -4 % to 9 % ) . CONCLUSIONS Participants who received the Internet intervention for insomnia significantly improved their sleep , whereas the control group did not have a significant change . The Internet appears to have considerable potential in delivering a structured behavioral program for insomnia . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00328250 BACKGROUND Benzodiazepines are the most frequently used drug for the treatment of insomnia . Prolonged use of benzodiazepine therapy is not recommended . However , many patients , particularly older patients , have difficulties discontinuing therapy . Melatonin , a hormone that is produced at night by the pineal gl and , promotes normal sleep in humans and augments sleep induction by benzodiazepine therapy . OBJECTIVE To assess whether the administration of melatonin could facilitate the discontinuation of benzodiazepine therapy in patients with insomnia . METHODS Thirty-four subjects receiving benzodiazepine therapy were enrolled in the 2-period study . In period 1 , patients received ( double-blinded ) melatonin ( 2 mg in a controlled-release formulation ) or a placebo nightly for 6 weeks . They were encouraged to reduce their benzodiazepine dosage 50 % during week 2 , 75 % during weeks 3 and 4 , and to discontinue benzodiazepine therapy completely during weeks 5 and 6 . In period 2 , melatonin was administered ( single-blinded ) for 6 weeks to all subjects and attempts to discontinue benzodiazepine therapy were resumed . Benzodiazepine consumption and subjective sleep- quality scores were reported daily by all patients . All subjects were then allowed to continue melatonin therapy and follow-up re assessment s were performed 6 months later . RESULTS By the end of period 1 , 14 of 18 subjects who had received melatonin therapy , but only 4 of 16 in the placebo group , discontinued benzodiazepine therapy ( P = .006 ) . Sleep- quality scores were significantly higher in the melatonin therapy group ( P = .04 ) . Six additional subjects in the placebo group discontinued benzodiazepine therapy when given melatonin in period 2 . The 6-month follow-up assessment s revealed that of the 24 patients who discontinued benzodiazepine and received melatonin therapy , 19 maintained good sleep quality . CONCLUSION Controlled-release melatonin may effectively facilitate discontinuation of benzodiazepine therapy while maintaining good sleep quality IMPORTANCE The American Board of Internal Medicine Foundation Choosing Wisely Campaign recommends against the use of benzodiazepine drugs for adults 65 years and older . The effect of direct patient education to catalyze collaborative care for reducing inappropriate prescriptions remains unknown . OBJECTIVE To compare the effect of a direct-to-consumer educational intervention against usual care on benzodiazepine therapy discontinuation in community-dwelling older adults . DESIGN , SETTING , AND PARTICIPANTS Cluster r and omized trial ( EMPOWER [ Eliminating Medications Through Patient Ownership of End Results ] study [ 2010 - 2012 , 6-month follow-up ] ) . Community pharmacies were r and omly allocated to the intervention or control arm in nonstratified , blocked groups of 4 . Participants ( 303 long-term users of benzodiazepine medication aged 65 - 95 years , recruited from 30 community pharmacies ) were screened and enrolled prior to r and omization : 15 pharmacies r and omized to the educational intervention included 148 participants and 15 pharmacies r and omized to the " wait list " control included 155 participants . Participants , physicians , pharmacists , and evaluators were blinded to outcome assessment . INTERVENTIONS The active arm received a deprescribing patient empowerment intervention describing the risks of benzodiazepine use and a stepwise tapering protocol . The control arm received usual care . MAIN OUTCOMES AND MEASURES Benzodiazepine therapy discontinuation at 6 months after r and omization , ascertained by pharmacy medication renewal profiles . RESULTS A total of 261 participants ( 86 % ) completed the 6-month follow-up . Of the recipients in the intervention group , 62 % initiated conversation about benzodiazepine therapy cessation with a physician and /or pharmacist . At 6 months , 27 % of the intervention group had discontinued benzodiazepine use compared with 5 % of the control group ( risk difference , 23 % [ 95 % CI , 14%-32 % ] ; intracluster correlation , 0.008 ; number needed to treat , 4 ) . Dose reduction occurred in an additional 11 % ( 95 % CI , 6%-16 % ) . In multivariate subanalyses , age greater than 80 years , sex , duration of use , indication for use , dose , previous attempt to taper , and concomitant polypharmacy ( 10 drugs or more per day ) did not have a significant interaction effect with benzodiazepine therapy discontinuation . CONCLUSIONS AND RELEVANCE Direct-to-consumer education effectively elicits shared decision making around the overuse of medications that increase the risk of harm in older adults . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01148186 We compared the effect of abrupt discontinuation of therapeutic doses of short half-life and long half-life benzodiazepines in 57 benzodiazepine-dependent patients ( daily use , greater than 1 year ) . Despite the use of a mean daily dose of 14.1 mg of diazepam equivalents , there were notable residual symptoms of anxiety and depression present at intake ( Hamilton Rating Scale for Anxiety score , 17.0 ; Hamilton Rating Scale for Depression score , 14.0 ) . Benzodiazepine intake was stabilized for 3 weeks before double-blind assignment to placebo ( n = 47 ) , or continued benzodiazepine use ( n = 10 ) . Clinical assessment s were performed daily , including  benzodiazepine plasma levels . Depending on the outcome criteria used , anywhere from 58 % to 100 % of patients were judged to have experienced a withdrawal reaction , with a peak severity at 2 days for short half-life and 4 to 7 days for long half-life benzodiazepines .  Relapse onto benzodiazepines  occurred in 27 % of patients who were receiving long half-life benzodiazepines and in 57 % of patients who were receiving short half-life benzodiazepines . Baseline predictors of relapse were nonpanic diagnoses , a higher  benzodiazepine dose , and a higher Eysenck neuroticism score . A short half-life and higher daily doses were associated with greater withdrawal severity , as were personality traits , such as dependency and neuroticism , less education and higher baseline levels of anxious and depressive symptoms . Patients who were able to remain free of benzodiazepines for at least 5 weeks obtained lower levels of anxiety than before benzodiazepine discontinuation . These results provide a detailed picture of the symptoms , time course , and multidimensional determinants of the benzodiazepine withdrawal syndrome BACKGROUND Long-term use of hypnotics is not recommended because of risks of dependency and adverse effects on health . The usual clinical management of benzodiazepine dependency is gradual tapering , but when used alone this method is not highly effective in achieving long-term discontinuation . We compared the efficacy of tapering plus cognitive-behavioural therapy for insomnia with tapering alone in reducing the use of hypnotics by older adults with insomnia . METHODS People with chronic insomnia who had been taking a benzodiazepine every night for more than 3 months were recruited through media advertisements or were referred by their family doctors . They were r and omly assigned to undergo either cognitive-behavioural therapy plus gradual tapering of the drug ( combined treatment ) or gradual tapering only . The cognitive-behavioural therapy was provided by a psychologist in 8 weekly small-group sessions . The tapering was supervised by a physician , who met weekly with each participant over an 8-week period . The main outcome measure was benzodiazepine discontinuation , confirmed by blood screening performed at each of 3 measurement points ( immediately after completion of treatment and at 3- and 12-month follow-ups ) . RESULTS Of the 344 potential participants , 65 ( mean age 67.4 years ) met the inclusion criteria and entered the study . The 2 study groups ( 35 subjects in the combined treatment group and 30 in the tapering group ) were similar in terms of demographic characteristics , duration of insomnia and hypnotic dosage . Immediately after completion of treatment , a greater proportion of patients in the combined treatment group had withdrawn from benzodiazepine use completely ( 77 % [ 26/34 ] v. 38 % [ 11/29 ] ; odds ratio [ OR ] 5.3 , 95 % confidence interval [ CI ] 1.8 - 16.2 ; OR after adjustment for initial benzodiazepine daily dose 7.9 , 95 % CI 2.4 - 30.9 ) . At the 12-month follow-up , the favourable outcome persisted ( 70 % [ 23/33 ] v. 24 % [ 7/29 ] ; OR 7.2 , 95 % CI 2.4 - 23.7 ; adjusted OR 7.6 , 95 % CI 2.5 - 26.6 ) ; similar results were obtained at 3 months . INTERPRETATION A combination of cognitive-behavioural therapy and benzodiazepine tapering was superior to tapering alone in the management of patients with insomnia and chronic benzodiazepine use . The beneficial effects were sustained for up to 1 year . Applying this multidisciplinary approach in the community could help reduce benzodiazepine use by older people We compared the effect on withdrawal severity and acute outcome of a 25 % per week taper of short half-life vs long half-life benzodiazepines in 63 benzodiazepine-dependent patients . Patients unable to tolerate taper were permitted to slow the taper rate . Ninety percent of patients experienced a withdrawal reaction , but it was rarely more than mild to moderate . Nonetheless , 32 % of long half-life and 42 % of short half-life benzodiazepine-treated patients were unable to achieve a drug-free state . The most difficulty was experienced in the last half of taper . Baseline personality , high Eysenck neuroticism , female sex , and mild-to-moderate alcohol use were found to be more significant predictors of withdrawal severity than the daily benzodiazepine dose or benzodiazepine half-life . These findings suggest that personality factors contribute significantly to the patient 's difficulties with gradual benzodiazepine discontinuation of therapeutic doses of benzodiazepines Objective : To identify predictors of resumed benzodiazepine use after participation in a benzodiazepine discontinuation trial . Method : We performed multiple Cox regression analyses to predict the long-term outcome of a 3-condition , r and omized , controlled benzodiazepine discontinuation trial in general practice . Results : Of 180 patients , we completed follow-up for 170 ( 94 % ) . Of these , 50 ( 29 % ) achieved long-term success , defined as no use of benzodiazepines during follow-up . Independent predictors of success were as follows : offering a taper-off program with group therapy ( hazard ratio [ HR ] 2.4 ; 95 % confidence interval [ CI ] , 1.5 to 3.9 ) or without group therapy ( HR 2.9 ; 95%CI , 1.8 to 4.8 ) ; a lower daily benzodiazepine dosage at the start of tapering off ( HR 1.5 ; 95%CI , 1.2 to 1.9 ) ; a substantial dosage reduction by patients themselves just before the start of tapering off ( HR 2.1 ; 95%CI , 1.4 to 3.3 ) ; less severe benzodiazepine dependence , as measured by the Benzodiazepine Dependence Self-Report Question naire Lack of Compliance subscale ( HR 2.4 ; 95%CI , 1.1 to 5.2 ) ; and no use of alcohol ( HR 1.7 ; 95%CI , 1.2 to 2.5 ) . Patients who used over 10 mg of diazepam equivalent , who had a score of 3 or more on the Lack of Compliance subscale , or who drank more than 2 units of alcohol daily failed to achieve long-term abstinence . Conclusions : Benzodiazepine dependence severity affects long-term taper outcome independent of treatment modality , benzodiazepine dosage , psychopathology , and personality characteristics . An identifiable subgroup needs referral to specialized care OBJECTIVE This study evaluated the effectiveness of a supervised benzodiazepine taper , singly and combined with cognitive behavior therapy , for benzodiazepine discontinuation in older adults with chronic insomnia . METHOD Seventy-six older adult out patients ( 38 women , 38 men ; mean age of 62.5 years ) with chronic insomnia and prolonged use ( mean duration of 19.3 years ) of benzodiazepine medication for sleep were r and omly assigned for a 10-week intervention consisting of a supervised benzodiazepine withdrawal program ( N=25 ) , cognitive behavior therapy for insomnia ( N=24 ) , or supervised withdrawal plus cognitive behavior therapy ( N=27 ) . Follow-up assessment s were conducted at 3 and 12 months . The main outcome measures were  benzodiazepine use , sleep parameters , and anxiety and depressive symptoms . RESULTS All three interventions produced significant reductions in both the quantity ( 90 % reduction ) and frequency ( 80 % reduction ) of benzodiazepine use , and 63 % of the patients were drug-free within an average of 7 weeks . More patients who received medication taper plus cognitive behavior therapy ( 85 % ) were benzodiazepine-free after the initial intervention , compared to those who received medication taper alone ( 48 % ) and cognitive behavior therapy alone ( 54 % ) . The patients in the two groups that received cognitive behavior therapy perceived greater subjective sleep improvements than those who received medication taper alone . Polysomnographic data showed an increase in the amount of time spent in stages 3 and 4 sleep and REM sleep and a decrease in total sleep time across all three conditions from baseline to posttreatment . Initial benzodiazepine reductions were well maintained up to the 12-month follow-up , and sleep improvements became more noticeable over this period . No significant withdrawal symptoms or adverse events were associated with benzodiazepine tapering . CONCLUSIONS A structured , time-limited intervention is effective in assisting chronic users of benzodiazepine medication to discontinue or reduce their use of medication . The addition of cognitive behavior therapy alleviates insomnia , but sleep improvements may become noticeable only after several months of benzodiazepine abstinence We conducted a double-blind , placebo-controlled trail in which 40 patients who had undergone long-term therapy with benzodiazepines  were switched to placebo or to diazepam in a dose approximately equivalent to their usual dose of the benzodiazepine ; the dose of diazepam was then tapered during an eight-week period . Patients were assessed clinical ly and psychologically and had weekly sessions of behavioral therapy . The subjects who received placebo had more symptoms , assessed their symptoms as more severe , and stopped taking the study drug at a higher rate than those receiving the tapering doses of diazepam . The subjects in the placebo group also had symptoms shortly after being switched to placebo , whereas those in the diazepam group had symptoms much later . Some withdrawal symptoms were distinct from those of anxiety ( e.g. , tinnitus , involuntary movement , and perceptual changes ) . Withdrawal symptoms occurred earlier in patients who had received short-acting benzodiazepines than in those who had received long-acting benzodiazepines . Symptoms gradually disappeared over a four-week period in both the placebo and the diazepam groups . Serial determination of plasma benzodiazepine concentrations was a useful way to assess compliance , treatment outcome , and relapse during withdrawal . We conclude that a clinical ly important , mild , but distinct withdrawal syndrome occurs after discontinuation of long-term therapeutic use of benzodiazepines DESCRIPTION The American College of Physicians ( ACP ) developed this guideline to present the evidence and provide clinical recommendations on the management of chronic insomnia disorder in adults . METHODS This guideline is based on a systematic review of r and omized , controlled trials published in English from 2004 through September 2015 . Evaluated outcomes included global outcomes assessed by question naires , patient-reported sleep outcomes , and harms . The target audience for this guideline includes all clinicians , and the target patient population includes adults with chronic insomnia disorder . This guideline grade s the evidence and recommendations by using the ACP grading system , which is based on the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) approach . RECOMMENDATION 1 ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia ( CBT-I ) as the initial treatment for chronic insomnia disorder . ( Grade : strong recommendation , moderate- quality evidence ) . RECOMMENDATION 2 ACP recommends that clinicians use a shared decision-making approach , including a discussion of the benefits , harms , and costs of short-term use of medications , to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia ( CBT-I ) alone was unsuccessful . ( Grade : weak recommendation , low- quality evidence )
target: This guideline does not apply to those with other sleep disorders or untreated anxiety , depression , or other physical or mental health conditions that might be causing or aggravating insomnia .
  Benzodiazepine receptor agonists are associated with harms , and therapeutic effects might be short term .
  Tapering BZRAs improves cessation rates compared with usual care without serious harms .
  Patients might be more amenable to deprescribing conversations if they underst and the rationale ( potential for harm ) , are involved in developing the tapering plan , and are offered behavioural advice .
background: OBJECTIVE To develop an evidence -based guideline to help clinicians make decisions about when and how to safely taper and stop benzodiazepine receptor agonists ( BZRAs ) ; to focus on the highest level of evidence available and seek input from primary care professionals in the guideline development , review , and endorsement processes .