Belgian Community Pharmacists Compound Tapering Schemes For Long Term Benzodiazepine Users

• By: SAEVELS, Jan (Association of Pharmacists Belgium, Belgium)
• Co-author(s): Dr Jan Saevels (Association of Pharmacists Belgium, Brussels, Belgium)
  Dr Michael Storme (Association of Pharmacists Belgium, Brussels, Belgium)
  Pharm Koen Straetmans (Association of Pharmacists Belgium, Brussels, Belgium)
  Dr Marc Van de Casteele (National Institute for Health and Disability Insurance, Brussels, Belgium)
  Dr Jean-Michel Michot (National Institute for Health and Disability Insurance, Brussels, Belgium)
  
• Abstract:

  INTRODUCTION
  The use of sleep medication (benzodiazepines and Z-drugs) in Belgium remains high. About 1.1 million doses per day were dispensed in Belgian pharmacies in 2021, that’s on average one daily dose for every 10 citizens. Long-term use is associated with multiple side effects, such as increased sedation, fall risk, and risk of dependency and abuse. Ideally, treatment should be avoided altogether or discontinued shortly after initiation. However, for patients who have been utilizing benzodiazepines for over three months, a deprescribing strategy should be adopted. Abrupt cessation, especially in cases of high-doses, may lead to severe withdrawal symptoms. It is recommended to gradually taper the dosage over several months to mitigate these risks.
  Pharmacy compounding allows to prepare and dispense individualized dosages to patients. Prescribing dose reduction schemes for patients motivated to taper off has always been possible; but this came at a high cost for patients because benzodiazepines are not reimbursed in Belgium.
  METHOD
  The National Institute for Health and Disability Insurance (NIHDI) is responsible for Belgium’s national health insurance. As from February 1st 2023, the NIHDI proposed a reimbursement scheme when tapering off benzodiazepines prescribed by to treat insomnia. The patient-GP-pharmacist triangle is at the core of the scheme:
  -Pharmacists raise awareness when dispensing prescribed benzodiazepines and motivate patients to enter a withdrawal program.
  -General Practitioners (GP’s) co-motivate patients and prescribe the program.
  -Patients engage in a tapering path and are intensively followed and motivated by the GP and the pharmacist.
  Once the program is initiated, pharmacists prepare and dispense individually dosed capsules and hold 2 counseling sessions, one at initiation and one as a follow-up interview.
  RESULTS
  When the new service was launched nationally, extensive communication and information campaigns towards doctors, pharmacists and patients were organized. In the first 12 months of the pilot project, more than 5000 patients have initiated a tapering program, clearly indicating the societal need of the service. More than half of these long-term users opted for a 10-step reduction program, where pharmacists compounded 10 different dosages (at 100%, 90%, 80%, etc.). Each dosage step was held for 10, 20 or 30 days. Total duration of the tapering schemes varied between 50 and 360 days. Lormetazepam, zolpidem, alprazolam and lorazepam were used in most of the programs. In terms of efficacy of the tapering programs, an initial/preliminary initial analysis realized with a relatively small sample of patients, show that between 40 and 65% of patients that have completed a program, remain off benzodiazepines the following months. Detailed results will be available and presented in September 2024.
  CONCLUSION
  Pharmacists collaborating with physicians to provide deprescription and tapering options for individuals with long-term benzodiazepine use, represent a significant advancement in enhancing the scope of responsibilities within the community pharmacy setting. Key determinants of success in these initiatives include the patient's intrinsic motivation, the establishment of a therapeutic contract involving all three parties (patient, prescriber, and pharmacist), the absence of financial repercussions for patients, and effective communication between the physician and the pharmacist.