*For correspondence: [email protected]

uke.de

Competing interests: The

authors declare that no

competing interests exist.

Received: 03 May 2018

Accepted: 20 August 2018

Published: 20 February 2019

This article is Open Access:

CC BY license (https://

creativecommons.org/licenses/

by/4.0/)

Author Keywords:

benzodiazepines , elderly,

healthcare professional,

qualitative research, Z drugs,

general practice

Copyright s 2019, The Authors;

DOI:10.3399/

bjgpopen18X101626

Long-term use of benzodiazepines and Z drugs: a qualitative study of patients’ and healthcare professionals’ perceptions and possible levers for change Aliaksandra Mokhar, MSc1*, Silke Kuhn, PhD2, Janine Topp, MSc3, Jörg Dirmaier, PhD, Dipl Psych4, Martin Härter, MD, PhD, Dipl Psych5, Uwe Verthein, PhD6

1Scientific Associate, Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 2Researcher, Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 3Scientific Associate, Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 4Research Group Leader, Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 5Institute Director, Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 6Head of Center for Interdisciplinary Addiction Research, Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Abstract Background: Although long-term use of benzodiazepines (BZDs) and Z drugs is associated with

various side effects, they remain popular among the older population. Possible reasons for this

phenomenon could be ineffective ways of transmitting information on the health risks associated

with long-term use, and communication gaps between patients and healthcare professionals.

Aim: The aim was to investigate the views of patients, physicians, nurses, and pharmacists

regarding long-term BZD and Z drug use.

Design & setting: The qualitative study design used focus group interviews with physicians,

pharmacists, and nurses in Hamburg. Patient interviews were conducted in Lippstadt, Germany.

Method: The interviews were audiotaped with each participant’s permission, transcribed, and

thematically analysed using a software program for qualitative research (MAXQDA).

Results: The data from the four focus groups consisting of 28 participants were analysed. Patients

indicated lack of knowledge about risks and side effects, difficult access to alternatives, and fears

of ceasing drug use without professional support. Although the physicians were reported to be

cautious about prescribing BZDs and Z drugs, the psychosocial problems of older patients are

often considered to be complex and treatment knowledge, experience, and resources are

frequently unsatisfactory. Nurses described that when BZDs were prescribed, they did not feel it

was their responsibility to evaluate their effects. Pharmacists were reported to be strongly

ambivalent in informing patients about the risks, which may contradict the prescription advice

provided by the physician.

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Conclusion: Patients, physicians, nurses, and pharmacists reported differences in the perception of

long-term BZD and Z drug use. Nevertheless, all of the participants described lack of information

and expressed the need for greater communication exchange.

How this fits in Several reasons have been identified for the associations between the long-term use of BZDs and Z

drugs in the older population, and the importance of the role of communication and collaboration

between patients and healthcare professionals. The results of the focus group interviews suggest

that more informational exchange is needed between patients and their healthcare professionals, as

well as more collaboration between different healthcare professionals.

Introduction The inappropriate prescribing of psychotropic drugs and polypharmacy are present in institutional-

ised and non-institutionalised older adults, which can cause serious side effects and might reduce

patients’ quality of life.1 Some of the most common potentially inappropriate prescribed medica-

tions in older people are BZDs.1 BZDs are effective drugs for treating anxiety symptoms, as well as

inducing and maintaining sleep, and muscle relaxation.2,3 The incidence of BZD prescription rates is

high worldwide, and treatment duration is often inappropriately longer than the recommended max-

imum 8-week period.3,4 Despite the fact that these drugs are effective in the short term, long-term

BZD therapy is associated with many side effects, the development of tolerance and, finally, addic-

tion.5 Long-term BZD and Z drug use occurs mainly in the older population.6 This patient group are

at particular risk of side effects because of their age-related physiological changes.7 Serious side

effects include cognitive disturbance, an increased risk of falls and therefore hip fractures,8–11 hospi-

talisation, and increased morbidity and mortality.12 Continual medication use after the primary indi-

cation usually results in physical and psychological dependency,13 manifesting in withdrawal

symptoms.

Recent research has identified several reasons for this occurrence; on the patient side, reasons for

prolonged use include chronic personal stress and sleep problems, fear of recurring symptoms, lack

of knowledge about risks and side effects, difficult access to alternatives, and poor motivation to

cease drug use.13–15 Research has shown that although physicians were cautious regarding initiating

BZD treatment, the psychosocial problems of patients are often considered to be complex, and

Table 1. Description of sample size

Focus group

Sample size, n

Male, n

Female, n Participant characteristics

1 Patients

8 3 5 P1: late 40s, male patient, 22 years BZD-dependent P2: 24 year old male patient, 3 years of BZD use P3: 75 year old female patient, 29 years of BZD use, 2.5 years without BZD P4: 85 year old female patient, 40 years of BZD use, 3 years without BZD P5: 58 year old male patient, 20 years of BZD and opiate use with massive dose increase, 6.5 years without BZD and opiates P6: mid-50s female patient, 30 years of use of opiates and occasional BZD, detoxified for the last 3 days P7: late 30s, female pain patient, BZD (if needed) P8: late 40s, female pain patient, BZD (if needed)

2 Physicians

7 2 5 Working area: 3 � own practice 1 � practice and hospital 2 � psychiatric hospital, institute outpatient clinic 1 � psychiatrist (parental leave)

3 Pharmacists

6 0 6 All of them reported years of experience in pharmacies throughout Hamburg

4 Nurses

7 0 7 Working area: 2 � inpatient care 5 � outpatient care, including one nursing service and one task line

Mokhar A et al. BJGP Open 2019; DOI: 10.3399/bjgpopen18X101626 2 of 10

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knowledge is often lacking regarding managing the psychological changes associated with ageing,

altered pharmacokinetics and pharmacodynamics, or using alternative strategies.15–18 Assessing the

issues and investigating the causes of the patient’s symptoms are often neglected because of a lack

of resources for the management of long-term medication use by older adults.19–21 Pharmacists play

an important role within the interprofessional healthcare team during the medical treatment of older

patients. They evaluate the appropriateness, effectiveness, safety, and compliance of medications

for a given patient.22,23 Other roles of the pharmacist include informing patients about the risks of

using the prescribed medications, which may contradict the prescription information provided by

the physician.21,22 Last but not least, nurses are involved in the healthcare management of older

patients, especially in nursing homes. Evidently, older people in nursing homes often have complex

illness profiles and require care and support concerning various symptoms. Nurses fulfil their duties,

but they often lack responsibility regarding the medication process in relation to BZD and Z drugs.24

An increased emphasis on patient-centred care could address the described reasons for long-

term use of BZD. International guidelines and reviews on improved medication use in general

address patient-centred care dimensions and stress the importance of clinician–patient communica-

tion and/or cooperation, shared decisionmaking, and information provision.25,26 The explanation of

the reasons for the long-term use of BZDs shows that there is missing information and a need for

cooperation between healthcare professionals and patients. The aim of this study is to investigate

the perspectives of physicians, nurses, pharmacists, and patients in focus groups to assess their per-

ceptions of the reasons for long-term BZD and Z drug use and find possible solutions to the identi-

fied difficulties.

The following research questions were addressed: first, different professional groups (physicians,

nurses, and pharmacists) were asked to describe long-term drug use and what they think about man-

aging this situation from the patient’s perspective. Second, all of the participants were asked about

the conditions that motivated them to seek a long-term prescription, and why it is problematical to

discontinue use. Third, the participants were asked for ideas, information they need, and ways to

communicate and solve the problem of long-term BZD and Z drug use.

Method

Study design The qualitative study design is indicated to better understand the individual experience of the indi-

vidual role of the participants, and to discuss possible solution strategies for this topic.27 The qualita-

tive study design was used based on the requirements of the standard guidelines for qualitative

research.28

Participant recruitment and setting A qualitative study in focus group design was conducted with patients, physicians, pharmacists, and

nurses. The participants were eligible if they had been using BZDs or Z drugs for >4 weeks (patients)

or if they were involved in the medical care process as doctor, pharmacist, or nurse; if they were Ger-

man-speaking; and if they were physically and mentally able to take part in the focus group.

The study was performed as part of the project ’Benzodiazepines and Z drugs: concepts for risk

reduction among older patients’, sponsored by the Federal Ministry of Health. Physicians and phar-

macists were contacted directly by the medical and pharmacist association in Hamburg. Nurses were

recruited from an outpatient nursing service in Hamburg. Patients were recruited at the LWL-Klinik in

Lippstadt, Germany, because of the existing cooperation in the context of the research project, in

which patients with long-term BZD use are treated. All of the participants were volunteers and

received financial compensation.

Four focus groups were conducted from June–August 2015. All of the applications the research

team received could be included in the focus groups. There were no withdrawals. Each group com-

prised 6–8 participants. Focus groups with physicians and pharmacists were conducted at the Uni-

versity Medical Center Hamburg-Eppendorf. The focus group with nurses was held at the

Martha Foundation, and the group with patients was conducted at the project associated partner

LWL-Klinik. Each focus group lasted 120 minutes. Focus groups were moderated by three members

of the research team.

Mokhar A et al. BJGP Open 2019; DOI: 10.3399/bjgpopen18X101626 3 of 10

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The participants in the focus groups were informed about the research project and signed a letter

of agreement.

Data acquisition and analysis The interview guide for the focus groups was developed based on the research questions.

. Assess views on using BZDs and Z drugs for a long time: . What could you say about the long-term use of BZDs and Z drugs (for example, reasons,

symptoms, and knowledge about side effects)? . Do you think you know enough about this medication?

. Explore barriers and changing points to reduce the long-term use of BZDs and Z drugs: . Have you ever tried to reduce the use (as patients) or initiate the reduction (as healthcare

physicians) of BZDs and Z drugs? . Did it work? If not, how would you explain that? . What do you think about the possible changing points in reducing the long-term use of

BZDs and Z drugs?

The complete interviews were audio-recorded with the participants’ consent. The data were ano-

nymised and thematically transcribed by student assistants at the University Medical Center Ham-

burg-Eppendorf. The content analysis was performed using MAXQDA software (version 10), which is

a qualitative research software program. The MAXQDA software prepares the data for further analy-

sis steps, in which it evaluates the transcripts to develop thematically categories. Two team members

independently coded the transcripts from each focus groups. Most of the categories showed high

consistency. Next, the final codes were cross-checked by a third team member. Any lack of clarity

was discussed with the research team. All the information from the transcripts was used for the anal-

ysis. When more than one quotation was available for a category, only one example was selected

and cited.

Results There were four focus groups consisting of physicians (n = 7), pharmacists (n = 6), nurses (n = 7), and

patients (n = 8), as shown in Table 1 .

Views on long-term use of BZDs and Z drugs Prescribers apply caution in prescribing BZDs and Z drugs. Participants have reported that the long-

term use of BZDs and Z drugs often starts in hospitals and its prescription is continued by GPs. The

reasons for the use of these medications were sleep problems and anxiety-related symptoms pro-

ducing especially an acute crisis:

’If a patient is in an acute crisis, I often have two options: either giving him BZD, or sending him

to the clinic.’ (Physician 3)

’In the clinic, there is an even stronger tendency towards BZD, even less in line with the

guideline.’ (Physician 4)

’BZD (e.g. lorazepam) are often prescribed for anxiety, not to help patients fall asleep. I’d say

patients only take it when they need it.’ (Pharmacist 6)

’Long-term use occurs, especially in cases of mourning and when social support is lacking.

Patients receive the medication during their hospital stay, notice that they slept fine and see the

physician to continue the prescription.’ (Pharmacist 2)

’Sleep disorders, anxiety, and depression are the most common causes of long-term BZD use.’

(Nurse 4)

The continued long-term prescription of BZDs and Z drugs often occurs because of problematical

factors in the clinical routine, such as overcrowded waiting rooms or lack of time to speak with

patients about their individual needs:

’I have 5 minutes per patient. When one patient sits there and cries, it makes me nervous and

aggressive, as I know that there are 20 other patients waiting for their doctor’s appointment

outside. These are not good conditions for making a differentiated decision.’ (Physician 4)

Mokhar A et al. BJGP Open 2019; DOI: 10.3399/bjgpopen18X101626 4 of 10

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’If we refer the patient back to the physician, this is often perceived as an encroachment. We’re

not supposed to interfere in things that don’t concern us.’ (Pharmacist 1)

’We know it from our patients that they have seen the physician, waited 2 hours and were inside

for 5 minutes.’ (Nurse 3)

Another reason for long-term use is that many patients are already familiar with these medica-

tions, and they directly demand prescriptions for BZDs or Z drugs without knowing about the nega-

tive aspects of the medications. In particular, pharmacists observe that patients have a careless

attitude. Nurses emphasise that most patients do not demand these medications:

’In my situation when I could not sleep anymore, I could not have taken up information about

side effects anyway. I wanted a pill so I could sleep.’ (Patient 3)

’I also realise that many patients know BZD, perhaps not the exact name but they have some

knowledge, saying: “My husband has the same pill and I occasionally take some of it”.’

(Physician 2)

’Maybe they do not even know what they are taking. They get it prescribed and they take it. I

think it has less to do with memory than with the fact that they have no idea about the

medication.’ (Nurse 3)

All of the professional groups agree that patients lack understanding about the likelihood of

addiction regarding long-term use of BZDs and Z drugs. The drugs are fully integrated into the

patients’ daily routine, awareness of potential problems is missing, and side effects such as dizziness,

unsteadiness while walking, or depression are not associated with the medications. The patients

themselves claimed that they did not feel addicted, although they were aware that consistent intake

was present, and the physicians claimed to clearly emphasise the side effects:

’I remember being fixed on a single pill of lexotanil for years: no more, no less. In the evening

exactly 6 mg bromazepam [. . .] and I did not think about dependency until I stopped taking the

drug and noticed these withdrawal symptoms. So, I was literally trapped.’ (Patient 5)

’Again and again, I experience that patients do not have a feeling for what they are taking.’

(Physician 6)

’Patients do not have the impetus to say: "I want to get away from it". The medication is

integrated in their everyday lives. Patients have no problem awareness, and nobody addresses

the problem, especially when they live alone.’ (Pharmacist 3)

Nevertheless, the pharmacist tends to take a critical view of the physician informing the patient

about all types of side effects (including the dangers of addiction):

’As pharmacists, we have an awe of medicines and we do not experience this awe in the

everyday life of the patients and the physicians . . . For them, it is self-evident. When I am

hungry, I eat a piece of bread. When I have a headache, I take a pill. When I cannot sleep, I take

a pill. That’s it.’ (Pharmacist 1)

Nurses commented that many patients could not say why they had received their medication after

their appointment with the physician, and said that patients had not been informed because of the

brief consultation time:

’ [. . .] especially the older ladies and gentlemen, they are happy if they had seen the physician

and left with a prescription of a new medication. And once they are asked what the physician

explained to them, they say it was too fast and they had no time to ask questions.’ (Nurse 4)

Barriers and changing points to reduce the long-term use of BZDs and Z drugs Nearly all of the interviewed patients had the experience of receiving BZDs over a long to very long

period (ranging from a number of weeks to many years) without any difficulties and then, suddenly

and inexplicably, they were denied the prescription or they were urged to discontinue the medica-

tion. There were no preparatory discussions or jointly made decisions, according to them:

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’I have taken the medication for years and subsequently increased the dosage [because of

husband’s care and death]. One day, the physician, who had been prescribing the medications,

said, “I think the medication needs to be withdrawn”.’ (Patient 4)

While physicians and some nurses tend not to initiate medication discontinuation among the old-

est patients nor discuss the dangers of addiction, pharmacists believe discontinuing the drugs is

beneficial at any stage of life. Pharmacists also report that GPs often abruptly stop prescribing, with-

out suggesting a more gradual discontinuation process. Based on this experience, they recommend

and motivate their customers to contact a psychiatrist, who can initiate and support a qualified step-

wise reduction:

’If patients are aware of the problem, we encourage them to find another physician [psychiatrist]

who can competently advise discontinuation of drug use.’ (Pharmacist 2)

’I have a patient [female, aged 85 years], I have been prescribing drugs to for years and I will

continue prescribing BZD to her for the rest of her life. I do not see the point in

discontinuing.’(Physician 6)

’Discontinuation rarely happens and is very difficult particularly in older people. Patients start

asking: “Where is half my pill for the night?” or they tell me: “I cannot sleep without it.” There is

no possibility of discontinuing the medication because they insist on this pill, whether they really

need it or not.’ (Nurse 1)

Alternative treatments were not discussed, and in one case, they were denied. Pharmacists

believe that if prescribers with further experience and knowledge of, for instance, homeopathy or

palliative medicine manage their patients more thoroughly, they would be more likely to oversee

attempts at discontinuation of drug use:

’Being a physician includes addressing alternative treatment options. I think that this is a

problem for many physicians.’ (Pharmacist 2)

Discussion

Summary In the four focus groups with patients, physicians, pharmacists, and nurses, the primary reasons for

prescribing BZDs and Z drugs were identified. These reasons were often sleep problems, anxiety

symptoms, and individual crises, and the initial drug use is often in an acute hospital setting. The rea-

sons for transitioning to long-term drug use are varied. Patients are often not informed of the poten-

tial risks and side effects when they initially receive the drug. Often patients do not know who to

contact when the drug use exceeds the expiration date, nor do they know with whom to discuss

medical issues when symptoms occur. The majority of the patients do not feel that using this medica-

tion is a problem. Physicians see the responsibility for the use of BZDs as in the patient’s hands, and

vice versa. Furthermore, there is often a lack of resources, time, or specific knowledge regarding

how to address sleep- or anxiety-related symptoms in older patients. Noticing reckless drug pre-

scriptions and intake behaviours, pharmacists often inform patients and motivate them to discon-

tinue the medication. Nonetheless, pharmacists are hesitant to contact the physician. Nurses

noticing the problematic BZD and Z drug use often feel unsure, and lack competency and knowl-

edge to inform patients or initiate discontinuation of the medication.

To the authors’ knowledge, this qualitative study is the first of its kind that looks at the percep-

tions of patients, as well as different healthcare professionals, on long-term use or prescription of

BZDs and Z drugs. As has been found in previous studies exploring BZD use from single perspec-

tives, the authors of the present study conclude that long-term use is an ongoing problem particu-

larly in older patients.1,6 Although physicians seem to be more cautious in prescribing medications,

further strategies need to be developed to tackle inappropriate long-term use. Therefore, the fol-

lowing issues need to be addressed: physicians do not know of appropriate treatment alternatives;

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patients have insufficient knowledge on healt