What information should a pharmacist include when counseling a patient on benzodiazepines?

From the Guidelines

When counseling a patient on benzodiazepines, a pharmacist should include information about the risk of withdrawal and seizures if the medication is stopped abruptly, as well as the potential for memory and concentration problems with long-term use, and advise against mixing the medication with opioids or alcohol due to the increased risk of potentially fatal overdose, as recommended by the CDC guideline for prescribing opioids for chronic pain 1.

Key Points to Discuss with the Patient

• The patient should not stop taking benzodiazepines abruptly due to the risk of withdrawal and seizures, and should instead work with their healthcare provider on a gradual tapering schedule if discontinuation is desired, with a commonly used tapering schedule being a reduction of the benzodiazepine dose by 25% every 1–2 weeks 1.
• Long-term use of benzodiazepines can cause memory and concentration problems, and patients should be aware of these potential side effects.
• Benzodiazepines should not be mixed with opioids or alcohol, as this can increase the risk of potentially fatal overdose, with concurrent use likely to put patients at greater risk for overdose death, as found in epidemiologic series and case-cohort studies 1.
• Patients should be instructed to take the medication exactly as prescribed, and to avoid driving or operating machinery until they know how the medication affects them.
• The pharmacist should emphasize the importance of keeping follow-up appointments with their healthcare provider to monitor treatment effectiveness and safety, and to discuss any concerns or side effects.

Additional Considerations

• Elderly patients may be more sensitive to the side effects of benzodiazepines, and should be closely monitored by their healthcare provider.
• Pregnant or breastfeeding women should use benzodiazepines with caution, and only under the guidance of their healthcare provider.
• Patients with a history of substance abuse should be closely monitored by their healthcare provider, as they may be at increased risk for dependence and withdrawal.

From the FDA Drug Label

Patients should be instructed to take clonazepam only as prescribed Physicians are advised to discuss the following issues with patients for whom they prescribe clonazepam: Risks from Concomitant Use with Opioids: Inform patients and caregivers that potentially fatal additive effects may occur if clonazepam is used with opioids and not to use such drugs concomitantly unless supervised by a health care provider Abuse, Misuse, and Addiction: Inform patients that the use of clonazepam, even at recommended dosages, exposes users to risks of abuse, misuse, and addiction, which can lead to overdose and death, especially when used in combination with other medications (e.g., opioid analgesics), alcohol, and/or illicit substances Withdrawal Reactions: Inform patients that the continued use of clonazepam may lead to clinically significant physical dependence and that abrupt discontinuation or rapid dosage reduction of clonazepam may precipitate acute withdrawal reactions, which can be life-threatening

When counseling a patient on benzodiazepines, a pharmacist should include the following points in their conversation:

• Risks of concomitant use with opioids: The patient should be informed of the potentially fatal additive effects of using benzodiazepines with opioids.
• Abuse, misuse, and addiction: The patient should be informed of the risks of abuse, misuse, and addiction associated with benzodiazepines, even at recommended dosages.
• Withdrawal reactions: The patient should be informed of the risk of clinically significant physical dependence and the potential for acute withdrawal reactions if the medication is discontinued abruptly or the dosage is reduced rapidly. These points are crucial to ensure the patient is aware of the potential risks and takes the medication safely 2.

From the Research

Information to be Included in Pharmacist Counseling on Benzodiazepines

When counseling a patient on benzodiazepines, the pharmacist should include the following points:

• Risk of Withdrawal and Seizures: Inform the patient not to stop the medication abruptly due to the risk of withdrawal and seizures 3, 4.
• Potential for Dependence and Tolerance: Long-term use of benzodiazepines can lead to dependence and tolerance, and the patient should be aware of this risk 3, 5.
• Cognitive Impairment: Long-term treatment with benzodiazepines can cause impairment in several cognitive domains, such as visuospatial ability, speed of processing, and verbal learning 6.
• Interactions with Other Medications: Benzodiazepines should not be mixed with opioids or alcohol, and the patient should be aware of potential interactions with other medications 3, 7.
• Proper Dosage and Administration: The patient should be instructed on the proper dosage and administration of the medication, including any specific requirements such as taking the medication with food or water.

Key Points to Emphasize

• The patient should be aware of the potential risks and benefits of benzodiazepines and should be instructed on how to use the medication safely and effectively.
• The pharmacist should emphasize the importance of not stopping the medication abruptly and of following the prescribed dosage and administration instructions.
• The patient should be informed of potential interactions with other medications and should be advised to consult with the pharmacist or physician before taking any new medications.

Relevant Studies

• A study published in the journal Drugs in 1994 found that benzodiazepines have a therapeutic value in a wide range of conditions, but that rational use requires consideration of the large differences in potency and elimination rates between different benzodiazepines 3.
• A study published in the journal Acta neurologica Scandinavica in 2008 found that benzodiazepines are important agents in the management of epilepsy, but that potential shortcomings include tolerance, withdrawal symptoms, and adverse events such as cognitive impairment and sedation 4.
• A study published in the journal The Journal of clinical psychiatry in 2005 found that long-term treatment with benzodiazepines can cause impairment in several cognitive domains, and that patients should be advised of potential cognitive effects when treated long term with benzodiazepines 6.