Assess Benzodiazepine Use

Common prescription benzodiazepines [generic (brand) names)]:

• Alprazolam (Xanax)
• Chlordiazepoxide (Librium)
• Clonazepam (Klonopin)
• Clorazepate (Tranxene-T)
• Diazepam (Valium)
• Estazolam
• Flurazepam
• Lorazepam (Ativan)
• Oxazepam
• Quazepam (Doral)
• Temazepam (Restoril)
• Triazolam (Halcion)

Resources

• Benzodiazepine Information Sheet (UNC resource) [recommended resource]
• Benzodiazepine & Z-Drug (BZRA) Deprescribing Algorithm (deprescribing.org provider resource)

Calculate the total daily dose (TDD) of all benzodiazepines the patient is taking, factoring in scheduled and on-demand doses (can convert to diazepam equivalents).

Resources

• Benzodiazepine Equivalency Table (UNC resource)

Determine how long the patient has been taking benzodiazepines (length of therapy), and if their use as been persistent or intermittent.

Clarify indication for use and goals of therapy, considering clinical, functional, and patient personal goals of therapy.

1. Assess anxiety and insomnia symptoms (should not be the sole assessment for effectiveness)
2. Assess functional status/functional goals

1. Assess benzodiazepine-induced side effects
2. Assess potential drug interactions and cumulative effects

Resources

• Benzodiazepine Information Sheet (UNC resource)

Assessing a patient’s adherence to a prescribed medication regimen is always important. For benzodiazepines, screening for misuse, abuse, and non-use is also critical for evaluating the safety and effectiveness of the medication.

1. Assess patient/caregiver understanding of regimen(s)
2. Utilize assessment tools
   • DSM-V Diagnosis for Sedative, Hypnotic and Anxiolytic Use Disorder – Overview (UNC resource)
   • Severity of Dependence Scale (SDS)
3. Perform a pill count for all benzodiazepines the patient is taking
   • Pill Count Procedure (UNC resource)
4. Check your state’s Prescription Drug Monitoring Program (PDMP) at least every 3 months [e.g., NC Controlled Substance Reporting System (CSRS)]
5. Perform Urine Drug Testing (UDT) at least annually, if available
   • UNC Sample Urine Drug Screening Report
   • Urine Drug Testing Factsheet (CDC handout)
   • Urine Drug Testing (AAFP resource)

At all follow-up visits:

1. Assess adherence to deprescribing regimen
   • Addressing Barriers to Benzodiazepine Tapering (UNC resource)
2. Assess symptoms/severity of anxiety and/or insomnia
3. Assess for side effects/withdrawal symptoms
   • Benzodiazepine Information Sheet (UNC resource)
   • CIWA-B Benzodiazepine Withdrawal Scale