Introduction

The benzodiazepine family of depressants is used therapeutically to produce sedation, induce sleep, relieve anxiety and muscle spasms, and to prevent seizures. In general, benzodiazepines act as hypnotics in high doses, anxiolytics in moderate doses, and sedatives in low doses. Short-acting benzodiazepines are generally used for patients with sleep-onset insomnia (difficulty falling asleep) without daytime anxiety. Benzodiazepines with a longer duration of action are utilized to treat insomnia in patients with daytime anxiety. Repeated use of large doses or in some cases, daily use of therapeutic doses of benzodiazepines is associated with amnesia, hostility, irritability, and vivid or disturbing dreams, tolerance, and physical dependence. The withdrawal syndrome is similar to that of alcohol and may require hospitalization. Abrupt cessation of benzodiazepines is not recommended and tapering-down the dose eliminates many of the unpleasant symptoms (Fransoo et al., 2009).

Long-term use of benzodiazepines is not recommended for older adults because they are more sensitive to the depressant effects benzodiazepines cause on the central nervous system, and because prolonged use can cause confusion, night wandering, amnesia and loss of balance. The use of high daily doses by older adults has been associated with an increased risk of hip fractures and accidental falls (Egan MY, Wolfson C, Moride Y, Monette J. High daily doses of benzodiazepines among Quebec seniors: Prevalence and correlates. BMC Geriatr. 2001;1:1-7). In addition, tolerance and physical and psychological dependence may occur with prolonged use. Lower rates of benzodiazepine prescription are therefore desirable (Katz et al., 2014).

Methods of Identifying Benzodiazepines - ATC Codes and Generic Drug Names

Methods for identifying the use of benzodiazepines include identifying ATC codes and generic drug names.

1. Fransoo et al. (2009) and Martens (2010)

In Fransoo et al. (2009) and in Martens et al. (2010), benzodiazepines were identified by specific ATC codes N05BA01, N05BA02, N05BA04 - N05BA06, N05BA08, N05BA10, N05BA12, N05CD01, N05CD02, N05CD04, N05CD05 and N05CD07, as well as the generic drug names diazepam, chlordiazepoxide, oxazepam, clorazepate potassium, lorazepam, bromazepam, alprazolam, flurazepam, nitrazepam, triazolam, and temazepam. In this scenario, medications with ATC code N05CD01 were included, as these are classified as "benzodiazepine-related drugs" and appropriate in this context.

2. Fransoo et al. (2013), Katz et al. (2014), Katz et al. (2019), and Fransoo et al. (2019)

In Fransoo et al. (2013), Katz et al. (2014), Katz et al. (2019), and Fransoo et al. (2019), benzodiazepines were defined using the ATC codes: N05BA, N05CD, N05CF, and N03AE01 **.

NOTE: ** Clonazepam (N03AE01) is categorized as an antiepileptic drug, not an anxiolytic, but it is a benzodiazepine derivative and is now included in this definition.

Indicators for Measuring Benzodiazepine Use

Two indicators for measuring benzodiazepine use have been developed at MCHP. They include rates for community-dwellling adults and rates for residents of personal care homes (PCHs).

1. Benzodiazepine Prescribing/Dispensations for Community-Dwelling Seniors (Adults 75 Years and Older)

The rates are calculated as the crude (unadjusted) percentage of residents age 75+ living in the community (i.e., not in a personal care home) who had at least two prescriptions for benzodiazepines or at least one prescription of benzodiazepines with a greater than 30 day supply dispensed.

For more information, see:


• Section 11.5 Benzodiazepine Prescribing for Community-Dwelling Seniors in Fransoo et al. (2013).
  
• Benzodiazepine Prescribing for Community-Dwelling Adults in Katz et al. (2014).
  
• Benzodiazepine Dispensations for Community-Dwelling Older Adults in Katz et al. (2019).
  
• Section 6.5 Benzodiazepine Dispensations for Community-Dwelling Seniors in Fransoo et al. (2019).

2. Benzodiazepine Prescribing/Dispensations for Residents of Personal Care Homes (PCH)

These rates are calculated as the crude percentage of PCH residents age 75+ who had at least two prescriptions for benzodiazepines or a greater than 30 day supply dispensed. If a resident lived in a PCH for one or more days during the study period, they were considered a resident of a PCH; otherwise they were considered to be living in the community. PCHs with hospital-based pharmacies were excluded from this analysis as their prescription data was unavailable.

NOTE: As mentioned above, the use of benzodiazepines is not recommended for seniors, so lower rates are better.

For more information, see:

• Section 11.6 Benzodiazepine Prescribing for Residents of Personal Care Homes (PCH) in Fransoo et al. (2013).
  
• Section 6.6 Benzodiazepine Dispensations for Residents of Personal Care Homes (PCH) in Fransoo et al. (2019).

Cautions

NOTE: Lists of drugs to treat diseases and conditions change all the time: new drugs are added, drugs are taken off the market, etc. Also it is very research specific. The list of ATC codes presented in this concept represent a starting point and it is advisable to verify with a clinician or pharmacist the list of current medications being used.