A 35-year-old female hemodialysis (HD) patient with end-stage renal disease was able
to successfully withdraw from benzodiazepines, which had been prescribed for managing
psychiatric and pain symptoms, following a mindfulness-based stress reduction (MBSR)
intervention. The patient, who had been undergoing HD since the age of 6 years, enrolled
in an MBSR program for HD patients consisting of 20- to 40-minute sessions over 8
weeks centred on breath work and directing attention to physical sensations (body
scan) and thoughts. The sessions were delivered via Zoom during HD by an MBSR-certified
psychologist. The patient had a long-standing history of mild depressive, anxiety,
insomnia, restless leg syndrome (RLS) and chronic pain symptoms. In addition to polypharmacy
for HD, she had been regularly taking a benzodiazepine since the age of 20 years,
clonazepam 0.75 mg twice daily for her anxiety and RLS, as well as citalopram 40 mg/d
for her depressive symptoms, quetiapine 75 mg nightly for her insomnia, pregabalin
150 mg nightly for her pain symptomatology and pramipexole 0.5 mg/d for her RLS.
The patient had previously tried to discontinue her benzodiazepine use by her own
initiative and with the help of a psychiatrist, but was unsuccessful. This discontinuation
was attempted with a gradual taper of approximately 10% of her dose every 2–3 weeks.
Unfortunately, the discontinuation was unsuccessful because of resulting rebound anxiety
and insomnia.
After the 8-week MBSR program, the patient reported experiencing a substantial decrease
in her anxiety, pain and depressive symptoms. Most notably, after her previously unsuccessful
attempts at discontinuing benzodiazepines, she was finally able to do so. She slowly
decreased her dose by 0.125 mg weekly and successfully withdrew from clonazepam over
12 weeks following the MBSR program by using the breathing techniques she learned
for managing the withdrawal symptoms. Furthermore, she reported successful self-management
of insomnia, chronic pain and RLS without benzodiazepines for more than 18 months
following the program. She reported practising daily mindfulness meditation for 5–10
minutes per day at least 4 days per week. Through this practice, she developed the
capability to face new health challenges and difficult emotions by calming down with
the breath and detaching herself from worries and negative self-talk.
Patients undergoing HD commonly experience symptoms of stress (29%), anxiety (12%–52%),
depression (25%) and chronic pain (60%).1–3 Restless leg syndrome is also common in
these patients and is associated with the accumulation of uremic solutes and toxins
that are not completely removed during renal replacement therapy, generating substantial
levels of discomfort and suffering. 4 Benzodiazepines are one of the most prescribed
drugs worldwide,5 and are given to 8%–26% of HD patients6 without any precise data
on adverse events and their efficacy in this population. They are prescribed for their
anxiolytic properties, insomnia and mild cases of RLS.7,8 Benzodiazepines act as positive
allosteric modulators of the activity of the main inhibitory neurotransmitter of the
central nervous system, γ-aminobutyric acid (GABA), producing sedative and anxiolytic
effects, muscle relaxation and the interruption of seizures. 9 International guidelines
recommend ideally only short courses of benzodiazepines, 10,12 as long-term use is
associated with physical and psychological dependence,8 cognition decline and increased
risk of falls, car accidents and possibly dementia.8,11,12
Benzodiazepine withdrawal is associated with distressing symptoms, including tachycardia,
headache, flu-like symptoms, nausea, vomiting and diarrhea, paresthesia, muscle rigidity,
sensory hypersensitivity, anxiety, agitation, panic attacks, depression, irritability
and insomnia.8,13 Physiologic dependence occurs after 3–6 weeks of regular use.8,13
Predictive factors of severe withdrawal include short half-life, longer duration of
use, high chronic doses, use of multiple benzodiazepines and rapid discontinuation.
8,13 Currently, there are few strategies to promote benzodiazepine discontinuation
in the general population, but none for HD patients. The most useful nonpharmacological
interventions targeting withdrawal symptoms have been relaxation techniques and cognitive
behavioural therapy in addition to gradual tapering of the medication.14 Although
mindfulness interventions have not been studied in benzodiazepine deprescribing, they
have shown promising results in opioid dose reduction in individuals with chronic
pain, opioid withdrawal and cravings, by increasing self-control.15–17 Furthermore,
a recent meta-analysis of mindfulness-based interventions in patients with cancer
reported positive results on alleviating sleep disturbance and decreasing benzodiazepine
use.18
Mindfulness meditation has been shown to alleviate stress and anxiety through neurobiological
mechanisms, including the modification of large-scale functional networks and neurotransmission
patterns.19 Furthermore, meditation has been found to improve emotion regulation through
increased activation of the prefrontal cortex, decreased amygdala activation and increased
GABA neurotransmission in GABAergic interneurons, which modulate cortical excitability.19–21
Therefore, mindfulness-based interventions may have a therapeutic impact for benzodiazepine
deprescription. A systematic review of mindfulness treatments for substance misuse
disorders (e.g., mindfulness-based relapse prevention, mindfulness-oriented recovery
enhancement, Vipassana meditation)22 found that, although each mindfulness-based therapy
differed, the main components of mindfulness were used in each: paying attention to
one’s present experience with a non-judgmental and accepting attitude, and cultivating
bodily awareness, attention and emotion regulation.22 However, it cannot be concluded
that a specific kind of mindfulness therapy is best for substance overuse, and thus
a personalized approach may be most beneficial.
Given the prevalence of benzodiazepine use with knowledge gaps on their safety and
efficacy for anxiety, insomnia and RLS as well as polypharmacy in this vulnerable
HD population, our patient’s case illustrates mindfulness-based interventions as a
potential adjunctive behavioural intervention for symptom management and benzodiazepine
deprescribing in HD patients, which could be further investigated in future clinical
trials.