12/3/21

ADVANCING PATIENT SAFETY AND ENGAGEMENT THROUGH THE USE OF A
PATIENT-CENTERED BENZODIAZEPINE EDUCATION TOOLKIT

Theodora Nwosu, MSN, RN, PMHNP-BC

A DNP Project Submitted to Clarion and Edinboro Universities
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
November 2021

Acknowledgments
I want to express my sincere gratitude to my committee chair, Dr. Meg Larson. My
completion of this project was possible because of your support and guidance from the beginning
to the end.
Thank you for your suggestions and comments to my committee members Dr. Allen
Masry, DFAPA, DAAAP, and Thelma Odoemene, RPH. Ida M. Boyens, Pharm. D., thank you
for your contributions and the learning opportunities. To the staff at the clinic, thank you for all
your hard work from the start to the end.
For your love and support throughout this journey, a special thank you to my loving
family Hon. Dr. Jacob Nwosu and our children, Jake, Jason, and Juline.
God almighty, I am grateful that you guided me through all the challenges to the finishing
line. To all those whose names I did not mention, thank you for your prayers and support.

ADVANCING PATIENT SAFETY AND ENGAGEMENT THROUGH THE USE OF A
PATIENT-CENTERED BENZODIAZEPINE EDUCATION TOOLKIT
THEODORA NWOSU, MSN, RN PMHNP-BC
Abstract
Background: Substance use disorders have increased in the U.S. in the past 20 years, with
opioid abuse causing over 70,000 deaths from 1999 to 2019. The growing public health problem
necessitates developing a patient-centered educational toolkit. Patients on benzodiazepines who
are at increased risk of morbidity and mortality are not engaged in their benzodiazepine
management and need a specific educational tool to provide the necessary knowledge for
medication management. In addition, there is currently no patient education to improve
benzodiazepine safety or evidence-based program to enhance the partnership between the
prescriber and the patient in many offices.
Method/Design: The investigator developed an evidence-based patient education toolkit to
enhance patients' knowledge about the safe use of Benzodiazepines and the risks of chronic
Benzodiazepine use. Forty-one participants completed a voluntary pre, and post-survey focused
on benzodiazepine-related knowledge and willingness to decrease or cease use. This
improvement project aimed to (i) educate and improve the patients' understanding of safe

Benzodiazepine use. (ii) Increase patient's readiness to decrease or cease long-term
Benzodiazepine use.
Participants: A convenient sample of 41 patients prescribed benzodiazepines at the behavioral
health clinic was selected.
Results: Results of linear regression indicated that patients improved their knowledge regarding
safe benzodiazepine use after using the patient-centered toolkit. However, no statistically
significant changes were observed in patient willingness to decrease or cease benzodiazepine
use.
Conclusion: The patient-centered toolkit is useful in improving patient knowledge regarding
safe usage of benzodiazepines. However, the toolkit was not beneficial in changing the patients’
willingness to cease or decrease benzodiazepine usage. Nevertheless, findings are helpful in
nursing practice and should be used to inform current practice. Future investigators should
improve the toolkit by completing projects focused on how the toolkit can be made more
effective or used in more focused interventions.

Table of Contents
Abstract .......................................................................................................................................... iii
Chapter 1 ......................................................................................................................................... 1
Introduction ..................................................................................................................................... 1
Background of the Problem......................................................................................................... 2
Statement of the Problem ............................................................................................................ 4
Project Questions......................................................................................................................... 5
Hypotheses .................................................................................................................................. 5
Operational Definitions ............................................................................................................... 6
Definition of Terms ..................................................................................................................... 7
Need for the Study....................................................................................................................... 8
Significance of the Problem ........................................................................................................ 9
Assumptions ................................................................................................................................ 9
Limitations ................................................................................................................................ 10
Summary of the Problem........................................................................................................... 10
Chapter 2 ....................................................................................................................................... 12
Literature Review ......................................................................................................................... 12
Search Strategy.......................................................................................................................... 12
Organization of the Chapter ...................................................................................................... 13
Theoretical Framework ............................................................................................................. 13
Review of Relevant Literature ...................................................................................................... 15
History and Usage of Benzodiazepines..................................................................................... 16
Recent Changes in Education on Benzodiazepines................................................................... 17
Preferences for Alternative Therapies to Benzodiazepine ........................................................ 19
Pharmacologic Management for Benzodiazepines Dependence, Withdrawal, and
Discontinuation ......................................................................................................................... 20
Conclusion & Chapter Summary .............................................................................................. 25
Chapter 3 ....................................................................................................................................... 27
Methodology ................................................................................................................................. 27
Project Design ........................................................................................................................... 27

Setting........................................................................................................................................ 28
Sample ....................................................................................................................................... 28
Ethical Considerations............................................................................................................... 29
Instrumentation.......................................................................................................................... 30
Data Collection.......................................................................................................................... 31
Data Analysis ............................................................................................................................ 32
Summary of Methodology ........................................................................................................ 33
Chapter 4 ....................................................................................................................................... 35
Results and Discussion ................................................................................................................. 35
Results ....................................................................................................................................... 36
Testing of Null Hypothesis 1 .................................................................................................... 40
Testing of Null Hypothesis 2 .................................................................................................... 41
Limitations ................................................................................................................................ 42
Summary ................................................................................................................................... 43
Chapter 5 ....................................................................................................................................... 44
Summary, Conclusions, and Recommendations........................................................................... 44
Summary of Findings ................................................................................................................ 44
Implications for Nursing ........................................................................................................... 45
Recommendations for Further Project ...................................................................................... 47
References ..................................................................................................................................... 49
Appendix A: Informed Consent .................................................................................................... 61
Appendix B: Evidence-Based Educational Toolkit ...................................................................... 62
Appendix C: Pre and Post Survey Questions................................................................................ 70

Chapter 1
Introduction
Benzodiazepines are useful in treating various disorders, such as panic and anxiety
disorders, insomnia, seizures, and alcohol dependence (Ameline et al., 2019; Kang et al., 2021).
Further, benzodiazepines possess psycholeptic, muscle relaxant, sedative, anticonvulsant, and
anxiolytic properties, making them helpful in mitigating many adverse health issues (Ameline et
al., 2019; Kang et al., 2021). Although Benzodiazepines are beneficial to patient health when
used correctly, they can also adversely impact patient health when misused (Kang et al., 2021).
Benzodiazepine misuse and abuse can result in many negative consequences, such as overdose,
suicide, life-threatening consequences of drug dependence, cognitive decline, car crashes, and
legal problems (Liang et al., 2019).
Substance use disorders have increased in the U.S. in the past 20 years, with opioid abuse
causing over 70,000 deaths from 1999 to 2019 (National Institute on Drug Abuse, 2021). Given
the many benzodiazepine-related overdose deaths in the United States, the growing public health
problem necessitates developing a patient-centered educational toolkit. This project focuses on
direct care change that aims to improve the knowledge and safety of adult mental health patients
taking benzodiazepines. The investigator has developed an evidence-based patient education
toolkit to enhance patients' knowledge about the safe use of Benzodiazepines and the risks of
chronic Benzodiazepine use. The toolkit will educate patients about safe Benzodiazepine use,
possible side-effects, and how to stop Benzodiazepines when ready safely. In addition to
educating patients about Benzodiazepine use, the toolkit will create opportunities for patients to
share responsibility as a partner to improve their overall quality of life. The project's expected

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direct care outcomes are to educate and improve the patients' knowledge of safe Benzodiazepine
use and increase their readiness to change by weaning and discontinuing Benzodiazepines.
This first chapter introduces the project. First, a background to the problem, the problem
statement, and the project questions are presented. Then, the operational definitions and the need
for and significance of the study are discussed. Finally, this chapter concludes with the project's
assumptions and limitations.
Background of the Problem
Benzodiazepines belong to the nervous system depressant drug group and work by
affecting the brain's neurotransmitters. These drugs are psychoactive, with providers commonly
prescribing for anxiety disorders, insomnia, muscle relaxation, seizures, and even alcohol
withdrawal (Ghosh et al., 2020). Common names for benzodiazepines include, Ativan,
Klonopin, Tranxene, Restoril, Valium, and Xanax. The dangers of combining Benzodiazepine
with dangerous substances or high-risk medications are a severe and dangerous concern for
many who work with mental health patients who take these drugs. Long-term use and
inappropriate Benzodiazepines are associated with a public health crisis such as overdose,
suicide, life-threatening consequences of drug dependence, cognitive decline, car crashes, and
legal problems (Liang et al., 2019). The risks and complications of benzodiazepine use include
paradoxical reaction, increased drowsiness, lack of concentration, decreased interest in normal
life activities, and alertness (Rapport et al., 2019). Other effects of long-term use include reduced
libido, impaired driving skills, erectile dysfunction (Orriols et al., 2019), depression and
disinhibition occurring with cognitive impairment, and behavioral problems (Sakshaug et al.,
2017).

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In addition to the various dangers of benzodiazepines, benzodiazepines were the most
common drug involved in prescription opioid overdose deaths (Cadogan et al., 2018). According
to the National Institute on Drug Abuse (2018), the use and misuse of benzodiazepines have
contributed substantially to the current opioid overdose epidemic. In addition, the Centers for
Disease Control and Prevention (2020) reported benzodiazepines were involved in over 30% of
opioid overdose deaths in 2019.
Experts found the trends in the consumption rate of benzodiazepines indicated a growing
public health problem (Sakshaug et al., 2017; Torres-Bondia et al., 2020). Further,
benzodiazepine overdose deaths have increased at an alarming rate in the past two decades
(Torres-Bondia et al., 2020). Statistics showed that benzodiazepine-related overdose deaths
increased by more than 400% from 1996 to 2013, with emergency department visits for
benzodiazepine overdoses rising by more than 300% from 2004 to 2011 (Bachhuber et al., 2016;
Jones & McAninch, 2015).
The theoretical framework that underpins this project is the theory of neuroadaptation.
Neuroadaptation is a theory of drug dependence based on mechanisms in the brain that change
when a person continually uses and administers drugs (Teesson et al., 2011). The brain adapts to
counter the drug's acute actions changing the brain chemistry, and either a within-system or
between-system adaptation occurs. The former changes at the site of the drug's activity, and the
latter creates changes in other systems triggered by the drug's action (Teesson et al., 2011). Thus,
with repeated administration, the brain's chemistry changes and eventually adapts.
However, when drug use is discontinued, the brain's homeostasis becomes disrupted, and
the brain must adjust to a lack of drug levels. The disruption creates a need in the brain to protect
itself and shut down the pleasure sensors. This shut down can cause drug withdrawal and create

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the sensation in the brain that the pleasure is gone (Wise & Koob, 2014). The investigator will
use this theory as a lens to view the existing literature, biologically help explain the process of
the toolkit and help form the project questions.
Statement of the Problem
The problem this current quality improvement project addressed is that patients on
benzodiazepines who are at increased risk of morbidity and mortality are not engaged in their
benzodiazepine management and need a specific educational tool to provide the necessary
knowledge for medication management. There is currently no patient education to improve
benzodiazepine safety or evidence-based program to enhance the partnership between the
prescriber and the patient in many offices (Bushnell et al., 2017; Guina & Merrill, 2018). Often
the patients see the attempt to wean their benzodiazepines as negative or one-sided (Guina &
Merrill, 2018). Through such education, the safe use of benzodiazepines could reduce deaths and
addictions in the population. The toolbox presented to correct the problem could become a longterm sustainability plan to minimize benzodiazepine-related mortality and lower the high cost of
addiction treatment in the United States.
The purpose of this project was to advance patient safety and engagement by using a
patient-centered benzodiazepine education toolkit. The project's expected direct care outcome
was to educate and improve the patients' knowledge of safe benzodiazepine use and increase
their readiness to change by weaning and discontinuing benzodiazepines. This initial program
evaluation helped clarify if the patient education benzodiazepine toolkit improves medication
knowledge and willingness to change. Supported in the short term, further studies are required to
see if this educational intervention improves patients' long-term knowledge retention. Further,
findings may reveal if the toolkit impacts readiness to change and results in decreased morbidity

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and mortality for patients who are using benzodiazepines. The PICO for the current project
states:
P: Patients prescribed benzodiazepines
I: Patient Education for benzodiazepines toolkit
C: Pre-survey of patient benzodiazepine knowledge and readiness to change (anonymous survey
online)
O: Post-survey of patients after educational Toolkit implemented (anonymous survey online)
Project Questions
Q1: Will education of patients on benzodiazepines using the investigator-developed
toolkit improve the patient's knowledge of safe benzodiazepine use?
Q2: Will education of patients on benzodiazepines using the investigator-developed
toolkit increase a patient's readiness to change by successfully weaning off after long-term
benzodiazepine use?
Hypotheses
H10: The education of patients on benzodiazepines using the investigator-developed
toolkit will not improve the patient's knowledge of safe benzodiazepine use.
H1a: The education of patients on benzodiazepines using the investigator developed
toolkit will improve the patient's knowledge of safe benzodiazepine use
H20: The education of patients on benzodiazepines using the investigator-developed
toolkit will not increase a patient's readiness to change by successfully weaning off after
long-term benzodiazepine use.

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H2a: The education of patients on benzodiazepines using the investigator-developed
toolkit will increase a patient's readiness to change by successfully weaning off after
long-term benzodiazepine use.
Operational Definitions
The following operational terms are defined in this section:
The Educational Benzodiazepine Toolkit. The investigator has developed an evidencebased patient education Toolkit to enhance patients' knowledge about the safe use of
Benzodiazepines and the risks of chronic Benzodiazepine use.
Patient Increased Readiness to Change Use of Benzodiazepines. The patient's
increased readiness to wean off long-term benzodiazepine use was measured through a pre and
post online survey (Appendix C). The surveys were used to test the participant's knowledge of
the risks and side effects of benzodiazepines to determine the readiness to stop using
benzodiazepines. The investigator added the responses to the survey before and after
implementing the toolkit to determine if patient scores improved. Improved scores would
indicate an increased knowledge of benzodiazepine usage and an increased willingness to
change.
Patient's Improved Knowledge on Benzodiazepines. The patient's improved
knowledge was measured through a pre and post online survey (Appendix C). The surveys test
the participant's knowledge of the risks and side effects of benzodiazepines. The surveys also
examined the participant's knowledge and experiences with safety issues, such as alcohol and
other medication use while taking benzodiazepines, and determine what impacts the use of
benzodiazepines. The investigator added up the responses to the survey before and after

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education to determine if the score improved, which would evaluate the patient's improved
knowledge on the use of benzodiazepines.
The variables used in the current project, with their respective descriptions, are shown in
Table 1.
Table 1
Variables & Descriptions
Variable

Description

Independent variable

Educational benzodiazepine toolkit

Dependent variable

Patient increased readiness to change

Dependent variable

Patients improved knowledge of benzodiazepines

Definition of Terms
The following key terms are defined in this section:
Benzodiazepine. Benzodiazepines are a class of heterocyclic organic compounds that a
patient takes as a tranquilizer (Guina & Merrill, 2018).
Drug Addiction. Drug addiction is a persistent condition in which a person continues a
cycle of reverting drug dependence, recovering, and returning to dependency (National Institute
on Drug Abuse, 2021). Drug addiction is considered a mental illness and a complicated brain
disorder (National Institute on Drug Abuse, 2021).
High-Risk Medications. High-risk medications are defined as pharmaceuticals that have
a potential for harmful consequences to a person while being highly sought after (Nguyen et al.,
2017).
Medication Management. Medication management is defined as a process of overseeing
and monitoring the use of medications prescribed to ensure a person is taking their drugs as
prescribed and planned so to achieve the potentially determined outcome (Cadel et al., 2021).
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Patient Education. Patient education is the practice of information sharing with patients
regarding their health, treatment planning, potential outcomes, and wellness (Rooney et al.,
2021).
Need for the Study
The existing literature on patient education and benzodiazepines examined patient
empowerment intervention, deprescribing benzodiazepines (Gnjidic et al., 2019; Reeve et al.,
2017). Experts discussed the potential benefits and harms following the barriers to and enablers
of deprescribing (Reeve et al., 2017; Silberman et al., 2020). The potential patient harm from
benzodiazepines withdrawal was shown to be dangerous, but explanations for improvement of
patient outcomes were limited (Carr et al., 2019; Gnjidic et al., 2019; Ng et al., 2018; Silberman
et al., 2020). Information on mitigating adverse patient outcomes because of withdrawal from
benzodiazepines is essential for providers who prescribe benzodiazepines because the need to
deprescribe safely must be addressed.
Current research focuses more on the use and overuse of benzodiazepines from
healthcare providers' perspectives but fails to include discussions on the importance of
deprescribing and assistive withdrawal for patients needing to stop using their benzodiazepines
(Carr et al., 2019; Rosenbaum, 2020). In addition, further research discussed the need for
providers' support when helping their patients discontinue such drug use. Yet, these studies fail
to present the means to do so, thereby making the current study applicable Toolkits for the
education necessary ((Carr et al., 2019; Gnjidic et al., 2019; Ng et al., 2018).
Experts found a need to examine the process of deprescribing Benzodiazepine for older
patients, admitting to the danger of safety, dependence, and misuse of benzodiazepines (Carr et
al., 2019; Silberman et al., 2020). In addition, studies observing the use of benzodiazepines in

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patients with a mental illness presented findings on such information as patterns of use,
development of addictive behaviors, propensity for misuse and abuse, long-term characteristics
from drug use, and the incidences of negative behaviors due to long-term use (Bernard et al.,
2018; Guina & Merrill, 2018; Maust et al., 2018; Taipale et al., 2020).
With the increase in benzodiazepines, there is a significant need to discuss the means for
providing education to patients who are prescribed such addicting medication. The safe use of
Benzodiazepine could reduce deaths and addictions in the population (Carr et al., 2019; Ng et al.,
2018; Taipale et al., 2020). Thus, implementing this toolkit could be a long-term sustainability
plan to minimize benzodiazepine-related mortality. Finally, the use of the toolkit could lower the
high cost of addiction treatment in the United States.
Significance of the Problem
The findings of this current project are expected to present significant information for
nursing and for mental health professionals, particularly those who work with patients taking
benzodiazepines. As healthcare providers continue to decrease the widespread use of prescription
abuse, the toolkit could be helpful. The implementation of the benzodiazepine toolkit has
excellent potential to provide education to patients needing to stop the use of benzodiazepines
and increase knowledge of those who need to continue or begin medication treatment through the
use of benzodiazepines. The investigator hopes to share the outcome of this initial program
evaluation with providers and patients. In addition, the results will add to the existing literature
on the management of benzodiazepine usage, providing much-needed information.
Assumptions
In research, assumptions are defined as those statements presumed to be accurate or
plausible that need to be accepted for the findings to have meaning (Wolgemuth et al., 2018).

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The most notable assumption is that all participants provided honest and truthful responses,
which bolsters the overall project's validity and credibility. For the current project, the
investigator assumes all experiences shared by the participants through the survey answers
provided trustworthy and reliable information. Additionally, there is an assumption that the
participants were forthright in their benzodiazepine use and dependency level.
The investigator also assumes that there will be a significant cause and effect between the
listed variables. The assumption of cause and effect is based on applying the independent
variable of education through the toolkit and changing the dependent variables of the patient's
increased readiness to change and improved knowledge of benzodiazepines. This assumption is
made based on the scores produced in the pre and post-surveys.
Limitations
Limitations are unavoidable consequences in a project that impacts data analysis results
(Ross & Bibler Zaidi, 2019). The investigator has no control over the limitations and, therefore,
will present these. The first limitation is the sample size. Due to time constraints on the project,
the investigator only sampled a limited number of 41 participants. Another limitation is the
generalizability of the findings, which was limited due to the smaller sample size. A third
limitation is the location of the study, as the participants were drawn from a single mental health
clinic.
Summary of the Problem
Chapter one discussed the methods and processes used for the current project through an
implemented and investigator-developed toolkit used for educational purposes. The investigator's
implementation of this patient-centered toolkit provided education focusing on mental health
patients regarding benzodiazepine use. This first chapter explained how the investigator would

10

assist in sharing the benefits and dangers of benzodiazepines and provide information on how to
avoid adverse effects from such use. The toolkit's potential use allowed the patent to share
medication management responsibility as a partner in their care and improve their safety.
Chapter two presents a comprehensive review of the literature. Then, Chapter 3 presents
the methodology. Finally, the data analysis findings are contained in Chapter 4, and a conclusion,
summary, and recommendations for future practice are presented in Chapter 5.

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Chapter 2
Literature Review
The general problem addressed in this quality improvement project was that patients on
benzodiazepines are at increased risk of morbidity and mortality, are not engaged in their
benzodiazepines management, and need a specific educational tool to provide the necessary
knowledge for medication management. There is currently no patient education to improve
benzodiazepines safety or evidence-based program to enhance the partnership between the
prescriber and the patient in many offices (Bushnell et al., 2017; Guina & Merrill, 2018). The
purpose of this project was to advance patient safety and engagement by using a patient-centered
benzodiazepines education toolkit. The project's expected direct care outcome was to educate
and improve patient knowledge of safe benzodiazepine use. Furthermore, the project focused on
increasing patients' readiness to change benzodiazepines use by weaning and discontinuing
benzodiazepines. This chapter presented a synthesis of existing literature that discussed topics
related to benzodiazepines use and safety.
Search Strategy
The investigator searched for existing literature in the following databases: CINAHL,
CHBD, the Cochrane Library, EMBASE, Global Health, Google Scholar, MEDLINE, PubMed,
and Science Direct. The terms and phrases used to search these databases for existing and current
literature included alternative treatments instead of benzodiazepine prescriptions, benzodiazepine
abuse, benzodiazepine use, benzodiazepine withdrawal, challenges and barriers of managing
benzodiazepines dependence, deprescribing benzodiazepines, deprescribing education,
deprescribing interventions, deprescribing methods, discontinuation of benzodiazepines,
education on benzodiazepines, long-term effects of benzodiazepines, misuse of benzodiazepines,

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prescribed beneficial use of benzodiazepines, reasons for benzodiazepine use, and risks with
benzodiazepines. In addition, reviewed literature had to meet the following criteria to be selected
for this chapter; a) published peer-review work, b) more than 85% of literature selected
published after 2017, c) must discuss the topic of interest, and d) must be written or translated in
English. The initial number of resources found was over 5,000 scholarly articles, books,
government documents, dissertations, and conference proceeding papers. After reviewing the
titles, the abstracts, and the content, 61 resources were used for the current chapter's review.
Organization of the Chapter
The chapter was organized, first introducing the theoretical framework and discussing its
development, history, and application to the current project. This section is followed with the
selected relevant studies, including research resources organized by the following themes: the
history and usage of benzodiazepines, recent changes in education on benzodiazepines,
preferences for alternative therapies to benzodiazepines, challenges and barriers of
pharmacologic management for benzodiazepines dependence, withdrawal, and discontinuation,
the deprescribing medication methods, and use of a toolkit for deprescribing medications.
Finally, the chapter ends with a section on how the problem was established and has been
addressed in previous literature.
Theoretical Framework
The theoretical framework that underpinned this project was the theory of
neuroadaptation. Neuroadaptation is a theory that posits drug dependence, and this dependence is
based on mechanisms in the brain that change when a person continually uses and administers
drugs (Teesson et al., 2011). The brain adapts to counter the drug's binding actions changing the
brain chemistry, and either a within-system or between-system adaptation occurs. The former

13

changes at the site of the drug's activity, and the latter creates changes in other systems triggered
by the drug's action (Fronk et al., 2018). Thus, with repeated administration, the brain's
chemistry changes and eventually adapts.
The theory of neuroadaptation includes addiction models, such as the moral model,
disease model, psycho-dynamic model, social learning model, socio-cultural model, and public
health model. The current project used the disease model to observe the assumptions that the
origins of addiction lie within the individual. Expert examination of addictions showed that an
individual addicted to a substance may lose control after their intake. Based on the neurobiology
of their brain, addicted people have no control once this substance enters their biological system
(Elman & Borsook, 2016; Volkow et al., 2019). The brain adapts to the increased intake of the
substance and, again, based on the brain's biological make-up, will prompt an addiction that was
not curable. Addiction is a disease that proves irreversible; there is no cure and can only be
controlled and treated through lifelong abstinence (Heather et al., 2018; Mollick & Kober, 2020).
Experts who support this theory then suggested that addiction does not exist on a continuum; it is
either present or is not (Nagy et al., 2005; Volkow et al., 2019).
The administration of a drug causes an acute drug effect which triggers the brain's
neuroadaptation. Figure 1 shows this cyclical process through both the administration of the drug
process and the withdrawal process. The process is constant with occurrences and
discontinuation of drug use and continues with an individual's choices regarding the use of the
substance.
Figure 1
Process of Neuroadaptation with Substance Dependence

14

Note: (Nagy et al., 2005)
The theory of neuroadaptation contends that with the brain's homeostasis becoming
disrupted, the brain triggers a stasis that adjusts to the lack of drug levels, creating a need in the
brain for protection which in turn shuts down the pleasure sensors first initiated by the
consumption of the substance (Wise & Koob, 2014). As the current investigative project focuses
on creating a toolkit to assist professionals with patient safety and engagement for prescribing
and deprescribing benzodiazepines, this theory was used as the lens for reviewing existing
literature and explaining the biological process of the toolkit.
Review of Relevant Literature
The existing literature reviewed for the current project provided insight into what experts
and researchers regarded as important when considering themes central to this topic. Information
provided in the following sections summarizes findings of current literature focused on patients'
using and abusing benzodiazepines. Additionally, information is provided on deprescribing
addictive pharmaceuticals, such as benzodiazepines.

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History and Usage of Benzodiazepines
Benzodiazepines are often prescribed to sedate or calm a person by raising the level of
the inhibitory neurotransmitter GABA in the brain (Cadogan et al., 2018). Common
benzodiazepines include diazepam (Valium), alprazolam (Xanax), and clonazepam (Klonopin),
among others (Hirschtritt et al., 2021; Silberman et al., 2020). Benzodiazepines were recognized
as the most prescribed but most misused and abused sedative-hypnotics parallel with opioids
(Fluyau et al., 2018; Kang et al., 2020). Benzodiazepines are commonly prescribed for both short
and long-term use (Guina & Merrill, 2018). While these sedative-hypnotics can provide rapid
relief for symptoms like anxiety and insomnia, they are also linked to various adverse effects
(Guina & Merrill, 2018; Sanabria et al., 2021).
Benzodiazepine use with or without opioid use was found to have an independent risk
factor for all-cause mortality. Additionally, Benzodiazepines are directly associated with
underlying conditions related to death. Experts agree that the long-term use of benzodiazepines
can cause the same symptoms and effects as alcohol addiction (Bogunovic & Greenfield, 2004).
Tolerance may develop with a risk of dependence, and a withdrawal syndrome may occur
when discontinuing use. In examining the risks of Benzodiazepines, experts found a high
prevalence prescribed to persons over 65 years of age (Bogunovic & Greenfield, 2004;
Tannenbaum, 2015). Existing literature showed the examination of such reasons for prescribing
benzodiazepines to this population was based on several indications, such as those in an elderly
age bracket were most likely to be diagnosed with the condition that benzodiazepines provide
relief (Singh & Sarkar, 2016; Tannenbaum, 2015). The most common conditions included
generalized anxiety disorder, adjustment disorder, anxiety, and insomnia. However,
benzodiazepines were also the first pharmaceutical prescribed to patients with multiple

16

concurrent physical and psychological problems. Benzodiazepines were also found to be
prescribed for an assortment of nonspecific symptoms, such as pallor, headache, malaise, and
dizziness. Another common reason providers were prescribing benzodiazepines in the elderly
was to relieve the anxiety associated with isolation following bereavement (Singh & Sarkar,
2016).
Even with previous research focusing on the correlations between benzodiazepines and
mortality, other experts suggested that the link between benzodiazepines and mortality was small
and insignificant. Researchers claiming residual confounding explained the slight increase in
mortality risk observed with benzodiazepine use which should not be overtly concerning
(Kaufmann et al., 2017). Whereas benzodiazepine and opioid cotreatment were further found as
increased long-term mortality risk, experts agreed that targeted interventions were necessary to
decrease overprescribing (Park et al., 2020; Patorno et al., 2017; Torres Bondia et al., 2020).
However, there continues to be a lack of tools, methods, and education to support the
deprescribing of benzodiazepines.
Recent Changes in Education on Benzodiazepines
Early literature on the addiction proclivity of benzodiazepines seemed reassuring, with
the suggestion that these prescribed pharmaceuticals were not strong reinforcers and were less
likely than others to be misused drugs (Ameline et al., 2019; Rosenbaum, 2020). Much of this
research discussed the However, later research found a risk in prescribing benzodiazepines with
findings proving benzodiazepines did inadvertently induce a substance use disorder (Mokhar et
al., 2020; Schepis et al., 2019). Many studies showed benzodiazepines emerged as a commonly
chosen prescribed drug for psychiatric conditions such as the clinical management of sleep
disorders and anxiety (Arora et al., 2020; Kaufmann et al., 2017). However, they were unaware

17

that the long-term effects of these prescriptions did more harm than good. Furthermore, recent
research showed that benzodiazepines, like opioids, were addictive substances that caused many
patients' abuse and misuse (Bernard et al., 2018; Carr et al., 2019).
In the past, research focused more on the use of benzodiazepines from healthcare
providers' perspectives, failing to include discussions on the importance of deprescribing and
assistive withdrawal for patients needing to stop using their benzodiazepines (Carr et al., 2019;
Rosenbaum, 2020). More recently, researchers found that such reasons for the current misuse of
benzodiazepines were primarily based on a lack of education available. Such previous research
provided information only on the widely prescribed beneficial use of benzodiazepines to treat
patients diagnosed with such conditions as obsessive-compulsive disorder (OCD), post-traumatic
stress disorder (PTSD), anxiety, or sleep disorders (Arora et al., 2020; Kaufmann et al., 2017).
Results of double-blind studies with clonazepam were controversial, with researchers
performing an open trial with alprazolam that did not support the efficacy of benzodiazepines for
OCD or anxiety symptoms (Dell'Osso et al., 2015). In addition, other studies showed the use of
benzodiazepines for OCD increased side effects that worsened OCD behaviors (Kang et al.,
2020; Mokhar et al., 2020). Based on such adverse outcomes, a few researchers did not
recommend considering these conditions with benzodiazepines (Kaufmann et al., 2017; Maust et
al., 2018). However, due to limited evidence of the negative efficacy of benzodiazepine use,
many providers continued to prescribe these pharmaceuticals, considering them adjunctive
therapy for patients diagnosed with OCD (Guina & Merrill, 2018; Miller et al. 2020).
Providers were made aware that certain recent advances in the synthetic chemistry of
benzodiazepines enable the synthesis with desired substitution pattern allowing for the medicinal
chemistry of benzodiazepines as therapeutic candidates with a good biological profile, including

18

insight into mechanistic studies (Arora et al., 2020). The correlation of biological data with the
structure and the structure-activity relationship studies was also included to provide an insight
into the rational design of more active agents (Silberman et al., 2020). Experts claimed that
giving a patient-educational booklet during hospitalization may encourage patients to discuss the
review and possible deprescribing of benzodiazepine therapy with their health professionals
(Gnjidic et al., 2019; Silberman et al., 2020; Taipale et al., 2020). The application of such
education for both healthcare providers and patients would prove advantageous and possibly
eliminate the abuse of benzodiazepines in the future.
Preferences for Alternative Therapies to Benzodiazepine
Researchers examined the use of benzodiazepines in patients with mental illnesses. They
presented findings on information that included patterns of use, development of addictive
behaviors, propensity for misuse and abuse, long-term characteristics from drug use, and the
incidences of negative behaviors due to long-term use (Guina & Merrill, 2018; Sake et al., 2019;
Taipale et al., 2020). In addition, experts examined the long-term use of benzodiazepines and the
adoption of alternative behavioral therapies that were useful when successfully developing
strategies to treat such disorders as anxiety and OCD (Osler & Jorgensen, 2020; Platt et al.,
2018).
Experts suggested that finding alternative therapies for treating anxiety and mood or sleep
disorders could alleviate the use of benzodiazepine and its addictive qualities (Maust et al., 2018;
Osler & Jorgensen, 2020). The nonpharmacological method as an alternative to benzodiazepine
drugs for treating psychiatric disorders and conditions produced positive outcomes. Platt et al.
(2018) showed how outcomes were established through such treatments using yoga, meditation,
and mindfulness. According to the authors, based on the successful outcomes from these three

19

methods, providers were less likely to prescribe benzodiazepines for anxiety disorders, PTSD,
and specific phobias (Platt et al., 2018).
Based on the reported preferences of benzodiazepine users, experts found providers
supported the development and evaluation of nonpharmacological options with collaborative
services to improve the uptake of behavioral therapies as an alternative to benzodiazepines was
recommended (Maust et al., 2018; Sake et al., 2019). Recognizing other options for individual
interventions by practitioners instead of prescribing benzodiazepines only occurs with education
on long-term effects and only with the advent of optional treatments. Researchers recommend
that future research focus on more alternatives to the use of benzodiazepines and thereby
avoiding long-term issues and addiction (Sake et al., 2019).
Pharmacologic Management for Benzodiazepines Dependence, Withdrawal, and
Discontinuation
There are many challenges and barriers to the management of medication treatment when
prescribing benzodiazepines. The research related to benzodiazepine use was mixed with some
experts finding it appropriate and safe to prescribe such drugs to patients with psychological
disorders claiming there was a lack of evidence to prove the use of benzodiazepines was unsafe
(Patorno et al., 2017; Xu et al., 2020). These experts also claimed that while benzodiazepines
were addictive, close monitoring provided the safety features necessary for such treatment
(Boggs et al., 2020; Liang & Shi, 2019). Other experts, however, felt that long-term use of
benzodiazepine was more harmful than helpful even with close monitoring (Bushnell et al.,
2017; Sakshaug et al., 2017). Some examples of these problems included cognitive decline,
increased fall risk, and suicide ideation, along with dependence.

20

Results from an examination of benzodiazepines' long-term effects on patients suggested
that cumulative use might be neuroprotective (Boggs et al., 2020; Liang & Shi, 2019). Even so,
experts' claims that benzodiazepines contributed to cognitive decline were not proven when
outcomes were accounted for use by indication (Picton et al., 2018; Sakshaug et al., 2017). With
treatment, altered cognition was suggested due to extended exposure to benzodiazepines;
however, there are mixed findings associated with benzodiazepine therapy. Such treatment
challenge was found when recent results exhibited that depression, often associated with anxiety
managed in part by benzodiazepines, was considered a risk for and often a precursor of dementia
(Singh Manoux et al., 2017; Song et al., 2020). In addition, studies showed that the trajectory of
depressive symptoms was aggravated when benzodiazepines were used long-term in patients
(Singh Manoux et al., 2017).
Fall risk was increased in older patients when prescribed a benzodiazepine; however, the
association between the elimination half-life of benzodiazepines and the difference between
benzodiazepines and non-benzodiazepines was not clear (Hart et al., 2020; Masudo et al., 2019;
Ng et al., 2018). Studies showed one in every ten falls resulting in emergency room visits were
due to medication association (Hart et al., 2020; Masudo et al., 2019). The most noted
medication causing falls was benzodiazepines. The use of benzodiazepines, often combined with
other medicines, impacts the tendency for car accidents and hip fractures leading to
hospitalization and potentially death, increasing the risk of falls.
Studies have also shown a strong association between suicide death and poor use of
benzodiazepine treatment guidelines. Benzodiazepines have been linked with suicidal ideation,
showing a high occurrence of recent benzodiazepine exposure, especially among women, people
with mental health issues, and people with physical health problems (Cato et al., 2019; Ghosh et

21

al., 2020; Schepis et al., 2019). Cato et al. (2019) examined the potential that benzodiazepines
were associated with suicide. A sample of 154 patients who had committed suicide was used to
ascertain this connection. The authors found benzodiazepines were prescribed to more than 70%
of these suicides; however, the results were interpreted in two ways (Cato et al., 2019). The
association between benzodiazepines and suicide may have increased only because the patients
were already at an increased risk for suicide based on anxiety, depression, and insomnia.
However, benzodiazepines may also increase the risk of suicide as many suicide attempts occur
because of benzodiazepine overdose (Cato et al., 2019).
Ghosh et al. (2020) assessed the epidemiology of suicide in benzodiazepine patients.
They examined the direct association of benzodiazepine use with suicide ideation in a sample of
3465 suicide deaths. The authors found benzodiazepine exposure was more common in those
suicide victims who were female versus male, with 50% of the overall sample taking a
benzodiazepine through prescription (Ghosh et al., 2020). The final assessment indicated a
relatively high prevalence of recent benzodiazepine exposure, which warrants further
investigation from clinical and public health perspectives. Common research findings suggested
that benzodiazepines caused increased multiple risks (Cato et al., 2019; Ghosh et al., 2020; Hart
et al., 2020). In addition, the research cited from these experts suggested that using
benzodiazepines was challenging and induced such barriers that caused further problems beyond
the condition the patient was being treated (Liang & Shi, 2019; Sakshaug et al., 2017).
Deprescribing Medication
Deprescribing is a method of intervention used intentionally to stop or reduce an
individual's medication consumption (Todd et al., 2018). Typically, deprescribing is used on
individuals with multiple comorbidities prescribed multiple medications that do not improve

22

well-being or health. In addition, the use of five or more prescribed medications, called
polypharmacy, contributes to an increased risk of adverse events. Thus, the individual benefits
from a reduction in the amount of medication taken.
Providers use deprescribing to reduce medication burden and harm, with an overall goal
of maintaining or improving their quality of life (Farrell & Mangin, 2019; Isenor et al., 2021).
Experts reviewed polypharmacy in different populations, with many finding patients exhibiting
manifestations from an adverse pharmaceutical reaction (Hall-Tierney et al., 2019; Wu et al.,
2021). Further examinations proved that drug-induced symptoms such as increased and frequent
falls, confusion, or signs of frailty resulted from the use of multiple drugs in a single patient.
Often prescribed medication does more harm than good and necessitates the supervised
process of stopping the use of a medication internationally. This process was called
deprescribing, and healthcare experts often recommend patients cease taking medication
completely, while others claim that a medication reduction should occur slowly over time (Isenor
et al., 2021; Wu et al., 2021). Studies showed that polypharmacy is highly significant with the
increased risks of adverse events from medication interactions, including falls, cognitive deficits,
and addiction (Isenor et al., 2021; Langford et al., 2021). The main recommendation from
providers with such occurrences was to target a medication and deprescribe to create necessary
changes in health outcomes from taking fewer medications. Deprescribing's goal is to reduce
medication burden and maintain or improve quality of life.
Long-term tolerance of medication does not necessarily suggest that taking such a
remedy is an appropriate treatment. Research showed that the reviewing of a medication regimen
for any given patient, a provider must first observe if increased issues have occurred and if so,
the provider should recognize the need for medication discontinuation as it may no longer be

23

necessary (Isenor et al., 2021; Liang & Shi, 2019; Nguyen et al., 2017). Experts found a need to
examine the process of deprescribing benzodiazepine for older patients, admitting to the danger
of safety, dependence, and misuse of benzodiazepines (Langford et al., 2021; Lumish et al.,
2017). Findings showed providers were unclear regarding methods of deprescribing as the
limited education on this topic was not readily available (Todd et al., 2018). In addition, studies
showed that medication management for deprescribing benzodiazepines was unreliable and
created more problems with both health and mental well-being (Cadel et al., 2021).
With the increase in drug overdose deaths involving benzodiazepines and prescription
opioids, prescription drug monitoring programs were recommended (Liang & Shi, 2019; Nguyen
et al., 2017). However, many of these programs were found to have issues with the execution and
maintenance of deprescribing. Many providers were found to have more patients who remain
addicted to benzodiazepines than not (Langford et al., 2021; Lumish et al., 2017; McGrath et al.,
2017). Many of the current research provided an expert opinion that programs for deprescribing
were necessary, but few programs had similarities in their methods. The limited research on
methods of deprescribing requires further investigation and necessitates a toolkit for its
intervention.
Methods and Interventions for Deprescribing
There is no one 'gold standard' for deprescribing. Experts who examined interventions for
deprescribing medications in patients with polypharmacy found patient education was essential
but with limited positive results (Gnjidic et al., 2019; Reeve et al., 2017). Gnjidic et al. (2019)
conducted a feasibility intervention study to provide patient education using a booklet that
offered patient-empowerment education on benzodiazepines and promoted deprescribing for
patients over 65 years. The author's goal was to calculate the viability and impact patient

24

empowerment had for patients admitted to a local hospital whose prescriptions included
benzodiazepines (Gnjidic et al., 2019). Evidence showed discussion about deprescribing
benzodiazepines versus usual care was provided to the patients. However, most patients simply
allowed the provider to implement with little to no questions or instructions. Cessation of
benzodiazepines occurred for most patients at one month following discharge. The researchers
suggested that future research should provide substantiated effectiveness with using a patientempowerment booklet to reduce inappropriate medication use (Gnjidic et al., 2019).
Reeve et al. (2017) claimed processes of deprescribing inappropriate medication varied
by healthcare provider supervising, yet there were no consistencies in these methods. The author
claimed that most tools available, few provide information on the development, implementation,
and evidence-based success (Reeve et al., 2017). Other experts agreed, finding the types of tools
available to aid deprescribing lacking in explicative instruction (Poots et al., 2017; Sun et al.,
2021). In addition, most researchers found research deficient on instruction, methods, or other
means for deprescribing overall.
Conclusion & Chapter Summary
The existing literature revealed the necessity for an evidence-based method to
deprescribe benzodiazepines as there was very little research on specifics and processes.
Addressing this gap was significant as it advanced how to discontinue patient use of
benzodiazepines safely. In addition, using this investigator-developed toolkit provided several
improvements in knowledge and experiences with safety issues, such as alcohol and other
medication use while taking benzodiazepines and determining the understanding of what all
encompasses the use of benzodiazepines for both healthcare providers and patients.

25

Much of the existing literature presented topics on how benzodiazepines were addictive
and dangerous, how providers used benzodiazepines even when alternate treatments that were
safer were available, and how the recent educational changes in benzodiazepines showed the
need to redirect the use of these addictive pharmaceuticals. Any expert discussion on
benzodiazepines and the means for deprescribing using such means as a toolbox were missing.
Stronger links have emerged from studies examining longer- rather than shorter-acting
benzodiazepines, longer rather than shorter use duration, or earlier than later exposure. However,
questions remain about causality and the impact of confounders on study interpretation.
Chapter 3 introduced the project design, discussing how the investigator achieved the
purpose for the project, explaining the setting and sample. The investigator also included in
chapter 3 a discussion on why this quality improvement project was appropriate in collecting
data to answer the research questions. This chapter also presented the ethical considerations, the
instrumentation used to manage the data, the data collection process, along with the data
analysis.

26

Chapter 3
Methodology
The current project was a quality improvement using an evidence-based educational
toolkit with changes in patient knowledge regarding safe benzodiazepine use measured by a preand post-survey. The purpose of this project was to advance patient safety and engagement
through the use of this patient-centered benzodiazepine evidence-based education Toolkit
(Appendix B). Chapter three discusses the project's design and the setting in which the project
recruited participants. Information includes the sample of participants and how they were
recruited from a specific and targeted population, the ethical considerations used to ensure
participant protections throughout the project, and the instrumentation used to measure
participant responses to an online survey, the data collection process, and the data analysis
method.
Project Design
The current research was a quality improvement project. This type of project encourages
an investigator to use an organized, systematic, and continuous action to measure specific
improvement in a kind of healthcare service within a targeted patient group (Jones et al., 2019).
This quality improvement project followed the U.S. Department of Health and Human Services,
Health Resources and Services Administration's ([HHS]; 2019) principles for quality
improvements. According to the HHS (2019), quality improvement projects operate as systems
and processes, always focusing on the patient, being part of a team effort, and using the collected
data to recommend changes.

27

Setting
The current project's setting was in a behavioral health clinic located in a medium-sized
urban community in the Southeastern region of the United States. The community sits in the
county seat, and the county has a population of approximately 506,707 (U.S. Census Bureau,
2021). The community's statistics show a high number of mental health patients, as
approximately 17.4% of adult residents report having 14 or more poor mental health days within
the past 30 days (NJ.gov, 2021). The clinic offers services to the community for mental health
patients that incorporate mental wellness and how daily cognitive habits affect a patient's overall
well-being, behaviors, and emotions (Gross et al., 2019). The clinic is staffed by several mental
healthcare professionals, including physicians, nurse practitioners, and physician associates who
have experience working within the mental health field and supporting staff.
Sample
The investigator used convenience sampling to recruit participants from a population of
mental health patients and target patients at one specific behavioral health clinic. Convenience
sampling is a non-probability sampling procedure that involves participant recruiting from a
population of people who meet set inclusion criteria and can be conveniently located by the
investigator (Qureshi, 2018). Convenience sampling is appropriate for the current project as the
investigator is familiar with the clinic's staff.
The participants were selected from a target population of clinic patients who met the
following inclusion criteria: a) must be a listed patient at the clinic, b) must be taking a
prescribed benzodiazepine, c) must be seen at least monthly by one of the clinic's mental health
professionals, d) must be willing and volunteer for participation, and e) must be 18 years of age
and speak the English language. Individuals meeting the inclusion criteria were selected and

28

required to sign an informed consent form (Appendix A) which provided the details of the
project and explained all the protections warranted to the participants involved in the project.
The investigator determined a sample of 41 patients provided the necessary results.
Recruitment for these participants first required the investigator to receive signed site permission
from the clinic. This permission allowed the investigator to recruit participants from the clinic.
Next, the investigator informed patients of this project when they arrived for their respective
scheduled appointments. Each participant received a written explanation of the project's purpose,
objectives, and procedures, as explained in this proposal. An email was then sent to each
participant during the session asking them to consent and take the pre-survey.
Ethical Considerations
Ethical considerations are necessary by federal law and university policy when
undergoing research. The Belmont Report expresses three specific and fundamental ethical
principles with their applicability to clinical trials: a) respect for persons, b) beneficence, and c)
justice (U.S. Department of Health and Human Services, 1979). The three principles ensure the
participants are protected by factors protecting participant rights. The investigator is responsible
for safeguarding the participant's identity and mental state during the project. The current project
was approved by the university's Institutional Review Board (IRB).
Additionally, the investigator required a signed informed consent from all participants
and ensured all project information was understood and supported the participant's privacy.
There were no potential risks to the participants. However, if any participant would have felt
discomfort or chose to discontinue the survey, they were advised they could exit the survey and
cease involvement with the study at any time without negative consequences.

29

All participants were not identified as the surveys were anonymously taken online. There
were no identifying markers attached to the surveys, and the investigator had no knowledge of
the participant's identity by the survey. There was no identifying information or way for the
investigator to know if a participant completed the surveys or which survey results were a
specific participant. Each participant selected the first initial of their mother's maiden name, the
first letter of their first job, favorite color, and favorite number. All participants were encouraged
to keep their codes.
The investigator also provided secure storage for all data collected. As the informed
consent and the pre and post-surveys were all given online, the data were downloaded onto the
investigator's laptop and placed in a password-protected folder to which only the investigator has
access. When not in use, the computer was secured in a locked room or office. The data will be
saved for three years and then permanently deleted from the investigator's laptop memory and
hard drive.
Instrumentation
The instrumentation used for this project was a pre and post-survey developed by the
investigator. Internet surveys are convenient and efficiently provided to participants with an
immediate download of anonymous data available. This survey consisted of 20 questions
(Appendix C) which the participants were asked to answer honestly and truthfully. The survey
questions included such topics as medication knowledge and readiness to change during regular
clinic appointments. At the end of the pre-survey, all participants were introduced to the Patient
Education for Benzodiazepines Toolkit. After completing the toolkit education with their
prescriber, they were emailed the voluntary, anonymous post-survey and requested to complete it
within two weeks.

30

Before recruiting, the investigator completed a pilot study. Two volunteers were recruited
after meeting the inclusion criteria and asked to take the survey, then provide comments on the
questions' viability. A pilot study is a small-scale, preliminary means to ensure the
instrumentation is valid (In, 2017). The use of a pilot study determined that the full-scale project
was feasible and produced recordable results.
Data Collection
After the pilot study and recruiting process were completed, each of the 41 selected
participants was provided via email with the pre-survey online URL during their scheduled
appointments. To begin the pre-test survey, each participant granted consent. Then, the survey
link was sent to each participant via email. These surveys took less than 10 minutes to complete,
and again the investigator assured the participants of confidentiality by protecting their identity.
After all 41 participants completed the pre-survey, the investigator provided each patient
the toolkit, which the investigator reviewed with patients during their respective sessions or
appointments. All patients retained the toolkit for use in the future. Once completed, the
participants emailed the investigator, who then emailed the post-survey URL. The participant
had 14 days to complete the survey but was encouraged to take the post-test survey the same day
the toolkit was explained.
The pre and post-test surveys contained 20 questions involving responses from the
participants related to their knowledge and use of benzodiazepines, the medication knowledge,
and examination of the participant's readiness to change during future therapy appointments. The
survey questions were based on the participant's current understanding of their prescribed
benzodiazepine medication. The toolkit provided comprehensive and informational education on

31

benzodiazepines and discussed the benefits and risks, dangers, and long-term effects of these
drugs.
Data Analysis
The purpose of this project was to advance patient safety and engagement through the use
of an investigative patient-centered benzodiazepine education Toolkit. The current project aimed
to answer the following research questions and support the associated hypotheses.
Q1: Will education of patients on benzodiazepines using the investigator-developed
toolkit improve the patient's knowledge of safe benzodiazepine use?
H10: The education of patients on benzodiazepines using the investigator-developed
toolkit will not improve the patient's knowledge of safe benzodiazepine use.
H1a: The education of patients on benzodiazepines using the investigator developed
toolkit will improve the patient's knowledge of safe benzodiazepine use
Q2: Will education of patients on benzodiazepines using the investigator-developed
toolkit increase a patient's readiness to change by successfully weaning off after long-term
benzodiazepine use?
H20: The education of patients on benzodiazepines using the investigator-developed
toolkit will not increase a patient's readiness to change by successfully weaning off after
long-term benzodiazepine use.
H2a: The education of patients on benzodiazepines using the investigator-developed
toolkit will increase a patient's readiness to change by successfully weaning off after
long-term benzodiazepine use.
The independent variable examined is the use of the educational benzodiazepine toolkit,
which caused changes in the two dependent variables of increased readiness to change and

32

improved knowledge of benzodiazepines. The raw data were exported from the survey program
and saved into an SPSS software program. The software identified the cause and effect using a
multiple linear regression test.
Multiple linear regression was used to test the independent variable, use of the toolkit,
and showed the dependent variables' predicted outcomes. The project's expected direct care
outcome was to educate and improve the patients' knowledge of safe benzodiazepine use and
increase their readiness to change by weaning and discontinuing benzodiazepines. This initial
program evaluation helped clarify if the patient education benzodiazepine toolkit improved
medication knowledge and willingness to change.
Summary of Methodology
Chapter three explained the methods and design used for the current project and included
the data collection and analysis methods. The chapter also consisted of the introduction of the
instrumentations provided to the participants. The instrumentations were in the form of online
pre-and post-surveys, each used to collect the answers from the participants. Each participant
was selected through convenience sampling and provided all the necessary ethical considerations
to protect their human data as required by the university's IRB and stated in the Belmont Report.
As the overall purpose of the current quantitative correlational study was to assess if the
independent variable causes a change in the posed dependent variables, the investigator
answered the research questions and either rejected or failed to reject the null hypotheses.
Chapter 4 of the proposed study continued with data collection, analysis, and presentation of the
survey results.

33

Chapter 4
Results and Discussion
The purpose of this project was to advance patient safety and engagement through the use
of a patient-centered benzodiazepine education toolkit. The project's expected direct care
outcome was to educate and improve the patients' knowledge of safe benzodiazepine use and
increase their readiness to change by weaning and discontinuing benzodiazepines. A sample of
mental health patients at one specific behavioral health clinic was asked to respond to an online
pre and post-test survey. The research questions and hypotheses that guided this project are as
follows:
Q1: Will education of patients on benzodiazepines using the investigator-developed
toolkit improve the patient's knowledge of safe benzodiazepine use?
Q2: Will education of patients on benzodiazepines using the investigator-developed
toolkit increase a patient's readiness to change by successfully weaning off after long-term
benzodiazepine use?
H10: The education of patients on benzodiazepines using the investigator-developed
toolkit will not improve the patient's knowledge of safe benzodiazepine use.
H1a: The education of patients on benzodiazepines using the investigator developed
toolkit will improve the patient's knowledge of safe benzodiazepine use
H20: The education of patients on benzodiazepines using the investigator-developed
toolkit will not increase a patient's readiness to change by successfully weaning off after
long-term benzodiazepine use.

34

H2a: The education of patients on benzodiazepines using the investigator-developed
toolkit will increase a patient's readiness to change by successfully weaning off after
long-term benzodiazepine use.
This chapter includes the presentation of the descriptive statistics of project variables.
This chapter also presents the summary statistics and the results of the linear regression analysis
conducted for this project. This chapter ends with the limitations and the summary of the results.
Results
A total of 50 participants were invited to participate. Among these, 41 participants
completed the pre-test survey while 34 participants completed the post-test survey. The response
rate for this project was 82%. Linear regression analyses were conducted to determine whether
there is a significant increase in the patient’s knowledge on safe Benzodiazepine use and the
patient's readiness to change by successfully weaning off after long-term benzodiazepine use.
The analyses determined that there was a significant increase in patients’ knowledge on safe
Benzodiazepine use. However, there was no significant increase in the patient's readiness to
change by successfully weaning off after long-term benzodiazepine use.
Discussion of Results
The majority of the participants have responded that they were using Benzodiazepine
because of anxiety. In the pre-test, 34 out of the 41 participants responded anxiety (82.9%),
while 29 of the 34 participants responded anxiety among the posttest participants (85.3%). There
were also some participants who responded that Benzodiazepine was used for panic attacks or
for sleep disorders.
Table 1
Frequencies and Percentages of the Reason for Benzodiazepine Use

35

Reason for
Benzodiazepine
Use

Anxiety
Cannot breathe
Panic attacks
Seizures
To make my life more manageable
To Sleep
To think clearly.
Missing

Total

Pre or Post
Pre
n
%
34
82.9
1
2.4
1
2.4
1
2.4
1
2.4
2
4.9
0
0.0
1
2.4
41
100.0

Post
n
29
0
1
1
0
1
1
1
34

%
85.3
0.0
2.9
2.9
0.0
2.9
2.9
2.9
100.0

The patient’s knowledge of safe benzodiazepine use was calculated using their responses
in the survey questionnaire. The correct answer was given 1 point, while an incorrect answer was
not given a point. The sum of the scores for all items was used to measure the knowledge of safe
benzodiazepine use. The mean pretest score for knowledge of safe use was at 11.29 (SD = 1.68).
A decrease in the mean score for knowledge of safe use was observed at the post-test (M =
10.35, SD = 1.45). For the patient's readiness to change by successfully weaning off after longterm benzodiazepine use, the responses of participants on their feeling about decreasing
benzodiazepine use and their feeling about stopping benzodiazepine use were used. Based on the
data gathered, the mean score on the feeling about decreasing benzodiazepine use increased from
pre-test (M = 4.05, SD = 3.22) to post-test (M = 4.24, SD = 3.80). Similarly, the mean score on
the feeling about stopping benzodiazepine use increased from 3.37 in the pre-test (SD = 3.39) to
3.41 in the post-test (SD = 3.44).
Table 2
Descriptive Statistics of Project Variables based on Pre and Post-test Groups

36

Patient's
knowledge of
Feeling about
Feeling about
safe
decreasing
stopping
benzodiazepine benzodiazepine benzodiazepine
Pre or Post
use
use
use
Pre
Mean
11.29
4.05
3.37
N
41
41
41
Std. Deviation
1.68
3.22
3.39
Minimum
7.00
1.00
1.00
Maximum
13.00
10.00
10.00
Post
Mean
10.35
4.24
3.41
N
34
34
34
Std. Deviation
1.45
3.80
3.44
Minimum
6.00
1.00
1.00
Maximum
13.00
10.00
10.00
Total
Mean
10.87
4.13
3.39
N
75
75
75
Std. Deviation
1.64
3.47
3.39
Minimum
6.00
1.00
1.00
Maximum
13.00
10.00
10.00
The dependent variables were tested for outliers to determine whether the assumption of
outliers for linear regression analysis was met. Based on the boxplots presented in Figures 1, 2,
and 3, an outlier for case 45 of the patient’s knowledge of safe benzodiazepine use was observed.
The outlier value was substituted with the minimum possible value to satisfy the outlier
assumption. There was no outlier observed for the feeling about decreasing benzodiazepine use
and the feeling about stopping benzodiazepine use responses.

37

Figure 1
Boxplots for Patient’s Knowledge of Safe Benzodiazepine Use

Figure 2
Boxplots for Feeling about Decreasing Benzodiazepines Use

38

Figure 3
Boxplots for Feeling about Stopping Benzodiazepines Use

Testing of Null Hypothesis 1
H10: The education of patients on benzodiazepines using the investigator-developed
toolkit will not improve the patient's knowledge of safe benzodiazepine use.
H1a: The education of patients on benzodiazepines using the investigator developed
toolkit will improve the patient's knowledge of safe benzodiazepine use
A linear regression analysis was conducted to determine whether there was a significant
increase in patients’ knowledge of safe benzodiazepine use from pretest to posttest. The result of
the regression analysis is presented in Table 3. To check the assumption of independence, the
Durbin-Watson Statistic was determined at 2.151. The value of the Durbin-Watson statistic was
between 1.5 to 2.5 indicating that the assumption of independence was met. Moreover, the
assumption of multicollinearity was not applicable for the analysis because there is only one
predictor. The result of the regression analysis determined that there is a significant change in the
patient’s knowledge of safe Benzodiazepine use from pre-test to post-test (B = -.910, p = .013).
39

Table 3
Linear Regression Analysis for Patient’s Knowledge of Safe Benzodiazepine Use
Unstandardized
Coefficients
Model
1 (Constant)
Pre or Post

B
11.293
-0.910

Standardized
Coefficients

Std.
Error
0.241
0.359

Beta
-0.285

t
46.766
-2.538

Sig.
0.000
0.013

Patient's knowledge of safe benzodiazepine use; R-squared = .081; F(1,74) = 6.443, p = .013

Testing of Null Hypothesis 2
H20: The education of patients on benzodiazepines using the investigator-developed
toolkit will not increase a patient's readiness to change by successfully weaning off after
long-term benzodiazepine use.
H2a: The education of patients on benzodiazepines using the investigator-developed
toolkit will increase a patient's readiness to change by successfully weaning off after
long-term benzodiazepine use.
A linear regression analysis was conducted to determine whether there was a significant
increase in the feeling about decreasing Benzodiazepine use from pretest to posttest. The result
of the regression analysis is presented in Table 4. To check the assumption of independence, the
Durbin-Watson Statistic was determined at 2.063. The value of the Durbin-Watson statistic was
between 1.5 to 2.5, indicating that the assumption of independence was met. Moreover, the
assumption of multicollinearity was not applicable for the analysis because there is only one
predictor. The result of the regression analysis determined that there is no significant change in
the feeling about decreasing Benzodiazepine use from pre-test to post-test (B = .187, p = .819).
Table 4
Linear Regression Analysis for Feeling about Decreasing Benzodiazepine Use

40

Unstandardized
Coefficients
Model
1 (Constant)
Pre or Post

B
4.049
0.187

Standardized
Coefficients

Std.
Error
0.546
0.811

Beta
0.027

t
7.416
0.230

Sig.
0.000
0.819

Feeling about decreasing benzodiazepine use; R-squared = .001; F(1,74) = .053, p = .819

A linear regression analysis was conducted to determine whether there was a significant
increase in the feeling about stopping Benzodiazepine use from pre-test to post-test. The result of
the regression analysis is presented in Table 5. To check the assumption of independence, the
Durbin-Watson Statistic was determined at 2.014. The value of the Durbin-Watson statistic was
between 1.5 to 2.5 indicating that the assumption of independence was met. Moreover, the
assumption of multicollinearity was not applicable for the analysis because there is only one
predictor. The result of the regression analysis determined that there is no significant change in
the feeling about stopping Benzodiazepine use from pretest to posttest (B = .046, p = .954).
Table 5
Linear Regression Analysis for Feeling about Stopping Benzodiazepine Use
Unstandardized
Coefficients
Model
1 (Constant)
Pre or Post

B
3.366
0.046

Standardized
Coefficients

Std.
Error
0.533
0.791

Beta
0.007

t
6.317
0.058

Sig.
0.000
0.954

Feeling about stopping benzodiazepine use; R-squared = .000; F(1,74) = .003, p = .954

Limitations
Limitations are unavoidable consequences in a project that impacts data analysis results
(Ross & Bibler Zaidi, 2019). The first limitation was the sample size. Due to time constraints on
41

the project, the investigator sampled a limited number of 41 participants. There were only 41
participants in the pretest and 34 participants in the posttest, which limited the one-to-one
correspondence to pretest and posttest data. Therefore, responses were not compared directly and
were analyzed using linear regression analysis. The analysis cannot determine whether there was
an increase in response scores for each participant from pre-test to post-test. Another limitation
was the generalizability of the findings, which was limited due to the smaller sample size. A
third limitation was the location of the study, as the participants were all from a single mental
health clinic. The limitations were considered in drawing conclusions and recommendations for
this project.
Summary
The purpose of this project was to advance patient safety and engagement through the use
of a patient-centered benzodiazepine education toolkit. The project's expected direct care
outcome was to educate and improve the patients' knowledge of safe benzodiazepine use and
increase their readiness to change by weaning and discontinuing benzodiazepines. The results of
the analyses determined that there was a significant increase in patients’ knowledge of safe
Benzodiazepine use. However, there was no significant increase in the patient's readiness to
change by successfully weaning off after long-term benzodiazepine use.

42

Chapter 5
Summary, Conclusions, and Recommendations
This chapter will provide a discussion on the findings of this DNP project. This chapter
will begin with a reiteration of the project’s problem and purpose. Then, a summary of project
findings will be presented. Subsequently, this chapter will discuss implications for nursing and
avenues for future projects. Finally, this chapter will end with project conclusions.
Summary of Findings
The prevalence of substance abuse disorders, especially those related to opioid misuse,
continues to increase within the United States. However, patients are often unengaged in
treatment. They have few resources available to explain the safe use of drugs, like
benzodiazepines, or what to do when wanting to decrease/cease drug use. The purpose of this
project was to advance patient safety and engagement through the use of a patient-centered
benzodiazepine education toolkit. A sample of 41 mental health patients at one specific
behavioral health clinic was asked to respond to an online pre and post-test survey. The research
questions and hypotheses that guided this project are as follows:
Q1: Will education of patients on benzodiazepines using the investigator-developed
toolkit improve the patient's knowledge of safe benzodiazepine use?
Q2: Will education of patients on benzodiazepines using the investigator-developed
toolkit increase a patient's readiness to change by successfully weaning off after long-term
benzodiazepine use?
H10: The education of patients on benzodiazepines using the investigator-developed
toolkit will not improve the patient's knowledge of safe benzodiazepine use.

43

H1a: The education of patients on benzodiazepines using the investigator developed
toolkit will improve the patient's knowledge of safe benzodiazepine use
H20: The education of patients on benzodiazepines using the investigator-developed
toolkit will increase a patient's readiness to change by successfully weaning off after
long-term benzodiazepine use.
H2a: The education of patients on benzodiazepines using the investigator-developed
toolkit will increase a patient's readiness to change by successfully weaning off after
long-term benzodiazepine use.
The project's expected direct care outcome was to educate and improve the patients'
knowledge of safe benzodiazepine use and increase their readiness to change by weaning and
discontinuing benzodiazepines. The results of the linear regression analyses determined that
there was a significant increase in patients’ knowledge on safe Benzodiazepine use when
comparing pre-test and post-test scores. Thus, the toolkit appeared to be helpful in engaging
patients in their respective care and teaching patients how to more carefully engage in
benzodiazepine use and possible side effects of benzodiazepine use.
However, when considering the second project question, the results were not statistically
significant. There was no significant increase in the patient's readiness to change by successfully
weaning off after long-term benzodiazepine use. Thus, even with the help of the patient-centered
toolkit, patients did not demonstrate statistically significant changes in wanting to decrease
benzodiazepine use nor stop benzodiazepine use altogether.
Implications for Nursing
Findings for both project questions have implications for nursing practice. First, when
considering the overall results of this project, patients demonstrated increased knowledge of

44

benzodiazepine use, demonstrating that the toolkit was easy to navigate and understand. Thus,
integrating a patient-centered toolkit focused on benzodiazepine use may continue to be helpful
to patients prescribed benzodiazepines as part of treatment. In addition, healthcare providers may
be encouraged to provide and discuss this toolkit with patients or adopt similar toolkits to
increase awareness of proper drug usage and willingness to change.
The first project question was established to answer whether participation in the patientcentered toolkit increased knowledge of safe benzodiazepine use. Although the sample for this
study was relatively small (N = 41), findings demonstrate that patients’ education on safe
benzodiazepine usage was significantly improved after using the toolkit. Therefore, mental
health care professionals, nurses, and other healthcare administrators may benefit from
implementing this toolkit or a similar toolkit to improve patient knowledge on benzodiazepine
use before or during treatment with benzodiazepines. Further, healthcare professionals may
benefit from implementing similar toolkits regarding opioid drugs as part of patient treatment
plans.
When considering the second project question, the toolkit did not facilitate statistically
significant changes in patients' willingness to change by either decreasing or ceasing the use of
benzodiazepines. Although findings were not significant, mental health professionals, nurses,
and medical professionals may find this information helpful in informing future initiatives to
decrease or stop benzodiazepine use among patients. With the understanding that the information
in the toolkit did not produce changes in willingness to cease or reduce benzodiazepine use,
future initiatives could bolster information and focus more on these aspects within future
toolkits. Additionally, healthcare providers may benefit by implementing strategies in
conjunction with the toolkit to try and increase patients’ willingness to change.

45

Recommendations for Further Project
Overall, the patient-centered toolkit was beneficial in improving patients’ knowledge
regarding safe usage of benzodiazepines. Although the results of this project are promising,
findings do indicate areas where future investigators may want to focus. First, a future
investigator could replicate this study to include more information on decreasing and ceasing the
use of benzodiazepines. Additionally, the replicated study could ask questions regarding which
aspects were most helpful/least helpful to participants to bolster the efficacy of the toolkit.
Future investigators may also want to include a matched-pair design, in which the
investigator can compare a participant’s pre-test and post-test scores. This way, the investigator
may learn the degree to which each participant found the toolkit useful. This may help develop
more targeted toolkits in the future.
Another avenue for future investigators is to replicate this study with a different sample.
Future investigators may want to use an increased sample size. This way, the reliability of test
results can be tested. In addition, the investigator might find it beneficial to sample from multiple
mental health clinics or from various settings to test the toolkit among a more heterogeneous
sample. Finally, future investigators may want to keep track of participants’ demographics to see
differences in toolkit efficacy when demographics are considered. Keeping track of patient
demographics may allow for more targeted toolkits for different genders, ethnicities, or ages to
be created in the future.
These avenues for future investigation may help develop and refine patient-centered
interventions focused on safe benzodiazepine usage or the willingness to decrease or cease
participation in benzodiazepine use. As the opioid crisis continues to impact the well-being of
thousands adversely, innovative treatment options are imperative. The findings of this project

46

should be used to inform current practice and guide future investigators in finding practical and
effective solutions to combat unsafe or unnecessary benzodiazepine use.

47

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Appendix A: Informed Consent

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Appendix B: Evidence-Based Educational Toolkit

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Appendix C: Pre and Post Survey Questions

1. Do you grant consent to participate?
2. What is the name of the benzodiazepines you are taking? (do not worry about your
spelling!)
3. Why are you taking the medication? (What is the goal)
4. The most severe risks in taking benzodiazepines include: (check all that apply)
a. Permanent brain changes
b. Frequency of accidents including motor vehicle
c. Frequency of falls
d. Addiction
e. Overdose
f. Death
g. All of the above
5. What are some other serious side effects of taking benzodiazepines (choose all that
apply)?
a. Feeling tired or sleepy
b. Feeling dizzy
c. Headaches
d. Confusion, memory loss
e. No emotions
f. Low awareness
g. Muscle weakness
h. Tremor/Shakes
i. Depression
j. Insomnia/Trouble sleeping
k. All of the above
6. Please choose the correct statements about the use of benzodiazepines
a. Taking street drugs will greatly increase your risk of being hurt or
overdosing
b. You should share information on all prescribed and street drugs with your
prescriber
c. Taking more medications than you have been prescribed can make you
addicted or dependent on Benzodiazepines
d. Benzodiazepines are often prescribed to be taken as needed. This means
that you should only take your Benzodiazepine when you are feeling
stressed, anxious, and are unable to stop or control your worries.
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e. All of the above

7. What should you do about the side effects?
a.
b.
c.
d.

Stop the medicine
Call your prescriber
Seek emergency care if serious
All of the above

8. Can you drive safely when you are feeling drowsy or notice the effects of your
Benzodiazepine?
a. Yes
b. No
9. Can you safely drink alcohol with this medicine?
a. Yes
b. No
10. When you are prescribed a new pain pill or sedative medicine you should discuss it
with your benzodiazepine prescriber before starting it.
a. True
b. False
11. Can you share this medication with other people that you think may need it?
a. Yes
b. No
12. How should you store your benzodiazepines medication (choose all that apply)
a.
b.
c.
d.
e.

Cool Dry Spot
Secure area
Where not one will accidently see it
With a child safety lid
In the bottle it comes in (With your prescription information)

13. How do you refill this medicine? (Check any that apply)
a.
b.

Call at least 7 days before the refill is needed
Keep or reschedule all appointments with your mental health prescriber

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14. Please choose true statements about benzodiazepines.
a. Benzodiazepines are often prescribed to be taken as needed. This means
that you should only take your Benzodiazepine when you are feeling
stressed, anxious, and are unable to stop or control your worries.
b. It is acceptable to adjust your own dose of Benzodiazepine
c. You should never share your Benzodiazepine
d. All of the above
15. You should inform your prescriber immediately if you are pregnant, think you may be
pregnant or are breastfeeding.
a. True
b. False
16. I have been given crisis numbers and contacts and know how to get emergency help
a. True
b. False
17. My prescriber can work with me to develop a plan to safely and comfortably wean off
my benzodiazepines
a. Yes
b. No
c. Maybe
18. How long are you supposed to take the medication?
19. On a scale of 1 to 10 starts how do you feel about decreasing your benzodiazepines
use?
20. On a scale of 1 to 10 starts how do you feel about stopping your benzodiazepines use?

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