CSTARS: Innovative Program Helps Older Adults Safely Discontinue Benzodiazepines

What Is CSTARS and Why Is It Important?

Researchers have developed a novel intervention combining pharmacist-led tapering with mindfulness-informed cognitive behavioral therapy (CBT) to help older adults safely discontinue benzodiazepines, addressing a significant public health concern. The program, named CSTARS (Confidence-Building Strategies for Reducing Sedative Medications), was designed as a scalable approach for primary care settings where most benzodiazepine prescribing occurs, yet few structured deprescribing programs exist.

Chronic benzodiazepine use among older adults remains stubbornly common despite well-documented risks including falls, cognitive impairment, functional decline, and increased mortality. The 2025 Joint Clinical Practice Guidelines on Benzodiazepine Tapering strongly recommends deprescribing in older adults, emphasizing the importance of gradual tapering combined with psychosocial support. While pharmacist-led tapering programs have shown promise, they typically don't address psychological barriers to discontinuation. Previous supportive interventions have largely focused on intensive, disorder-specific CBT treatments that are difficult to implement broadly due to resource constraints and limited generalizability across patient populations. CSTARS addresses this gap by offering a brief, generalizable intervention designed for primary care implementation. The developers used a step-wise approach, starting with a literature review to identify key factors affecting discontinuation success, followed by qualitative interviews with patients who had previously attempted tapering and feedback from a national stakeholder group including patients and caregivers. This data informed the development of the intervention manual and conceptual model, which targets self-efficacy as a primary mechanism for successful deprescribing. The program consists of a 10-week pharmacist-led tapering protocol combined with three psychologist-led CBT sessions at weeks 0, 2, and 6. The pharmacist component emphasizes patient control over the taper pace, collaboratively developing personalized plans for reduction or discontinuation. The CBT sessions focus on building confidence through addressing fears about the tapering process, teaching mindfulness techniques to respond purposefully rather than automatically to difficulties, and providing concrete coping strategies for managing withdrawal symptoms.

What Do Patients and Stakeholders Say?

Qualitative data from eight individual interviews revealed several important themes that shaped the intervention. Participants were on average 74 years old, predominantly male (63%), and White (87%), with most previously prescribed lorazepam. Patients consistently emphasized the importance of autonomy in the tapering process, with one participant noting, "It was between the two of us, discussing what I was comfortable with... I felt like I had somebody on my team." Many expressed concerns about withdrawal symptoms and sleep difficulties during tapering, with another stating, "I ended up getting on the Internet saying, I'm going crazy. Something's wrong with me. I didn't know that was really connected to the withdrawal of the med." Stakeholders stressed the need for realistic expectations, with one focus group participant explaining, "I think the biggest piece for me was acceptance... I basically got comfortable feeling uncomfortable and I stopped fighting the symptoms and that's when things sort of progressed for me." These insights directly informed the intervention's emphasis on patient control, education about withdrawal symptoms, and mindfulness-based acceptance strategies.

How Does CSTARS Redefine Deprescribing Models?

The CBT component of CSTARS distinctly differs from existing approaches by targeting confidence for completing the taper rather than treating an underlying disorder, making it applicable to a broader range of patients. It incorporates mindfulness strategies to help patients purposefully respond to difficulties during tapering rather than reacting automatically, and focuses on building confidence through addressing fears, normalizing withdrawal experiences, and providing concrete coping skills. The Week 0 session focuses on addressing common fears and worries about the taper process, using the "benzodiazepine flu" metaphor to emphasize the temporary nature of withdrawal symptoms. Participants are introduced to the 3-minute breathing space exercise and various coping strategies including scheduling pleasant activities, positive coping statements, self-compassion, and relaxation techniques. Weeks 2 and 6 focus on reviewing progress, problem-solving barriers, and developing plans for continued skills practice.

CSTARS represents a notable shift from existing deprescribing models by prioritizing scalability and generalizability while maintaining personalization through individual sessions. Unlike traditional disorder-specific interventions that require extensive therapeutic resources, this brief intervention model could potentially be implemented across diverse primary care settings. The national stakeholder focus group, which included five participants representing patient, family, and organizational interests, emphasized the need for a slow, patient-led taper process, frequent reassurance, and whole-person care. Stakeholders also highlighted the value of peer support from individuals who had already completed a taper and the importance of providers being knowledgeable about and not dismissive of withdrawal experiences.

What Broader Industry Trends Does CSTARS Reflect?

If proven effective, CSTARS could offer healthcare systems a cost-effective approach to addressing inappropriate benzodiazepine use in older adults. The research team is currently conducting a pilot feasibility trial, which will inform further refinements before a larger efficacy study to determine whether the addition of mindfulness-informed CBT sessions improves outcomes beyond pharmacist-led tapering alone. Future research will need to assess whether three CBT sessions are sufficient for improving outcomes and whether targeting self-efficacy as the primary mechanism is adequate for producing meaningful change. Additional studies may develop decision trees to determine which patients need more intensive, disorder-specific support versus the generalized support offered by CSTARS.

Industry Context: The development of CSTARS reflects growing recognition of deprescribing as a critical component of medication management in aging populations. As healthcare systems face mounting pressure to reduce inappropriate medication use and associated costs, scalable interventions that can be implemented in primary care settings are increasingly valuable. The integration of behavioral health approaches with medication management aligns with broader trends toward collaborative care models, potentially offering pharmaceutical and healthcare stakeholders new frameworks for addressing medication safety concerns beyond traditional prescribing guidelines. If successful, this approach could inform similar interventions for other high-risk medications, representing an important advancement in addressing polypharmacy challenges in older adults.

Summary

Researchers have developed CSTARS (Confidence-Building Strategies for Reducing Sedative Medications), an innovative intervention combining pharmacist-led benzodiazepine tapering with mindfulness-informed cognitive behavioral therapy to help older adults safely discontinue these medications. The program addresses a significant public health concern, as chronic benzodiazepine use among older adults carries well-documented risks including falls, cognitive impairment, and increased mortality, despite clinical guidelines recommending deprescribing. Unlike traditional approaches, CSTARS offers a brief, scalable intervention designed specifically for primary care settings, consisting of a 10-week pharmacist-led tapering protocol combined with three psychologist-led CBT sessions. The intervention was developed through literature review, qualitative interviews with patients who had previously attempted tapering, and stakeholder feedback, targeting self-efficacy as the primary mechanism for successful deprescribing. Qualitative data from participants revealed key themes including the importance of patient autonomy, concerns about withdrawal symptoms, and the need for realistic expectations, which directly shaped the intervention design. The CBT component distinctively focuses on building confidence for completing the taper rather than treating underlying disorders, incorporating mindfulness strategies to help patients respond purposefully to difficulties and providing concrete coping skills. CSTARS represents a notable shift in deprescribing models by prioritizing scalability and generalizability while maintaining personalization, potentially offering healthcare systems a cost-effective approach to addressing inappropriate benzodiazepine use. The research team is currently conducting a pilot feasibility trial to inform further refinements before a larger efficacy study, with future research planned to assess optimal session numbers and identify which patients may need more intensive support. This development reflects broader healthcare trends toward deprescribing as a critical medication management component and the integration of behavioral health approaches with medication management in collaborative care models.