Friday, January 29, 2016

Attitudes Towards a Maintenance (-agonist) Treatment Approach in High-Dose Benzodiazepine-Dependent Patients

High-dose benzodiazepine dependence constitutes a major clinical concern. Although withdrawal treatment is recommended, it is unsuccessful for a significant proportion of affected patients. More recently, a benzodiazepine maintenance approach has been suggested as an alternative for patients' failing discontinuation treatment. While there is some data supporting its effectiveness, patients' perceptions of such an intervention have not been investigated.

An exploratory qualitative study was conducted among a sample of 41 high-dose benzodiazepine (BZD)-dependent patients, with long-term use defined as doses equivalent to more than 40 mg diazepam per day and/or otherwise problematic use, such as mixing substances, dose escalation, recreational use, or obtainment by illegal means. A qualitative content analysis approach was used to evaluate findings.

Participants generally favored a treatment discontinuation approach with abstinence from BZD as its ultimate aim, despite repeated failed attempts at withdrawal. A maintenance treatment approach with continued prescription of a slow-onset, long-acting agonist was viewed ambivalently, with responses ranging from positive and welcoming to rejection. Three overlapping themes of maintenance treatment were identified: "Only if I can try to discontinue…and please don't call it that," "More stability and less criminal activity…and that is why I would try it," and "No cure, no brain and no flash…and thus, just for everybody else!"

Some patients experienced slow-onset, long-acting BZDs as having stabilized their symptoms and viewed these BZDs as having helped avoid uncontrolled withdrawal and abstain from criminal activity. We therefore encourage clinicians to consider treatment alternatives if discontinuation strategies fail.

...In this explorative study, participants often used the term “substitution” in their initial narrative, primarily while referring to the substitution of benzodiazepines for other psychotropic substances like alcohol or heroin. The statement of VP22 exemplifies this perception:

“…Initially I took mostly heroin and when I wanted to sleep I just waited until the flash wore off. But when I could not fall asleep this way, then I thought, instead of taking more Heroin, I take a benzodiazepine, then I did not just save money, but it also helped better to fall asleep. O.k. with heroin you can also fall asleep, but actually out of cost considerations I switched over to benzodiazepines...”
VP 22, male, 46 years

Furthermore, participants associated “substitution” with the replacement of BZDs with a non-BZD class of agents such as antipsychotics or antidepressants, which was something they had often experienced during treatment. In addition, some participants described a long-term BZD maintenance approach with a slow-onset, long-acting BZD, when referring to previous experiences and preferences for different kinds of BZDs. Only few participants had heard of a “maintenance” approach by their treating physicians, reflecting the heterogeneity of this sample in regard to treatment duration (weeks to years) and form of intervention, ranging from abstinence-oriented benzodiazepine discontinuation approach to the more permanent prescription of slow-onset, long-acting BZDs.

Perceptions and beliefs about an agonist treatment (or “maintenance”) approach had to be elucidated using non-judgmental questions: “How would you feel about a substitution for benzodiazepines? Like, for example, heroin, that gets substituted with methadone?” Furthermore and in cases of highly knowledgeable participants, we gave more specific examples for slow-onset, long-acting benzodiazepines usually by mentioning specific brand names.

However, participants’ statements in regard to such a treatment strategy sometimes appeared to contradict their previous statements or explanations. Although we tried to clarify apparent inconsistencies using additional probes, they persisted in four instances:

“…For me, personally, that is nothing…I think that is a stupid question, but with heroin you have, but I never tried heroin, as far as I know you have a “high.” And that is something you don’t have with methadone. The “high” feeling is removed with methadone—it just eases withdrawal effects…And benzodiazepines do not make a “high,” so there is no “high” feeling, at least not with me…so I would not take (substituting drugs) since I don’t have side effects from benzodiazepines…if someone just overcomes feelings of anxiety and then does not need benzos anymore, then I think it is good, if there is such a development…but I am very happy that they are around...”
VP6, male, 30 years... 

Full article at:

  • 1Department of Forensic Psychiatry, Institute of Legal Medicine, University of Bern, Bern, Switzerland.
  • 2Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.
  • 3Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland.
  • 4Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.
  • 5Ulmenhof, Sozialtherapie, Ottenbach, Switzerland.
  • 6University of Pennsylvania Health System, Philadelphia, USA.
  • 7Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland. 
  •  2016 Jan 8;13(1):1. doi: 10.1186/s12954-015-0090-x.

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