BACKGROUND:
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.
METHODS:
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.
RESULTS:
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!"
CONCLUSIONS:
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...
- 1Department of Forensic Psychiatry, Institute of Legal Medicine, University of Bern, Bern, Switzerland. Michael.Liebrenz@fpd.unibe.ch.
- 2Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland. Michael.Liebrenz@fpd.unibe.ch.
- 3Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland. marcelandre.schneider@gmail.com.
- 4Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland. Anna.Buadze@puk.zh.ch.
- 5Ulmenhof, Sozialtherapie, Ottenbach, Switzerland. marie-therese.gehring@diealternative.ch.
- 6University of Pennsylvania Health System, Philadelphia, USA. Anish.Dube@gmail.com.
- 7Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland. Carlo.Caflisch@puk.zh.ch.
- Harm Reduct J. 2016 Jan 8;13(1):1. doi: 10.1186/s12954-015-0090-x.
