Of Substance 2010 Vol 3 p11 ‘Research digest’.
View from the coalface … Redfern, inner Sydney
Andrew Byrne*
After many years of wrestling with the problem of
benzodiazepine use in opioid-dependent patients, it was
reassuring to read this prominent paper by Liebrenz
and colleagues. Their hypothesis is an approach using
what appear to be harm reduction principles, parallel to
methadone maintenance. Our original practice policy
was to ‘just say no’ but despite our entreaties, about one-
third of our patients continued to use benzodiazepines on
urine testing. A number did succeed at abstinence, only to
relapse with significant harms occurring due to disinhibited
behaviour, often involving amnesia of the events.
Some patients were able to function almost normally
while taking illicit benzodiazepines. Others became
disorganised regarding their finances, housing and
interpersonal relationships, some even coming to the
attention of the police or emergency departments.
Although there appeared to be a number of patterns
of tranquilliser use, from binge and recreational use to
quasi-therapeutic, we treated all such patients the same
way initially, using diazepam 5mg tablets supervised at the
clinic. Those currently abusing alcohol were excluded.
Each patient needed to return at least once, about three
hours after a witnessed dose for a brief examination to
confirm their tolerance and exclude intoxication. All
patients also had to agree to random urine testing and
regular medical consultations to assess progress.
Our impression has been that when given access to
diazepam under close supervision, stability returned
to most such patients. A recent audit of our referral
dependency practice showed that of 167 pharmacotherapy
patients (80% methadone, 20% buprenorphine), 30%
were being prescribed benzodiazepines, mostly under
supervision. The mean dose was 14 mg daily (range
2mg-25mg). One-third were gainfully employed.
Thus we can confirm that some of the protocols alluded
to in the forward-thinking item in Addiction are feasible
and are ripe for research. Inquiries showed that many of
our colleagues had one or two pharmacotherapy patients
taking long-term benzodiazepines and nearly all had
organised supervised dosing at least once.
Benzodiazepine use has been the ‘elephant in the room’
in addiction treatment. While most centres still use an
abstinence approach, many patients continue to use
these drugs. Since benzodiazepines, along with alcohol,
constitute a major source of drug-related harm, it may
be timely to reassess our approach. Severe restrictions
on supply alone have historically never solved drug
problems. Such restrictions also necessarily reduce access
to those who need the drugs therapeutically. As with
many other areas of public health, we believe that it is
possible to translate the principles of ‘harm reduction’ to
benzodiazepine use by utilising the protocols of ‘universal
precautions’ espoused by Dr Gourlay in Canada.
The use of benzodiazepine maintenance is probably at
the same stage of ‘evidence’ as methadone treatment was
in about 1980. It appears to be acceptable to the patient
population; it appears to be safe in practice, yet definitive
research is awaited to prove its effects … and to identify
optimal dosing, supports and necessary supervision.
* Dr Andrew Byrne is a Sydney GP specialising in
drug dependency.
http://www.ofsubstance.org.au/images/archive/pdf/ofsubstance_2010_3.pdf [full newsletter download]
Byrne A. View from the coalface … Redfern, inner Sydney. Of Substance. 2010;3:11
Liebrenz M, Boesch L, Stohler R, Caflisch C. Agonist substitution-a treatment alternative for high-dose benzodiazepine-dependent patients? Addiction. 2010 Apr 27 Early View
