A Randomized, Placebo-controlled trial of Buspirone for the Treatment of Anxiety in Opioid-dependent Individuals. McRae AL, Sonne SC, Brady KT, Durkalski V, Palesch Y. American Journal on Addictions 2004 13;1:53-63
Dear Colleagues,
This study identified 130 of 297 methadone maintained patients who exhibited symptoms of anxiety, of whom 62 met criteria for treatment with non-benzodiazepine sedative buspirone (‘Buspar’). By randomising subjects to receiving placebo or active drug they found no significant difference in outcomes in a 3 month trial period. The groups were treated using average methadone doses between 85 and 103mg daily (range 20-200mg) which should be adequate according to most clinical recommendations. Up to 60mg buspirone daily was prescribed in increasing doses. Riboflavin was used as placebo which allowed a check for compliance.
Although no significant differences were found in the buspirone group, this study shows the frequency of anxiety and depressive symptoms in the addict population. It also showed that there may be some improvement in depressive symptoms with buspirone although it is not an antidepressant.
The connection between drugs and anxiety/depression is very complex. In some the symptoms may precede drug use while in others it may stem from the dependency and life situation. Alcohol is probably the most common drug used for anxiety but in some it becomes a problem, causing acute intoxication, dependency and other mischief. Benzodiazepines have major disadvantages which are now clearly spelled out by the drug manufacturers such that they advise against them for longer-term conditions like chronic anxiety, and contraindicate them altogether in patients who are prone to dependency.
Thus some doctors are reluctant to prescribe benzodiazepines even when they might still be clinically indicated and in whom they have been used as self-medication. Some methadone patients appear to do well with maintenance diazepam where they have been unsuccessful at dose reductions, but this needs to be supervised. The total daily dose and degree of supervision depends on the individual but more research is needed to document whether such prescribing is safe and effective, and when it can safely be diminished. Some anxious patients say that heroin is the best ‘treatment’ they have had! Hence we are starting at some serious disadvantage with such patients. Methadone dose should always be optimised in such patients by considering post-dose examinations, blood methadone levels, dose adjustments or even dose splitting.
Comments by Andrew Byrne ..
