Bakker A, Streel E. Benzodiazepine maintenance in opiate
substitution treatment: Good or bad? A retrospective primary care case-note
review. Journal of Psychopharmacology 2016 1-5
Dear Colleagues,
Finally we have some strong evidence that prescribing
benzodiazepines for patients on opiate maintenance treatment is not only safe
and effective but in some cases may be obligatory, under careful supervision
with adequate psychosocial supports.
Dr Bakker in London has done us the great service of
publishing the data he has extracted from his own general practice from over 20
years of caring for drug dependent patients.
His practice is based on sound harm reduction principles, prescribing
long acting, low potency benzodiazepines such as diazepam or clonazepam using
graduated supervision for dependent patients.
In this he bucked the trend based on what he considered good medical
practice, albeit non-evidence based (like much prescribing practice).
Bakker reports on 278 OTP patients since 1998 (1289
patient/treatment years) comprising a high proportion of socio-economically
deprived citizens, two thirds being male.
Regarding prescription for benzodiazepines (bzd) from the practice, patients
were classified ‘never prescribed bzd’, ‘occasional prescription bzd’ and
‘maintenance bzd. Further, he examined
those still in treatment against those who had departed (96% still in UK, 4%
gone overseas, lost to follow-up). From
comprehensive statistics kept by the British NHS Bakker was able to derive
accurate mortality figures for these six groups with surprising results for
retention and mortality.
Never Occasional Maintenance
Current pats: 223t/y 301t/y 765t/y
Mortality: 1.79p100ty 0.33p100ty 1.31p100ty
Retention 34
months 51
months 72
months
Ex-patients: 267t/y 320t/y 305t/y
Mortality: 2.24
p100t/y 0.63
p100t/y 5.90 p100t/y
Excess mort: 125% 191% 450%
T/y = treatment years
Contrary to some expectations, retention was highest in the
group prescribed maintenance benzodiazepines.
Furthermore, mortality was lower than in the group never prescribed
sedatives and the lowest mortality was intriguingly in those occasionally
prescribed sedatives. However, the most
meaningful, and very worrying statistic is the high mortality in maintenance
patients who transferred elsewhere for their treatment (more than 4 fold those
remaining in treatment at Dr Bakker’s practice in London). The authors report that following health
authority directives very few maintenance prescribers in the UK allow
benzodiazepine prescription in parallel as Dr Bakker’s practice does. Hence the likely inference that these patients
had legal supplies of benzodiazepines curtailed on transferring elsewhere for
their OTP treatment.
Another important finding was that the death rates were lowest,
and very significantly lower, in those prescribed benzos occasionally, both in-house
patients and in those transferred elsewhere.
This report is not a randomised controlled trial, nor was it
prospective, yet it involves large numbers of patients in a normal medical
population over a long period with very few lost to follow-up (4%). Hence the findings are very meaningful for
those involved in comparable practice providing opiate maintenance with
methadone and/or buprenorphine in a community setting.
From this paper is it apparent that withdrawing
benzodiazepines may increase mortality substantially. Hence, official guidelines and clinical
recommendations which warn against benzodiazepine prescription may be
contributing to excess deaths rather than preventing them. In my experience most OTP prescribers have a
small number of patients who are prescribed benzodiazepines, some long-term. Yet up to 70% of our patients have had
problems with sedatives and so to ignore this and advise: ‘just say no’ may not
be the proper approach. However,
prescribing is well beyond the comfort zone for many in our field without
formal protocols.
It is my view that all dependent patients should be able to
access benzodiazepines under some clinical framework although this should not
be open-ended, just like methadone.
There should be dose supervision initially ranging to normal
unsupervised prescription for those who are socially integrated but unable or
unwilling to cease sedative use. Those abusing
alcohol should be excluded until they can demonstrate abstinence. Trial dose reductions should be negotiated
periodically, as with methadone. In our
own practice we use diazepam and we aim to a dose of 4-15mg daily which is
satisfactory for the great majority after initial reductions.
Notes by Andrew Byrne ..
Bakker article PDF:
References: Franklyn AM, Eibl JK, Gauthier G, Pellegrini D,
Lightfoot NK, Marsh DC. The impact of benzodiazepine use in patients enrolled
in opioid agonist therapy in Northern and rural Ontario. Harm Reduction Journal
2017 14:6
Weizman T, Gelkopf M, Melamed Y, Adelson M, Bleich A. 2003
Treatment of benzodiazepine dependence in methadone maintenance treatment
patients: A comparison of two therapeutic modalities and the role of
psychiatric comorbidity. Aust N Z J Psychiatry 37: 458–463
Lader M. Benzodiazepines revisited—will we ever learn?
Addiction 2011 106:2086-2109
Liebrenz M, Boesch L, Stohler R, Caflisch C. Agonist
substitution-a treatment alternative for high-dose benzodiazepine-dependent
patients? Addiction 2010 105;11:1870–1874
