7 July 2003

Benzodiazepine dependence - randomised reduction study.

In-patient benzodiazepine withdrawal: comparison of fixed and symptom triggered taper methods. McGregor C, Machin A, White JM. Drug and Alcohol Review (2003) 22:175-180

Dear Colleagues,

This group from Adelaide University has come up with yet another instructive study of great clinical relevance. Benzodiazepine dependence has been neglected for too long. Considering the substantial profits made by drug companies it is disappointing (cynics may say predictable) that so little funding has been given to the potential for harm from benzodiazepines in vulnerable populations such as the elderly and recreational drug users.

The authors remind us that although many treatment agencies give supervised tapering doses of diazepam, this procedure has not been systematically evaluated. As with nicotine, opiates and even stimulants, such therapeutic substitutions and subsequent reductions can be a feasible way of addressing dependency management. Longer term drug maintenance is a 'fall back' position, generally using long acting, oral forms with low toxicity, in cases where reductions repeatedly result in relapse.

This study showed no significant differences between those given fixed reductions versus symptom initiated dosing with diazepam. The intervention demonstrated numerous positive outcomes at one month follow-up in such poly-drug users up to a month after treatment. Patients had used a spectacular daily mean 'Valium-equivalent' of 115mg or 23 tablets! Two thirds were using more than one type of sedative on the week of admission. At least half of the 44 subjects were also opioid habitu├ęs. The mean hospital stay was 5 days, with subsequent tapering doses offered as outpatient treatment. At the end of one month, sedative use had declined dramatically from previous levels.

We know from the British 'NTORS' research and other opioid studies that even poor quality, non-evidence-based treatments can yield positive outcomes. Hence there still needs to be much more comparative work with benzodiazepine addiction. In the meantime, either of the treatments offered in this study would seem to be appropriate, safe and effective, at least in the short term. The fixed dose regimen started with an estimated equivalent up to 80mg diazepam daily in four divided doses, reducing at 10mg daily down to 40mg and by 5mg daily thereafter. Although supervised consumption is preferable, excessive supervision may cause patients to drop out. Also, hospital admission is neither acceptable nor necessary for the majority in community practice.

In our own practice, we have found that daily attendance with supervised dosing is suitable for patients whose drug use is chaotic. Later, second or third daily attendance can suffice as patients demonstrate features of stability. A small proportion seem to need to continue daily doses of diazepam indefinitely. Some may have pre-existing anxiety or panic disorders and a proportion may have unacceptable withdrawal symptoms. This distinction may become blurred with time, but the required treatment may be the same for either diagnosis.

comments by Andrew Byrne ..