Post-its from Practice:
Benzodiazepines are not always the bad guys (Feb 2007)
One of my partners at the surgery came to ask me to see a patient he was concerned about. Imran was a 34 year old Asian man, who had been housed temporarily around the corner from the practice in bed and breakfast. He suffered from depression and was receiving methadone from one of the local specialist drug services. His behaviour at the surgery was also causing problems. He was attending erratically, seeing a variety of doctors and demanding benzodiazepines. On some occasions he received them and then overused them, on other occasions he didn't and then verbally complained.
I said I was happy to see him and assess the situation. When Imran attended he seemed frightened. He talked rapidly and appeared distressed. On discussion he told me he had had a benzodiazepine problem for nearly twenty years. He was receiving 80mg of methadone from the drug service and using no opioids on top. They had assessed that he did have a benzodiazepine problem but their policy, like many other drug services, was only to prescribe for a short-term detoxification. Admittedly this is also the advice given in the last clinical guidelines, but I feel it doesn't deal with the reality of this problem (Ref 1).
He explained that Valium had been his first addiction after a traumatic childhood and that he had used it for over 20 years consistently. It had even been prescribed during his two short periods in prison, although his methadone wasn't! He also explained that his alcohol intake dramatically increased when he couldn't get them. As he is hepatitis C positive this is important. His whole story was confirmed on talking to the drug service, even including that they were increasingly concerned about his alcohol intake and that all urines taken had been positive for benzodiazepines!
Imran said he was taking on average 30mg/day of diazepam but found them hard to manage when he bought or got them from the surgery. We consequently agreed as he was picking up his methadone daily that we would prescribe him 30mg of diazepam on a daily pickup also. He has very relieved and grateful as he left the surgery with his instalment prescription for diazepam and the benefits of this decision have since become very apparent.
Illicit benzodiazepine use, particularly by opioid users, is prevalent and a major problem for users in and out of drug treatment. Up to 90% of people attending drug treatment centres reported benzodiazepine use in a one-year period and there is a high prevalence of benzodiazepine use in methadone maintenance patients. Some GPs are still more comfortable with prescribing benzodiazepines than methadone to problem drug users, whereas the reverse should be true (Ref 2). There is still no "gold standard" treatment for benzodiazepine dependency and little evidence for the value of substitute prescribing of benzodiazepines, which I feel allows most of us to resort to opinion-based medicine. But does the lack of evidence mean it is bad?
Clinically, I find maintenance benzodiazepine prescribing very useful in certain selected patients and feel that a policy of never prescribing them creates enormous difficulties for some, for whom they are a serious problem.
Imran, I feel is one of those. He now attends the surgery regularly, usually early for his appointment with the counsellor or myself. He never overuses, his mood has improved and he has stopped drinking altogether! He is very grateful and his view is that he has been given back his life.
Benzodiazepine addiction is a serious problem and I am not underplaying it, but they are also incredibly useful drugs so let's not throw the baby out with the bath water.
1. DOH (Department of Health) (1999). Drug Misuse and Dependence- Guidelines on Clinical Management. London: The Stationery Office.
2. Ford, C., Roberts, K. and Barlolin JC. (2005) "Guidance on Prescribing Benzodiazepines to Drug Users in Primary Care". Substance Misuse Management in General Practice.