Benzodiazepine use in a methadone maintenance programme: patient characteristics and the physician's dilemma

Benzodiazepines (BZD) are among the most prescribed and used psychotropic medications in western countries. In populations of illegal drug abusers benzodiazepine use and abuse is even more widespread. In methadone maintenance treatment (MMT) programmes the physician is confronted daily with the demand for prescribing benzodiazepine. There is a lack of evidence-based data on indications and duration of benzodiazepine prescription to patients in a methadone maintenance treatment.Benzodiazepine abuse in MMT patients is associated with poorer outcome concerning illegal drug abstinence and psycho-social rehabilitation. The aim of this cross-sectional study was to determine the prevalence of regular benzodiazepine consumption in 101 patients treated in a public methadone maintenance programme in Geneva and evaluate the clinical practice of benzodiazepine prescription. We also assessed the characteristics of the regular benzodiazepine users and compared them with the non-users’. Demographic, medical, psychiatric and social variables from medical charts, Addiction Severity Indexes and auto-questionnaires on benzodiazepine use were compared. We found a prevalence of 51.5% regular benzodiazepine users in our population. Regular benzodiazepine users showed significantly more psychiatric comorbidity, significantly more abuse of other psychoactive substances and received higher daily doses of methadone. A very large majority of the regular benzodiazepine users received a controlled and regularly evaluated prescription.The prescriptions concerned essentially benzodiazepines with a long half-life, slow absorption and low value on the local black market. A majority of patients were able to diminish their benzodiazepine consumption during treatment.Our study showed that longterm prescription of benzodiazepine was frequent, although evidence-based guidelines in this domain are lacking. In the presence of regular, often anarchic,benzodiazepine consumption at the beginning of a methadone maintenance treatment, it can be extremely difficult to impose a complete and immediate abstinence. Concerning benzodiazepine prescription, physicians prescribing methadone maintenance treatment often find themselves in a dilemma: not prescribing risks denying the high prevalence of current benzodiazepine abuse and dependence and inducing premature dropout from the methadone maintenance treatment; prescribing risks maintaining benzodiazepine dependency and can be considered a medical act without evidence-based justification. We suggest that before prescribing benzodiazepines, alternative treatment options should be considered and benzodiazepine treatment conditions be specified in a therapeutic contract that is frequently re-evaluated with the patient. Also, treatment-compliance issues should be considered and progressive withdrawal should be regularly proposed.