High-dose benzodiazepine dependence: a qualitative study of patients’ perception on cessation and withdrawal

BMC Psychiatry

Carlo Caflisch¹  Anna Buadze¹  Marie-Therese Gehring²  Michael Liebrenz¹ 

[1] Psychiatric University Hospital, Lenggstrasse 31, Zurich, 8032, Switzerland;Klinik Im Hasel AG, Hasel 837, Gontenschwil, 5728, Switzerland

关键词: Interview;    Qualitative study;    Patients’ perception;    Withdrawal;    Benzodiazepines;   

Others  :  1210180
DOI  :  10.1186/s12888-015-0493-y

 received in 2014-11-28, accepted in 2015-04-29,  发布年份 2015

【 摘 要 】

Background

Benzodiazepine withdrawal syndrome has been reported following attempts to withdraw even from low or therapeutic doses and has been compared to barbiturate and alcohol withdrawal. This experience is known to deter patients from future cessation attempts. Research on other psychotropic substances shows that the reasons and motivations for withdrawal attempts – as well as the experiences surrounding those attempts – at least partially predict future efforts at discontinuation as well as relapse. We therefore aimed to qualitatively explore what motivates patients to discontinue this medication as well as to examine their experiences surrounding previous and current withdrawal attempts and treatment interventions in order to positively influence future help-seeking behavior and compliance.

Methods

To understand these patients better, we conducted a series of 41 unstructured, narrative, in-depth interviews among adult Swiss patients with a long-term dependent use of benzodiazepines in doses equivalent to more than 40 mg diazepam per day and/or otherwise problematic use (mixing benzodiazepines, escalating dosage, recreational use or illegal purchase). Mayring’s qualitative content analysis was used to evaluate findings.

Results

These high-dose benzodiazepine-dependent patients decision to change consumption patterns were affected by health concerns, the feeling of being addicted and social factors. Discontinuation attempts were frequent and not very successful with fast relapse. Withdrawal was perceived to be a difficult, complicated, and highly unpredictable process. The first attempt at withdrawal occurred at home and typically felt better than at the clinic. Inpatient treatment was believed to be more effective with long term treatment (approaches) than short term.

Patients preferred gradual reduction of usage to abrupt cessation (and had experienced both). While no clear preferences for withdrawal were found for benzodiazepines with specific pharmacokinetic properties, participants frequently based their decision to participate in treatment on the availability of their preferred brand name and furthermore discarding equivalent dosage rationales.

Conclusions

Our findings provide greater understanding of the factors that motivate high-dose benzodiazepine-dependent individuals to stop taking these medications, and how they experience withdrawal and treatment strategies. They underscore how patients’ perceptions of treatment approaches contribute to compliant or non-compliant behavior.

【 授权许可】

   
2015 Liebrenz et al.; licensee BioMed Central.

【 参考文献 】

• [1]Nelson J, Chouinard G: Guidelines for the clinical use of benzodiazepines: pharmacokinetics, dependency, rebound and withdrawal. Canadian Society for Clinical Pharmacology. J Can Pharmacol Clin 1999, 6(2):69-83.
• [2]Michael Kaplan E, DuPont RL: Benzodiazepines and anxiety disorders: a review for the practicing physician. Curr Med Res Opin 2005, 21(6):941-950.
• [3]Dell’osso B, Lader M: Do benzodiazepines still deserve a major role in the treatment of psychiatric disorders? A critical reappraisal. Eur Psychiatry 2013, 28(1):7-20.
• [4]Buffett-Jerrott SE, Stewart SH: Cognitive and sedative effects of benzodiazepine use. Curr Pharm Des 2002, 8(1):45-58.
• [5]Gorenstein C, Bernik MA, Pompeia S: Differential acute psychomotor and cognitive effects of diazepam on long-term benzodiazepine users. Int Clin Psychopharmacol 1994, 9(3):145-153.
• [6]Lader M: History of benzodiazepine dependence. J Subst Abuse Treat 1991, 8(1–2):53-59.
• [7]Fang SY, Chen CY, Chang IS, Wu EC, Chang CM, Lin KM: Predictors of the incidence and discontinuation of long-term use of benzodiazepines: a population-based study. Drug Alcohol Depend 2009, 104(1–2):140-146.
• [8]Lader M: Long-term anxiolytic therapy: the issue of drug withdrawal. J Clin Psychiatr 1987, 48(Suppl):12-16.
• [9]de las Cuevas C, Sanz E, de la Fuente J: Benzodiazepines: more" behavioural" addiction than dependence. Psychopharmacology 2003, 167(3):297-303.
• [10]Petitjean S, Ladewig D, Meier CR, Amrein R, Wiesbeck GA: Benzodiazepine prescribing to the Swiss adult population: results from a national survey of community pharmacies. Int Clin Psychopharmacol 2007, 22(5):292-298.
• [11]O’Brien CP: Benzodiazepine use, abuse, and dependence. J Clin Psychiatr 2005, 66(2):28-33.
• [12]Ashton H: The diagnosis and management of benzodiazepine dependence. Curr Opin Psychiatry 2005, 18(3):249-255.
• [13]Lader M: Coming off tranquillizers: a Sisyphean toil. Addiction 2009, 104(1):25-26.
• [14]Voshaar RC, Gorgels WJ, Mol AJ, Van Balkom AJ, Mulder J, van de Lisdonk EH, et al.: Predictors of long-term benzodiazepine abstinence in participants of a randomized controlled benzodiazepine withdrawal program. Can J Psychiatr 2006, 51(7):445-452.
• [15]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.
• [16]Quaglio G, Pattaro C, Gerra G, Mathewson S, Verbanck P, Des Jarlais DC, et al.: High dose benzodiazepine dependence: description of 29 patients treated with flumazenil infusion and stabilised with clonazepam. Psychiatry Res 2012, 198(3):457-462.
• [17]Hallstrom C, Lader M: Benzodiazepine withdrawal phenomena. Int Pharmacopsychiatry 1981, 16(4):235-244.
• [18]Poyares D, Guilleminault C, Ohayon MM, Tufik S: Chronic benzodiazepine usage and withdrawal in insomnia patients. J Psychiatr Res 2004, 38(3):327-334.
• [19]Fontaine R, Beaudry P, Le Morvan P, Beauclair L, Chouinard G: Zopiclone and triazolam in insomnia associated with generalized anxiety disorder: a placebo-controlled evaluation of efficacy and daytime anxiety. Int Clin Psychopharmacol 1990, 5(3):173-183.
• [20]Lader M: Benzodiazepine Harm: How Can It Be Reduced? Br J Clin Pharmacol 2014, 77(2):295-301.
• [21]Chouinard G: Issues in the clinical use of benzodiazepines: potency, withdrawal, and rebound. J Clin Psychiatry 2004, 65:7-12.
• [22]O’Connor KP, Marchand A, Belanger L, Mainguy N, Landry P, Savard P, et al.: Psychological distress and adaptational problems associated with benzodiazepine withdrawal and outcome: a replication. Addict Behav 2004, 29(3):583-593.
• [23]Baillargeon L, Landreville P, Verreault R, Beauchemin JP, Gregoire JP, Morin CM: Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial. CMAJ 2003, 169(10):1015-1020.
• [24]Lader M, Tylee A, Donoghue J: Withdrawing benzodiazepines in primary care. CNS Drugs 2009, 23(1):19-34.
• [25]Tyrer P: Benzodiazepine substitution for dependent patients: going with the flow. Addiction 2010, 105(11):1875-1876.
• [26]Borland R, Yong HH, Balmford J, Cooper J, Cummings KM, O’Connor RJ, et al.: Motivational factors predict quit attempts but not maintenance of smoking cessation: findings from the International Tobacco Control Four country project. Nicotine Tob Res 2010, 12(Suppl):S4-S11.
• [27]Zhou X, Nonnemaker J, Sherrill B, Gilsenan AW, Coste F, West R: Attempts to quit smoking and relapse: factors associated with success or failure from the ATTEMPT cohort study. Addict Behav 2009, 34(4):365-373.
• [28]Mayring P: Qualitative Content Analysis [28 paragraphs]. In Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 1(2), Art 20; 2002. http://www.qualitative-research.net/index.php/fqs/article/view/1089.
• [29]Buadze A, Stohler R, Schulze B, Schaub M, Liebrenz M: Do patients think cannabis causes schizophrenia?- A qualitative study on the causal beliefs of cannabis using patients with schizophrenia. Harm Reduct J 2010, 7:22. BioMed Central Full Text
• [30]Liebrenz M, Frei A, Fisher CE, Gamma A, Buadze A, Eich D: Adult attention-deficit/hyperactivity disorder and nicotine use: a qualitative study of patient perceptions. BMC Psychiatry 2014, 14(1):141. BioMed Central Full Text
• [31]Parr JM, Kavanagh DJ, Young RM, McCafferty K: Views of general practitioners and benzodiazepine users on benzodiazepines: a qualitative analysis. Soc Sci Med 2006, 62(5):1237-1249.
• [32]Wild TC, Cunningham JA, Ryan RM: Social pressure, coercion, and client engagement at treatment entry: a self-determination theory perspective. Addict Behav 2006, 31(10):1858-1872.
• [33]Cunningham JA, Koski-Jannes A, Toneatto T: Why Do People Stop Their Drug Use-Results from a General Population Sample. Contemp Drug Probs 1999, 26:695.
• [34]Blomqvist J: Paths to recovery from substance misuse: change of lifestyle and the role of treatment. Substance use & misuse 1996, 31(13):1807-1852.
• [35]Ashton H: Protracted withdrawal syndromes from benzodiazepines. J Subst Abus Treat 1991, 8(1):19-28.
• [36]Schopf J: Withdrawal phenomena after long-term administration of benzodiazepines. A review of recent investigations. Pharmacopsychiatria 1983, 16(1):1-8.
• [37]Seivewright N, Dougal W: Withdrawal symptoms from high dose benzodiazepines in poly drug users. Drug Alcohol Depend 1993, 32(1):15-23.
• [38]Thomas P, Lebrun C, Chatel M: De novo absence status epilepticus as a benzodiazepine withdrawal syndrome. Epilepsia 1993, 34(2):355-358.
• [39]Fialip J, Aumaitre O, Eschalier A, Maradeix B, Dordain G, Lavarenne J: Benzodiazepine withdrawal seizures: analysis of 48 case reports. Clin Neuropharmacol 1987, 10(6):538-544.
• [40]Preodor D, Wolpert E, Gimble A: Seizures induced by abrupt discontinuation of alprazolam. Am J Psychiatry 1984, 141:1606-1607.
• [41]Andreasen C, Errebo-Knudsen L, Kristensen K: Patient information might reduce the use of benzodiazepines in general practice. Ugeskr Laeger 1989, 145:2968-2970.
• [42]Ridout S, Waters W, George C: Knowledge of and attitudes to medicines in the Southampton community. Br J Clin Pharmacol 2012, 21(6):701-712.
• [43]Vermeire E, Hearnshaw H, Van Royen P, Denekens J: Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther 2002, 26(5):331-342.
• [44]Urquhart J: Patient non-compliance with drug regimens: measurement, clinical correlates, economic impact. Eur Heart J 1996, 17:8-15.