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Benzodiazepine use among opiate-dependent subjects in buprenorphine maintenance treatment: Correlates of use, abuse and dependence

https://doi.org/10.1016/j.drugalcdep.2008.07.017Get rights and content

Abstract

Background

Previous studies from North America, Europe and Australia have reported high levels of benzodiazepine use among opiate-dependent patients in opiate maintenance treatment. However, to date, there are no available data on patterns of abuse and dependence on benzodiazepines according to DSM criteria among these patients.

Aims

To describe the independent correlates of use, abuse and dependence on benzodiazepines among buprenorphine patients selected from standard treatment settings.

Methods

Cross-sectional study in France between June 2001 and June 2004. Buprenorphine patients treated for over 3 months were recruited via physicians prescribing buprenorphine. Patients answered a self-administered questionnaire, the DSM-IV criteria for benzodiazepine abuse and dependence, the Beck Anxiety and Depression Inventories (BAI, BDI) and the Nottingham Health Profile (NHP). Main outcome was modalities of benzodiazepine use: no use vs. simple use vs. problematic use (abuse or dependence according to DSM-IV).

Results

170 patients were recruited. 54% did not use benzodiazepines during the previous month, 15% were simple users and 31% were problematic users. Benzodiazepine use (all modalities) was associated with poly-use of psychotropics. Simple users of benzodiazepines were not statistically different from non-users for the other factors explored. Problematic users of benzodiazepines had higher depression and anxiety levels, correlated with quality of life impairment and precariousness. They used higher dosages of benzodiazepines than simple users.

Conclusions

Characteristics of simple benzodiazepine users were distinct from problematic users but not from non-users in this sample of buprenorphine patients. This should be taken into account in the clinical management of benzodiazepine use among buprenorphine patients.

Introduction

Buprenorphine maintenance is known to be an effective treatment for opiate dependence in terms of retention, reduction in illicit opiate use, HIV and Hepatitis C contamination, mortality and crime (Auriacombe et al., 2001, Giacomuzzi et al., 2005, Kakko et al., 2003, Mattick et al., 2003). In 2006, in France, it was estimated that up to 200,000 persons were problematic opiate users and that 95,000 of them were in pharmacologically assisted maintenance treatment with buprenorphine and 26,000 with methadone (Fatseas and Auriacombe, 2007; French Monitoring Centre for Drugs and Drug Addiction, 2004). Any French physician can prescribe buprenorphine and any pharmacy can provide the medication, whereas methadone treatment can be initiated only in specialized treatment centers (Auriacombe et al., 2004). Consequently, the more commonly prescribed pharmacological treatment for opiate dependence is buprenorphine instead of methadone (Fatseas and Auriacombe, 2007; French Monitoring Centre for Drugs and Drug Addiction, 2004).

As is the case for methadone, the use of benzodiazepines with buprenorphine is cause for some concern because the combination (especially in overdose) has been reported to be associated with deaths and inappropriate behaviors (Center for Substance Abuse Treatment, 2004). Benzodiazepine use is frequent in buprenorphine-treated patients (13–47% of subjects) and is higher than in the general age-matched population in France, other countries in Europe, North America and Australia (Bramness and Kornor, 2007, Fatseas and Auriacombe, 2007; French Monitoring Centre for Drugs and Drug Addiction, 2004; Morel, 2000, Nielsen et al., 2007, Thirion et al., 2002). Among these patients, benzodiazepines may be abused and lead to misuse (increased dose, off-prescription use, etc.). Bramness et al. studying a medical insurance database reported that the amounts of benzodiazepines prescribed could suggest abuse or dependence (Bramness and Kornor, 2007). Perera et al. and Miller et al. reported that 18–50% of opioid-dependent patients may abuse or be dependent on benzodiazepines (Miller and Gold, 1991, Perera et al., 1987). However, to our knowledge, there are no available data on the characteristics of abuse and dependence on benzodiazepines according to DSM criteria for buprenorphine-treated patients. Studies focusing on the individual factors associated with benzodiazepine use among opiate-dependent patients in treatment have mostly concerned methadone patients (Backmund et al., 2005, Barnas et al., 1992, Bleich et al., 1999, Bleich et al., 2002, Darke et al., 1993, Gelkopf et al., 1999, Stitzer et al., 1981). In these studies, patients using benzodiazepines were found to have more psychopathology and emotional distress, higher levels of polydrug use, poorer psychosocial functioning, and higher methadone dosage. However, benzodiazepine users were not stratified according to DSM criteria for abuse or dependence on benzodiazepine.

It is important to investigate how benzodiazepines are used in opiate maintenance treatment in general and especially in buprenorphine patients, whose number worldwide is increasing as an alternative to methadone. Better understanding of the characteristics of benzodiazepine use in this population would lead to better treatment responses to this persistent problem. In this study our objective was to characterize use, abuse and dependence on benzodiazepines among buprenorphine patients according to DSM criteria, and to describe its associated factors.

Section snippets

Study design and subjects

This was a cross-sectional study among buprenorphine patients in Aquitaine, France, from June 2001 to June 2004. To be included, patients had to be in buprenorphine maintenance treatment for opiate dependence for at least 3 months with the same physician.

Procedure

Participants were recruited through their prescribing physicians, who were recruited by way of addiction health networks and a list of physicians who had already participated in studies by our university. After informed consent was obtained,

Results

One hundred and seventy patients were included (median age, 35 years; 77.5% males). They were in buprenorphine treatment for a median length of 3 years (minimum, 4 months; maximum, 10 years). Median buprenorphine dosage was 8 mg (minimum, 0.4 mg; maximum, 24 mg). Lifetime prevalence of benzodiazepine use was 67%. During the past 30 days, 54.1% of the subjects had not used benzodiazepines, 15.3% were simple users and 30.6% were problematic users (6.5% met DSM-IV criteria for abuse and 24.1% for

Discussion

In this study our objective was to characterize benzodiazepine use among buprenorphine-treated patients according to DSM criteria for abuse and dependence. Results from the regression analysis discriminated between problematic and simple benzodiazepine users on the basis of the variables assessed. Benzodiazepine use (all modalities) was associated with current polysubstance use. Except for current polysubstance use, non-problematic benzodiazepine users did not differ statistically from

Conflict of interest

All authors report no conflict of interests.

Acknowledgements

Pr Tignol, Dr Daulouède and Dr Franques are thanked for their participation on a preliminary version of this study. We thank all physicians and participants for their contribution.

Preliminary aspects of this study were presented at the 2003 and 2007 Annual Meetings of the College on Problems of Drug Dependence (USA).

Role of funding source: This study was supported in part by a Research Grant PHRC 2001 from the French Ministry of Health to M. Auriacombe and an unrestricted Research Donation from

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