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Welcome to the May 2012 homepage edition of i2P-Information to Pharmacists. Rollo Manning has been having some time out having staples removed from the site of his open heart surgery.He is now at home recuperating in Darwin, having arrived home last Friday, beating a cold and hasty retreat from Canberra.We all wish him a speedy recovery and hopefully, he will be fit enough to contribute by next month.
This month, Pharmedia discusses the toll that is taken when someone complains about you to an authority without good cause. Well, the good news is that you can now take action to protect yourself if such a complaint is made, and that may even include action for defamation. Read about a recent case involving two doctors, with Mark Coleman drawing on personal experience to illustrate.

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Tranquillizer use rife amongst OTP subjects world-wide, most legally prescribed

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	Dr Andrew Byrne & Associates articles by this author...
A Harm-Minimisation Research Perspective: Dr Byrne (and his associates) advocate for better policies which are proven to reduce risks for drug users and the general community, under a framework in parallel with Australia’s official policy of harm minimisation.

Prolonged use of benzodiazepines is associated with childhood trauma in opioid-maintained patients. Vogel M, Dürsteler-MacFarland KM, Walter M, Strasser J, Fehr S, Prieto L, Wiesbeck GA. Drug & Alcohol Dependence 2011 119:93-98

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Dear Colleagues,

While these authors have emphasised an association between childhood trauma and benzodiazepine (BZD) use, their study tells us much more than that about opioid dependent patients in treatment in Switzerland and beyond. 
Furthermore, their bibliography of benzodiazepine use amongst opioid maintained patients is exemplary and it clearly demonstrates that the current approach is simply not working. 
As the authors state: “if abstinence from BZD is conveyed as primary treatment aim, as has generally been the norm in the past, this finding illustrates the limits of current therapeutic management and therapeutic options”. 

We are told that ‘point’ and ‘lifetime’ BZD use reportedly occurs in 18-55% and 35-94% of OTP patients from numerous reports including from Australia. 
The current surveys were taken in two large opioid maintenance programs in Basel, Switzerland.
These provided a variety of medications, including prescribed heroin, both oral and injected, methadone, morphine, buprenorphine and codeine. 

Of 315 patients approached, 193 (61%) responded to a survey including childhood trauma (a validated instrument ‘CTQ’ was used), drug use and other clinical and demographic characteristics. 
Reports of drug use were confirmed with urinalysis showing a high degree of concordance. 
Psychiatric diagnoses were obtained from the detailed medical files which were updated regularly. 

The rate of reported benzodiazepine use in the current sample was 61%, 47% being ‘prolonged’ (>2 months duration) while lifetime use was 85%. 
Thus almost half of the cohort had prolonged use at some time in the previous five years. 

There was at least one childhood trauma sub-score of moderate to severe level in 67% of the subjects who completed the survey. 
As well as BZD use, the degree of trauma was significantly related to methadone dose (or equivalent for other opioids). 

After multivariate analysis the authors found that there was an association between prolonged benzodiazepine use and (1) excessive childhood trauma, (2) hepatitis C, (3) psychiatric family history and (4) methadone dose in milligrams.  The odds ratios were 1.5, 4.0, 2.3 and 1.01

Rather than using the loaded (British) term ‘misuse’, these authors wisely stick to ‘use’. 
They also categorise sedative use into (1) ‘hedonistic’ or ‘recreational’ use, (2) self-medication to counteract or amplify the effects of primary drugs of abuse (eg. to ‘come down’ from stimulants), (3) prescription use for anxiety, insomnia, PTSD, panic disorders, etc, and (4) ‘off-label’ prescription as benzodiazepine ‘maintenance’. 
The great majority of patients obtained their BZD from legal prescription (84% of those with ‘prolonged use’). 

The authors point out that none of these associations can prove causality. 
This will always be difficult to determine when so many overlapping issues occur in OTP patients such as childhood abuse, PTSD and self medication. 
However, the authors seem persuaded that ‘zero tolerance’ is no longer tenable as a policy, just as it did not work for opioids (or alcohol in a different era). 
They support the measured prescription of benzodiazepines in research trials as advanced by Liebrenz in Addiction. 

In our own practice we provide diazepam under close supervision and in limited quantities to those who are unwilling or unable to cease the use of benzodiazepines, and who agree to alcohol abstinence, in the context of OTP. 

Summary written by Andrew Byrne .. http://methadone-research.blogspot.com/

Reference:

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

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