BENZODIAZEPINE DEPENDENCE: WHEN ABSTINENCE IS NOT AN OPTION

Abstract

We are grateful for this opportunity to respond to the commentaries on our paper 1. In particular, we appreciate the interesting account of Peter Tyrer on the development of the recommendations made by the Royal Collage of Psychiatrists for the use of benzodiazepines (BZD) 2. It reminds us that the results of consensus meetings and the derived clinical recommendations (or guidelines) need to be interpreted with some care. His cautionary comments on who to enrol in future randomized trials comparing substitution with withdrawal of BZD are important, in order to avoid premature restrictions of a possible target group. Of course, our group agrees fully with his assessment that ‘we are now in a position of equipoise whereby randomized controlled trials of such procedures would be fully justified and both the advantages and disadvantages of a substitution policy exposed for all to view’. In the eyes of Dr Soyka, however, as there are no empirical data supporting our somewhat ‘astonishing’ view on BZD substitution, our contribution is solely an ‘academic’ discussion 3. He does not consider the wealth of studies which found that BZD withdrawal treatment is not very successful in the long term, not only but even more so in the patient group, for which we proposed substitution treatment (see references in 1). Therefore, he thinks that the focus of research should rather be upon means to encourage treatment acceptance (abstinence?) among the—probably undertreated—group of patients who have become dependent upon BZD and upon modulators of its receptors. While we do not contest the meaningfulness of these points made by Dr Soyka, we still think that it is critical to explore alternatives to withdrawal treatment for those who have failed ‘here and now’. Further, we did not simply propose to evaluate BZD with a long half-life, but ‘a slow-onset and long-acting benzodiazepine’. Whether such an endeavour should be called substitution or maintenance is not important. What is important is that our proposition might be a viable way for those who were not able to profit from withdrawal, might attract more patients and result in better outcomes than simply fruitlessly repeating withdrawal treatment again and again. To qualify such a procedure as a form of ‘therapeutic pessimism’ and ‘unconditional surrender’ by simply replacing one BZD by another is exactly what has been carried out in Germany and elsewhere with regard to heroin dependence. In the former, until the early 1990s, both the political and medical establishments were extraordinarily hostile towards any approach to addiction that was not rigidly orientated towards abstinence as a process as well as a goal, with well-known deleterious consequences 4. None.