Research Article: High-Dose Benzodiazepine Dependence: A Qualitative Study of Patients’ Perceptions on Initiation, Reasons for Use, and Obtainment

Date Published: November 10, 2015

Publisher: Public Library of Science

Author(s): Michael Liebrenz, Marcel Schneider, Anna Buadze, Marie-Therese Gehring, Anish Dube, Carlo Caflisch, Silvia Alessi-Severini.


High-dose benzodiazepine (BZD) dependence is associated with a wide variety of negative health consequences. Affected individuals are reported to suffer from severe mental disorders and are often unable to achieve long-term abstinence via recommended discontinuation strategies. Although it is increasingly understood that treatment interventions should take subjective experiences and beliefs into account, the perceptions of this group of individuals remain under-investigated.

We conducted an exploratory qualitative study with 41 adult subjects meeting criteria for (high-dose) BZD-dependence, as defined by ICD-10. One-on-one in-depth interviews allowed for an exploration of this group’s views on the reasons behind their initial and then continued use of BZDs, as well as their procurement strategies. Mayring’s qualitative content analysis was used to evaluate our data.

In this sample, all participants had developed explanatory models for why they began using BZDs. We identified a multitude of reasons that we grouped into four broad categories, as explaining continued BZD use: (1) to cope with symptoms of psychological distress or mental disorder other than substance use, (2) to manage symptoms of physical or psychological discomfort associated with somatic disorder, (3) to alleviate symptoms of substance-related disorders, and (4) for recreational purposes, that is, sensation-seeking and other social reasons. Subjects often considered BZDs less dangerous than other substances and associated their use more often with harm reduction than as recreational. Specific obtainment strategies varied widely: the majority of participants oscillated between legal and illegal methods, often relying on the black market when faced with treatment termination.

Irrespective of comorbidity, participants expressed a clear preference for medically related explanatory models for their BZD use. We therefore suggest that clinicians consider patients’ motives for long-term, high-dose BZD use when formulating treatment plans for this patient group, especially since it is known that individuals are more compliant with approaches they perceive to be manageable, tolerable, and effective.

Partial Text

To varying degrees, benzodiazepines (BZDs) exhibit amnestic, sedative, anticonvulsant, and muscle-relaxant effects. These effects are believed to result from BZDs’ properties as modulators of GABAA receptors, binding to the chloride-channel molecular complex and thereby enhancing the effects of GABA by increasing chloride (Cl−) flux and frequency of channel opening that ends in hyperpolarization and neuronal inhibition [1–3]. The specific properties of BZDs have led to their wide use in general clinical practice, as well as in psychiatry for the treatment of anxiety and mood disorders, insomnia, states of withdrawal, delirium, management of acute agitation or aggression, and catatonic syndrome [4–6]. Furthermore, BZDs are used in anesthesiology for anesthesia induction and maintenance, prior to diagnostic or therapeutic interventions; and in neurology for the treatment of acute prolonged epileptic seizures (duration ≥ 2min) [7–10]. BZDs have well-documented effectiveness over the last 50 years [11] and remain one of the most commonly prescribed medication classes by practitioners for various indications [12–14], despite their side effects [15, 16]. The development of dependence is characteristic of BZDs and typically follow long-term high, normal, or even low-dose use [17]. The definitions for “long term use” have varied widely over the years, ranging from 6 weeks [18] to greater than one year [19, 20]. Prevalence of BZD use in the general population is estimated to be between 2.0–7.4% with data suggesting that 14.1–76% of this BZD using population are long term (more than 4 to 6 months) users [21–24]. Although data on “high-dose” users is not readily available, a study from Switzerland estimated that 1.6% of the Swiss adult population uses doses, exceeding at least twice the maximum recommended daily dose [12]. According to some authors, however, current diagnostic manuals have not reliably defined BZD dependence [25], and they argue for two [17] or three subgroups, respectively [26]. The first group consists of patients who become dependent as a result of regular, repeated prescriptions of BZDs for an underlying disorder such as for sleep or anxiety, but continue to use within the recommended doses. A second group is comprised of individuals who begin with the use of physician-prescribed BZDs and subsequently progress to inappropriate use and increase their dosage excessively. The third group consists of individuals who were never prescribed BZDs and use them for recreational purposes (e.g., enhancing or alleviating the effects of other psychotropic substances, reducing withdrawal symptoms, or seeking a euphoric effect by using high doses). [26].

41 participants completed the one-on-one in depth interviews. The participants were predominantly male (75.6%). The mean age of the participants was 39.5 years ± SD 9.2 (median 39.0 years). At the time of the interview participants were using benzodiazepines for a self-reported mean time of 8.2 years ± SD 6.82 (median 5.0 years). The mean diazepam equivalent dosage (maximum, self-reported) was 83 mg ± SD 69 (median 70 mg, range 10 mg– 300 mg). Three participants were included despite using diazepam equivalents of only 10mg/d because they fulfilled other inclusion criteria: obtaining BZDs by illegal means and experiencing negative social consequences.

This exploratory study highlights the beliefs and perceptions of high-dose, long-term BZD- dependent patients in regard to their initial drug use and the reasons for their continued use, as well as their obtainment strategies and related experiences.

We addressed two areas of research that focused on patients with high-dose BZD dependence and elicited their perceptions of: (1) the reasons they initiated and continued their use of BZDs, and (2) how they obtained the drugs. We identified a multitude of reasons that perpetuated BZD use, including psychological distress and symptoms of mental disorder (e.g., substance use and/or somatic illness; recreational and social reasons). Irrespective of comorbidity, participants had a clear preference for medically related explanatory models. Subjects with a previous history of use and/or abuse of multiple substances often viewed BZDs as less dangerous and associated their use more frequently with harm-reduction measures than with recreational purposes or social reasons.