Managing Benzodiazepine Dependence and High-Risk Use with Opiates: A feasibility study of a Co-produced Intervention

Background: Problematic benzodiazepines use alongside opiates contributes to mortality among people who use drugs in Scotland. Clinical practice currently manages benzodiazepine dependence through tapered dosing. An intervention to address the root causes of benzodiazepine use with opiates was needed.

Methods: This study designed and tested the feasibility of a co-designed intervention to address concurrent benzodiazepine and opiate use.  Recruitment and outcome measures were piloted to inform a future randomised controlled trial (RCT).

The intervention development phase followed the MRC complex intervention development framework.  Three workshops (with people who use/used benzodiazepines, clinicians, academics, psychologists, pharmacists) and three PPI (patient and person involvement) groups were held. The co-produced intervention included: a prescription of 30mg diazepam, anxiety, sleep and pain management, harm reduction resources and 'safety conversations', delivered by a trained nurse over a 4-6 month period.  In the testing phase patients were recruited in three Scottish sites to test the intervention feasability and pilot recruitment and data collection.  Inclusion criteria were people stable on opiate replacement treatment but at ongoing risk of harm and overdose due to 'harmful' use of street benzodiazepines. Outcomes measured were anxiety (GAD), depression (PHQ), quality of life (EQ5D-L5), Substance use recovery measure (SURE), Cognitive function (ACE-III), self reported street drug use and oral fluid testing. Interviews were conducted with patients and clinicians to provide insight into their experience of the intervention.

Results: 39 patients were recruited, 30 male and 9 female, mean age 42 years. Of these, 30 completed the study (77%). There were improvements in scores for anxiety, depression, quality of Life and substance use recovery. Cognitive function remained the same. Self-reported 'street' benzodiazepine use reduced from 100% at baseline to 35% (n=10) at follow up. There was a reduction in the number of different substances reported from a mean of 2.9 to 1.8. Oral fluid testing was incomplete and inconclusive which would need addressed in a larger trial.

Interviews with patients and clinicians found general satisfaction with the intervention. The increased nursing time and strong therapeutic alliance  was important to address problems like anxiety and trauma. The diazepam prescription was also important as patients appreciated a safe, regular supply. Others noted the importance of being ready to make meaningful change that reduced drug use.

Conclusion: A co-produced intervention was successfully developed and implemented.  Recruitment and retention proved feasible  and a full RCT is recommended.