Research project DR/91 (Research action DR)
The use of benzodiazepines and Z-drugs (a class of psychoactive medications that encompasses sedatives, anxiolytics and hypnotics, here further referred to as BZD/Z) is high in Belgium, with 12% of the population using a BZD/Z in 2018. Once treatment exceeds the recommended duration of two to four weeks, the risk/benefit ratio of prescribing BZD/Z is highly debatable. Nonetheless, one in every three users in Belgium who starts BZD/Z still takes these medications after eight years. Such long term, habitual use is not recommended due to adverse effects such as tolerance, physiological and psychological dependence and withdrawal and rebound symptoms following attempts to quit, even when used in low and constant doses. Eventually, effects of habitual BZD/Z use might be subtle and difficult to differentiate from original symptoms. Overall, both BZD and Z-drugs have a high potential for abuse. While many habitual users develop a low dose dependence without dose escalation or other drug seeking behaviour, others develop high dose dependence. High dose dependence is often a complex issue, associated with comorbidity with severe mental disorders or dual diagnosis and sometimes polysubstance use. Additionally, chronic BZD/Z use is often accompanied by multiple unresolved mental health care needs.
In Belgium, so far most research has focussed on low dose dependence and gradual discontinuation completed in primary care or assisted by community pharmacists. However, international evidence shows that many users who are dependent on high doses are unable to achieve long-term abstinence via such recommended discontinuation strategies. For these users comprehensive integrated care seems more successful.
In general, the use of care facilities by persons with a mental health care problem in Belgium is below average and a significant proportion of those seeking help do not receive effective treatment, which points to a vast treatment gap in mental health care. It remains unclear how many people with a BZD/Z related use disorder or comorbidity in need of treatment actually find their way to addiction and mental health care services, nor is it known how many of them receive a successful treatment.
Addressing this gap is particularly important in light of a) the recent deinstitutionalization of the mental health care sector, with its shift from inpatient and hospital-based care to community-oriented and outreaching support which aims at guaranteeing continuity of care and b) the integration of addiction care in mental health care since 2019.
Furthermore, it remains understudied how dependence on BZD/Z is actually viewed by professionals in current mental health and addiction care, equally little is known about the lived experiences of individuals with a BZD/Z substance use disorder (SUD) and possible co-occurring mental illness(es) who are treated with psychotropic medications or in mental care services (contrary to other illicit substances).
Objectives
In order to address the described knowledge gaps, the aims of this study are:
- to study the accessibility of mental health care for persons with a BZD/Z SUD
- to analyse professionals’ experiences and perceptions of BZD/Z SUD (needs, gaps, barriers, facilitators)
- to investigate (recovered) users’ experiences and perceptions of these services (needs, gaps, barriers, facilitators) as tailored treatment should take subjective experiences into account
- to explore and unravel the ambiguous role of BZD/Z in the mental health care sector
- to develop sound, tailored and feasible policy recommendations.
Research questions
To meet the objectives, the project will answer the following research questions:
- What are professionals’ experiences in treating patients with a BZD/Z related SUD? (RQ1a)
- How do professionals perceive the role of BZD/Z in clinical practice? (RQ1b)
- How do patients with a BZD/Z SUD perceive their treatment and recovery trajectories? (RQ2)
- Which needs, barriers and enabling factors or facilitators do professionals detect? (RQ3a)
- Which needs, barriers and enabling factors or facilitators do patients detect? (RQ3b)
- How can the accessibility of mental and addiction care facilities be improved for patients with a BZD/Z SUD? (RQ4)
To explore this uncharted area, we use an innovative qualitative research design consisting of in-depth interviews with both professionals and patients in the entire country to compare both perspectives. This analysis will result in a Delphi study to compile sound policy recommendations in collaboration with experts in the field. As such, our results will be translated into relevant recommendations to provide appropriate care for this growing group of patients. By doing so, this study also strives to enhance the accessibility of these services for this, thus far, understudied group.
