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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 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).
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.
Melissa Ceuterick is a medical anthropologist working as a postdoctoral researcher at Hedera, Department of Sociology Ghent University. She has been working as the principal investigator on BENZONET (Perception, habitual use and cessation of BENZOdiazepines: a multi-method NETnography).
Beatrice Scholtes: Beatrice Scholtes studied European Public Health at the university of Maastricht. She defended her PhD on health policy for child injury prevention in 2018 at the same university in the Department of International Health. During her career she has developed a strong interest in health service research, implementation science and building equity into healthcare. She focusses on the primary care setting and is co-director of the research unit Primary care and health and the
Department of General Medicine, University of Liège.
Piet Bracke is a health sociologist connected to the Department of Sociology at Ghent University. Mental health and mental health services are in the core of his research interests. He is a full Professor in Sociology at Ghent University (2010-), teaching amongst others specialized master courses in the sociology of health and illness, and he is the Director of Hedera-Health and Demographic Research Ghent University (2014)
Pauline Van Ngoc has just arrived at the Department of General Medicine at the University of Liège after her Master in Social and Work Psychology at Uliège. Before arriving, she had some work experience in Walloon associations and one year in research in Public Health.
Jean-Luc Belche is a is Professor at the Department of General Medicine, University of Liège and a general practitioner in Liège. His research interests include communication in healthcare, care coordination, integrated care and inter-professional collaboration.