Withdrawal of temazepam gelcaps

Editor, – I was disappointed to read certain advice and factual inaccuracies in the article regarding issues relating to the use/misuse of temazepam capsules (Aust Prescr 2004;27:58-9). The withdrawal by Sigma of its temazepam capsules from the market has not led to a complete lack of this drug in Australia and temazepam gelcap injection still continues to be a problem.

Furthermore, I am concerned about the comment, 'in this instance they have a duty of care not to prescribe benzodiazepines'. While doctors should not respond to coercion, as alluded to in the article, appropriate management of benzodiazepine abuse/dependence might include notification to the relevant government department and an appropriate prescription for benzodiazepines (usually diazepam) in controlled amounts; such as by daily, or alternate daily, pick-up from a nominated chemist. Such an approach, conducted as part of a planned strategy to attempt to gradually wean the patient off benzodiazepines, is a more appropriate, caring and responsible response to a request for benzodiazepines than an outright refusal. It will ensure that the individual will not suffer the possibility of withdrawal seizures as well as diminishing the possibility of ever-increasing demands on other healthcare providers further down the track as the individual becomes ever more desperate in their attempt to obtain such drugs.

Martyn Lloyd-Jones
Director, Drug and Alcohol Services
Delmont Private Hospital
Melbourne

Dr H. Wilce, the author of the article, comments:

I am not sure what factual inaccuracies Dr Lloyd-Jones is referring to as nowhere in the article does it state that the removal of temazepam gelcaps has led to a complete lack of this drug in Australia. The article states that front-line services are seeing a reduction in problems since the removal of gelcaps from the market. Unfortunately we will continue to see problems with this medication until stockpiles have been depleted. Gelcaps may also continue to be available via the internet or via overseas imports. It is possible that we will continue to see the physical sequelae of past injecting misuse for years to come.

Dr Lloyd-Jones has misinterpreted the advice that 'doctors have a duty of care not to prescribe benzodiazepines'. This statement was made in the context of coercion. While the article does not attempt to discuss the vexed issue of benzodiazepine reduction regimens, there is little good evidence that such regimens are effective and in fact they may be associated with an escalation rather than reduction in use. This problem is one that is likely to continue while the ongoing supply of benzodiazepines is difficult to control. However, it is clear that these regimens have the greatest chance of success if there is an effective therapeutic relationship between the doctor and patient. This is very unlikely to be the case if the doctor is coerced into providing scripts for benzodiazepines.