Tackling benzodiazepines and their role in Scotland’s drug deaths.
Benzodiazepines are a group of anxiolytic or psychoactive drugs originally designed for controlled medical use in the treatment of anxiety and insomnia. Some commonly known brand names for these include Diazepam, Temazepam and Valium. Usage of these kind of drugs in conjunction with opiates such as heroin or methadone has become an increasingly prevalent part of Scotland’s poly-drug usage, and a key part of Scotland’s unique challenge, as this recent article explains.
Poly-drug use with high-risk mixtures of opiates, cocaine and benzodiazepines are at the heart of Scotland’s unique challenge.
Recent evidence shows a rising trend, with drugs such as Etizolam and Alprazolam/Xanax at the forefront. These drugs are part of the relatively new arrivals in the Scottish context – ‘street benzo’s’, unregulated and illegally sourced. Evidence suggests that the illicit supply of ‘street’ benzo’s has replaced the brand names that would have been available via prescription by doctors and then diverted into other supply, but which have now become more scarce as a result of some doctors to continue to prescribe following abuses of the system.
These new drugs can be many times more concentrated and potent than those before – in some recorded cases 50x stronger - and with misleading or non-existent labelling and packaging. Many overdose incidents will be the result of an effect far beyond intended use. Equally, the times some take to have an effect – the half life of the drug – will also vary, some taking longer and opening up the further risk of double-dosing through insomnia or impatience. Once in the system, a combination of benzo’s and opiates can place high pressure on the body’s vital organs and their function, markedly increasing the risk of heart or breathing failure. This is especially the case with those who are older in this situation whose physical resilience may have been already compromised by a long-term dependency.
What can we do to address this and tackle the rising danger of poly-drug use?
A specialist team has been formed within the MAT Sub-Group to gather, evaluate and disseminate best advice on the psychological management of Benzodiazepine dependencies and guidance on prescription of these drugs as part of an overall strategy for those in Medication Assisted Treatment. Operating within the MAT Sub-group will allow rapid implementation of advice within the MAT implementation programme and bring greater consistency to the treatment pathways being offered across Scotland.
Benzo Working Group - Interim Guidance
The Group has developed an Interim Guidance document which has been updated in August 2021 - MAT Standards Informed Response for Benzodiazepine Harm Reduction which is available here.
This followed a survey exercise to provide feedback to the original guidance, whose summary results are available here.
The taskforce has now established a Benzo update as a standing item in its monthly meetings on the current status of the Scottish Benzo challenge. This will include briefings on any changing pattern of usage, outcomes, and the names and nature of drugs in circulation as identified by Public Health Surveillance and wider intelligence form Taskforce members. Our intention is to share a common, up to date understanding and to take local and national actions accordingly including further dissemination of information via the taskforce network.
An animated video explainer detailing the nature of the Scotland’s Benzo Challenge and the response to it as been developed and is available via this page and the Taskforce’s YouTube channel, having been commissioned in January 2021. We hope that this can be used widely by Taskforce stakeholders to raise initial awareness and understanding.
The above work is intended to compliment relevant work taking place out with the Taskforce including the Benzo resource developed by CREW, available on their website for public information https://www.crew.scot/benzo-resource-2020/ , and the online training resource developed by SDF https://www.sdftraining.org.uk/online-learning/1115-what-s-happening-on-the-streets-with-benzos.
Two key projects will further inform the best practice guidelines the Taskforce will issue as findings and results become available. We will ensure these are put into action via the MAT standards implementation programme. The projects are:
A Taskforce -funded project from the University of Stirling to compare the expected outcome for those on receiving benzodiazepine (BZD) prescribing in addition to opiate replacement therapy (ORT), against a control group receiving only the latter. This is a piece of primary research, using data gathered from a retrospective cohort of people who are representative of those who received ORT from a specialist addiction service in four Health Boards (Lothian, Ayrshire and Arran, Greater Glasgow and Clyde, and Tayside). Health board data on patient characteristics and outcomes will be securely linked to national data on prescriptions, hospitalisation, DRD and all-cause mortality. A survival analysis and modelling exercise will explore differences between exposed and unexposed groups. Full findings are expected to be available in December 2021.
A Chief Scientist Office funded project starting in April 2021 to develop and test an intervention for benzodiazepine dependence for people in Opiate Replacement Treatment. The intervention is being coproduced across people who used/have used benzodiazepines, clinicians, and academics. The intervention will be tested in 50 patients across Aberdeen, Lanarkshire, and Edinburgh. Full results of trial are expected by March 2023.
Given the increasingly unpredictable, unreliable and variable strength, toxicity and effects of street Benzo’s in circulation, the taskforce has identified the laboratory testing of drugs as a key service in reducing the risk of harm and death from benzodiazepines.
A 2 year project funded by the Taskforce via the Corra Foundation will seek to establish a drug testing service for Scotland. This will involve collaborative development across the Crown Office, Police Scotland, and Public health Scotland. The long-term aim of the drug testing service will be to anonymously inform those using benzodiazepines on the potency and content of their drugs so that they can make informed choices on their use, and also to use the service as a touchpoint to engage about wider issues of harm reduction and available treatment pathways.
The Taskforce is working with Scottish Government and third sector organisations to develop a detailed community training programme, including ‘train the trainer’ elements. This will include training on harm prevention and the use of Benzos amongst polydrug use. The evidence shows that additional training is needed in this space and this work will fill an existing gap.
The Taskforce intends for this work to assist in the development of community networks, providing additional support, active roles for people who use drugs and a feedback loop for the Taskforce and Scottish Government, amplifying the voice of people with living experience.
The Taskforce supports the request by Scottish Government, also supported by Police Scotland, to the UK Government to take action on unregulated sales of pill press machines. These are implicated in the manufacture and supply of street benzo’s, specifically the re-formatted smaller pill taken from a concentrated block of illegally sourced benzodiazepines and mixed with other substances.
The request to take action was made in September 2020, and dialogue between the UK and Scottish Government is ongoing.
When I meet someone and they tell me they have started to combine their methadone with street benzo’s as and when they are available, I know in my heart there is not much time left.