Benzodiazepines in Scotland
A continued feature anticipated in our drug death statistics is the role of benzodiazepines.
70% of all drug deaths involved a benzodiazepine in 2019 and this trend is anticipated to continue in 2020. The majority of benzos are now described as ‘street benzos’ – i.e. not a prescribed or prescribable drug like diazepam. Street benzos are illicit, unregulated copies with terrifying variances in potency. These are manufactured in the UK (from imported raw materials) in makeshift production units so the supply during covid was able to continue – and may even have increased. Unfortunately, any quality control, and guidance labelling, is non existent.
In my role as Chair of the Scottish Drug Death Taskforce I hear too many tragic stories of overdose but two come to mind in relation to benzos – both involving young people. One, a young man who was out at the football with friends and when he came home he fell asleep on the sofa. The family noticed him snoring – and left him to sleep. He died. In a similar situation a young man was out with friends and ‘passed out’. His friends phoned his mum and said they thought he just needed to sleep ‘it’ off. Luckily his mum insisted they phone an ambulance. He survived.
As a pharmacist I think it is worth explaining how these drugs work and affect people. Benzodiazepines are used and prescribed across our society – whether the supply is legal via a prescription, or bought on the street or internet. Scotland has a history of benzodiazepine use that plays into our current drug death challenge. Benzodiazepines are a group of drugs that have been around since the early 1960s in the UK to treat anxiety, sleep problems, seizures and muscle pain because they are muscle relaxants. However benzos also affect people's memory and ability to think clearly. The clinical term is ‘cognitive impairment’. This is one of the reason they feature highly in our drug deaths but also a reason they cause problems in our general older population when prescribed for sleep. People forget whether they have taken their dose and take more– leading to overuse. In addition for people struggling to overcome problematic drug use and addiction, it can lower their resistance and they might be tempted to take other drugs like heroin. One women I met about 3 years ago described to me if she took benzodiazepines, she felt relaxed and less anxious but then was more likely to go out and score heroin. That woman sadly is now dead.
The muscle relaxing properties of benzo plays a role in deaths in combination with other drugs. Opiate drugs like morphine (also prescribed for pain) or diamorphine/heroin suppresses breathing. When you add benzodiazepines, their muscle relaxing properties in the throat and chest, supresses breathing further and may even stop. This might not happen quickly. Unusual snoring is a sign as someone struggles to breath. Slower rate of breathing (less than 7 breaths per minute) is another warning sign. This might happen slowly and even take several hours. Gabapentin, a drug increasingly used for pain can also supress breathing and make the situation worse. This can happen in people being prescribed these drugs for pain and anxiety as well as people self medicating.
We have added problems in Scotland because cocaine is increasingly popular (across society). Cocaine increased heart rate and blood pressure. Some people might think this will help to counteract the effects of opiates and sedative drugs- It doesn't. Instead, it puts additional stress on the circulation and can cause cardiac arrest.
Our physiology changes as we age. Many drugs are metabolised in the liver. In other words the liver changes the chemistry and breaks the drug down so it can be excreted. Excretion is generally then through the kidney. As we age liver and kidney function reduces so they're not able to clear some of these more toxic substances from the body. So, the body's just not able to process these substances in the same way. Whether you are an older person prescribed benzos for sleep and an opiate and a gabapentin for pain - or a person struggling to cope with drug dependence and the pain, anxiety and trauma that comes with that – the effect is the same.
So what do we do?
We want to stop the supply of these drugs and the police are working on that. But we also have to work at this from the other end. A feature of the Scottish challenge is that people might use very high doses of these street benzos and in combination with other drugs. Coming off high doses of benzos is clinically difficult as well as being pretty horrible for the person being detoxified. It's more difficult than detoxifying from heroin. The withdrawal syndrome includes the very effects that the drugs are used for – anxiety, mood disturbance, poor sleep and – at worse seizures. This can go on for weeks. So the Drug Death Taskforce has developed guidance and a call to action around a safer prescribed supply of benzodiazepines, (I say safer because any medicine, any drug has risk). Furthermore, there is a need for inpatient monitoring and medical care to stabilize the situation for people at high risk before you can contemplate other treatment options. This is the current focus of the Drug Death Taskforce to get a grip of our benzo challenge.
Parts of the above appeared in Sunday Times article on 25th July 2021.