By Catriona Matheson and Karen Berry
In this blog we consider interventions for people with dependent benzodiazepine (benzos) use alongside opiate use. We consider this in the context of the Medication Assisted Treatment (MAT) standards which would still largely apply in principle in Scotland, with some differences in emphasis. The principles of trauma informed care and providing a psychologically informed environment are, if anything, more important for those using benzos. However same day prescribing is unlikely as stabilising someone’s opiate dose is generally considered first by clinicians, before considering starting a benzo prescription. Benzo harm reduction is different to that traditionally proposed for opiate use which is focused around safer injecting. In this blog we share some information on a bespoke intervention for those using street benzos with other substances that is currently being tested in Scotland.
As a reminder, let’s go back to what we know about why people use street benzos. Reasons include self management of trauma, anxiety, sleep problems and pain. This is why trauma informed care is all the more important as you can generally make an assumption that trauma and/or anxiety play a role in a person using street benzos with other drugs, particularly opiates.
So, there are three components to consider in this intervention: 1) reasons for use, 2) harm reduction and safety and 3) prescribing.
Firstly, considering a person’s reason for taking benzos and their needs means providing tailored psychosocial treatment to people using benzos with opiates. This covers exploring past trauma, substance use, sleep, pain and anxiety. This aspect of the intervention is provided by community psychiatric nurses (CPNs) already working in substance use services who have had additional bespoke training around benzos, they take on the role of dedicated intervention nurse. People receiving the benzo intervention meet their intervention nurse on a weekly to fortnightly basis. Continuity of delivery by these dedicated intervention nurses is intended to enhance the therapeutic relationship which people tell us is so important to them. Support from peers is important through a peer led support group of those receiving the intervention. These relationships – professional and peer may be key for the intervention.
The second component, harm reduction, needs to take on board the effects of benzos, particularly alongside other sedative drugs like opiates i.e. loss of short term memory and impaired cognition/ability to think clearly – what can you do to reduce impacted memory in people? For example, as we saw in the first blog, some people have problems with short term memory so harm reduction messaging is likely needed to be repeated a number of times, and be available to people in different forms, as and when they need that information.
Another aspect of harm reduction is about safety. There is a possibility that those receiving a prescription for diazepam may be targeted for their prescription, so we need to work out strategies with them to avoid that situation. Similarly, from a safety point of view they will be given a locked box for their prescription as a safeguard to others in the house, such as children, from accessing these drugs. In addition, a locked box acts as an aid memoir for patients to think about when they last took their prescribed dose.
The third component of the intervention is providing a ‘safer’ supply of benzos by prescribing diazepam to those in the study. This is designed to reduce their need to access unregulated and unknown sources of benzos, similar to that seen with opiate replacement therapy. The emphasis is on the term ‘safer’, and the quotation marks are very deliberate. We do not know yet if this will result in better outcomes for people as there is always risk involved in taking drugs – prescribed or not. However, we are doing all we can to make sure all aspects are considered.
This intervention was co-produced by people who use benzos or have used them in the past, clinicians and nurses who support people, as well as a psychologists and academics. The development of the intervention was carried out through a series of online workshops and meetings over a 4-month period, with all involved agreeing on the intervention components described here. The trial of the intervention is currently being carried out in three Scottish sites (Aberdeen, Lothian and Fife). It will provide information on the feasibility and acceptability, of prescribing benzos to patients on ORT, of exploring, and hopefully addressing, people’s specific reasons for using benzos and providing them with harm reduction and safety tips. The trial will be complete by August 2023.
If you have any queries regarding this work, please contact Dr Karen Berry (firstname.lastname@example.org).