By Catriona Matheson, Professor in Substance Use
This is the first of a series of three articles on tackling benzodiazepines. In this I consider how and why benzodiazepines contribute to drug related deaths. In the next two articles I will describe what we know about ‘safe supply’ and other interventions and what this means for service delivery.
A continued feature of our tragic drug death statistics is the role of benzodiazepines – 69% of all drug deaths involved a benzodiazepine in 2021. 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. The supply during covid was able to continue – and may even have increased. Unfortunately any quality control, and guidance labelling, is non existent! Now England, Wales and Northern Ireland are seeing street benzos increasing in their rising drug death statistics.
Over recent years I heard too many heart-breaking 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 because this is the crux of understanding why they are so lethal in certain circumstances. Benzodiazepines are used and prescribed across our society – whether the supply is legal via a prescription, or bought on the street or internet. 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. Crucially benzos also affect people’s memory and ability to think clearly. The clinical term is ‘cognitive impairment’. This is one of the reasons they feature highly in drug deaths but also a reason they cause problems in our 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 woman I met a few years ago described that 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 benzos 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 increases 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 a benzodiazepine for sleep and opiate and 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? 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.
We will not get on top of our tragic drug deaths without getting to grips with benzo use alongside other drugs. So how do we manage this? In my next article I will explore the options and consider the evidence.