This story is part of an ongoing collaboration with Drink and Drug News (DDN), where we author a monthly column on cases of patient advocacy. The original story is here.
It’s time for a new approach, say Dr Kate Blazey and Shayla Schlossenberg.
This is what we know from a clinical perspective. Drugs and alcohol charity WithYou is seeing people in treatment services with unexpectedly high levels of benzodiazepine dependence, rendering this group more vulnerable to, among other harms, overdosing. The high levels of dependence have also created uncertainty amongst clinicians about how to respond.
It’s believed that these high levels of dependence are caused by street benzos; pills sold illicitly under names such as Valium or Xanax but often containing other – often more potent – substances. In this article, a ‘novel benzo’ refers to a completely new benzo that has entered the illicit supply. ‘Street benzo’ is used for benzos that have been in the supply for a while, and are more established.
To provide better treatment to people who detox from street benzos as well as reduce the risk of overdoses and deaths, WithYou’s clinical team has discussed how benzodiazepine can be prescribed during street benzo detoxification.
Release initially shared Nick’s* story (DDN, July/August, page 18) to raise awareness about the need to adapt the clinical treatment offered to people detoxing from street benzos. Nick approached Release while dependent on street benzos, mainly diazepam. On at least one occasion, he had taken the street benzo bromazolam (thinking he had bought diazepam). While less is known about street benzos, many are more potent, which can increase the risk of overdose and death.
Later in treatment, Nick was only offered a diazepam prescription for a short time — at a dose much lower than the amount which would be equivalent to his daily benzodiazepine use at the time — affecting his ability to detox in a meaningful way. Unable to convince his clinician to prescribe him the dose that he would have needed to stabilise, Nick instead turned to his illicit supply. He shared his story with Release in the hope of raising awareness about the need for more flexibility when detoxing from street benzos.
Finding a way to better support people like Nick – WithYou’s approach
According to the ‘Orange Book’, diazepam can, under certain circumstances, be part of a benzo detox programme, while not specifying for how long the drug can be prescribed.
Separate from Nick’s experience, WithYou noticed an increase in the number of clients using street benzos such as flualprazolam and flubromazolam, thinking they were taking regular benzos – this meant clients were often in the dark about increased potency and risk. In addition, WithYou noticed an increase in people with severe dependence to what was believed to be diazepam but turned out to be street benzos after testing. Having made these observations, the clinical team decided to review WithYou’s approach.
Firstly, the clients were encouraged to test their samples using the WEDINOS external testing facility and harm reduction project. In some instances, flubromazolam was identified and it was possible to screen for it as part of the treatment programme.
Following this — working with Dr Rachel Britton (formerly clinical director at WithYou, now clinical lead at Via) and other senior clinicians — WithYou adapted its benzodiazepine guidance. The new guidance allows a slightly higher starting dose of diazepam for clients who would struggle with unpleasant and potentially risky withdrawal symptoms under the regular regime (and therefore be more inclined to top up with benzos obtained illicitly).
In addition, the level of support for those replacing high-strength benzodiazepines with the reduction regime was increased, including more frequent check-ins. Once stabilised, the gradual reduction could proceed regularly. The revised approach meant that clients suffered less unpleasant withdrawal symptoms and were less likely to turn to an illicit supply to cope with these during their initial detoxing journey.
This is one example of how to better cater to the clinical needs of people like Nick. However, it’s important to remember that not all people who use street benzos will require this approach, many can withdraw safely themselves, supported by treatment services or primary care. The challenge from a clinical perspective is to identify those more at risk and be prepared to be flexible, within a safe, clinical framework.
A revised approach to supporting people dependent on street benzos – Release
Having initially shared Nick’s story to raise awareness about the need to adapt clinical treatment offered to people detoxing from street benzos, it’s important to remember that there are several under-addressed dangers for people who use illicit benzodiazepines. Firstly, the increased presence of novel benzos in the illicit benzo supply. For instance, in Scotland, where benzodiazepines were implicated in more than half of 2022’s drug-related deaths, Public Health Scotland notes an ‘increase in harms related to the use of new benzodiazepines such as bromazolam’.
In October alone, WEDINOS received more than 20 samples from around the UK containing new benzodiazepines largely from samples believed to be either diazepam or alprazolam when purchased. The consumers of these benzodiazepines often lack access to a steady supply at a known and controlled dose, with these substances also often significantly stronger than legally prescribed ones.
Additionally, there have been many recent instances of drugs purported to be benzodiazepines turning out to contain nitazenes. Nitazenes are potent and high-risk synthetic opiates, posing great danger to people who use them. This is especially true for people who use benzodiazepines and don’t regularly use opiates.
Given the risks above, including the likelihood of new, unregulated substances emerging around the country, we need a revised approach to supporting people dependent on benzodiazepines across the sector.
This approach must include promoting drug testing to all people who use drugs, as well as greater access to naloxone. Additionally, we must improve screening tests to have an understanding of what benzodiazepines – and potentially other substances such as nitazenes – the person has used in order to respond appropriately.
As drug supplies evolve, the sector must stay current to be relevant to people who are using drugs and are at risk of drug-related harms. Updating how we collectively work with people who use benzodiazepines is paramount to the greater mission of keeping people who use drugs alive.
*not his real name