tag:theconversation.com,2011:/ca/topics/benzodiazepines-5036/articlesBenzodiazepines – The Conversation2024-01-12T16:12:10Ztag:theconversation.com,2011:article/2205172024-01-12T16:12:10Z2024-01-12T16:12:10ZFour street drugs that could pose the biggest threat to UK public health in 2024<figure><img src="https://images.theconversation.com/files/569021/original/file-20240112-25-j3jcoe.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4025%2C3017&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Xanax pills</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/muncie-indiana-united-states-june-5-1416893333">gremlinworks/Shutterstock</a></span></figcaption></figure><p>As with fashion and music, illicit drugs go through peaks and troughs of popularity. There are popular staples, such as cannabis, and more disruptive and transient substances, such as <a href="https://theconversation.com/meow-hear-this-mephedrone-is-a-curious-khat-2164">mephedrone</a>. As with <a href="https://youtu.be/Ja2fgquYTCg?si=AjGVwuw92NiEPnMS">clothing fashion</a>, the drugs that most people are able to buy are <a href="https://www.emcdda.europa.eu/publications/eu-drug-markets_en">determined by</a> the choices of designers, manufacturers and logistical operations, rather than consumers. </p>
<p>Predicting how the UK drug market may change in 2024 relies not only on recent trends in drug use but also on international developments. Geopolitical events in <a href="https://geographical.co.uk/news/myanmar-becomes-worlds-biggest-producer-of-opium">south-east Asia</a> or <a href="https://www.bbc.co.uk/news/world-latin-america-67912242">South America</a> are just as important as organised crime activity in cities such as London or Liverpool. We suggest that there are four types of drugs that will be of increasing concern in 2024. </p>
<h2>1. Opioids</h2>
<p>Heroin sold in the UK is primarily sourced from opium grown in Afghanistan. Any change in the <a href="https://theconversation.com/afghanistan-what-the-conflict-means-for-the-global-heroin-trade-165995">production and distribution</a> of opium has a direct effect on the <a href="https://theconversation.com/nitazenes-synthetic-opioids-more-deadly-than-fentanyl-are-starting-to-turn-up-in-overdose-cases-212589">UK heroin market</a>. </p>
<p>After seizing power in 2022, the Taliban announced a clampdown on opium farming in Afghanistan. While other growing regions have <a href="https://www.unodc.org/roseap/en/2023/12/southeast-asia-opium-survey-report-launch/story.html#:%7E:text=Bangkok%20(Thailand)%2C%2012%20December,Asia%20released%20in%20Bangkok%20today.">increased production</a>, this has not been at the level of the Afghan crop. </p>
<p>Large stockpiles of opium and heroin stored along trafficking routes have depleted. 2024 will see the impact of this. </p>
<p>The estimated number of people who use heroin has <a href="https://www.gov.uk/government/publications/opiate-and-crack-cocaine-use-prevalence-estimates/estimates-of-opiate-and-crack-use-in-england-main-points-and-methods">increased</a> over the past decade, with an estimated 341,032 current users in England. </p>
<p>This is a highly profitable market, and suppliers are adaptable and nimble in responding to changes like these. As a consequence of the shortfall in Afghan heroin production, new, highly potent <a href="https://www.bmj.com/content/383/bmj.p2421">synthetic opioids</a> have already emerged to fill the gap. These include the group of synthetic opiates known as <a href="https://theconversation.com/nitazenes-synthetic-opioids-more-deadly-than-fentanyl-are-starting-to-turn-up-in-overdose-cases-212589">nitazenes</a>, which have contributed to the <a href="https://theconversation.com/generation-x-hardest-hit-as-drug-deaths-rise-yet-again-in-england-and-wales-220064">record levels</a> of drug-related deaths recorded in 2023 in the UK. </p>
<p>Increased market penetration of these drugs could lead to a big rise in deaths in 2024. Worryingly, <a href="https://www.bbc.co.uk/news/uk-england-manchester-67777938">misselling</a> as other products and unintentional contamination of other non-opioid drugs could increase the harms further. Government and treatment services must act now to prepare for an increase in the supply of these drugs, as the costs of not doing so might lead to a <a href="https://www.sciencedirect.com/science/article/pii/S0955395923003614?via%3Dihub">“nightmare scenario”</a>. </p>
<h2>2. Cocaine</h2>
<p>Cocaine has never been purer, more affordable and more available to those <a href="https://www.theguardian.com/commentisfree/2023/dec/23/coke-consumption-uk-millennials-generation-x">who want it in the UK</a>. While <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/drugmisuseinenglandandwales/yearendingmarch2023">levels of use</a> have been relatively stable over the past 20 years, <a href="https://theconversation.com/generation-x-hardest-hit-as-drug-deaths-rise-yet-again-in-england-and-wales-220064">deaths and hospitalisations</a> have increased due the nature of the product on the market and increases in the frequency and length of use. </p>
<p>Unlike other class A drugs, such as heroin, there are few effective treatments, and users tend to be more socially integrated. This means that they are less likely to come into contact with police or present to treatment services. </p>
<p>They may not identify themselves as having a drug problem, despite the effect it may be having on their lives. When disposable income continues to be squeezed as it is in the current cost of living crisis, powder cocaine (as opposed to crack cocaine) is a drug that will continue to provide good “value for money”. Sadly, we predict yet another rise in poisonings and hospitalisations in 2024.</p>
<figure class="align-center ">
<img alt="Older man snorting coke." src="https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cocaine users tend to be more ‘socially integrated’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/old-male-writer-smoking-cigarette-2284921057">Elnur/Shutterstock</a></span>
</figcaption>
</figure>
<h2>3. Ketamine</h2>
<p>Ketamine has been used in medicine as an anaesthetic for many years, and more recently as an <a href="https://theconversation.com/how-antidepressants-ketamine-and-psychedelic-drugs-may-make-brains-more-flexible-new-research-216025">antidepressant</a>. Taken recreational at lower doses, the drug <a href="https://www.talktofrank.com/drug/ketamine">induces</a> feelings of detachment and happiness. </p>
<p>This is another drug that has become increasingly <a href="https://bjgp.org/content/73/727/87">popular</a> because it is cheap, fast-acting and easy to get hold of. </p>
<p>Around <a href="https://news.sky.com/story/student-died-after-taking-ketamine-now-her-mother-wants-to-address-naivety-among-parents-13039959">3.8% of young people</a> (aged 16 to 24) report having used the drug. This has been steadily rising over the past decade. Police report that the weight of <a href="https://www.gov.uk/government/statistics/seizures-of-drugs-in-england-and-wales-financial-year-ending-2022/seizures-of-drugs-in-england-and-wales-financial-year-ending-2022">seizures</a> of ketamine that they made increased sharply from 187kg in 2021 to 1,837kg in 2022. Drug seizures are often used as a proxy for estimating levels of supply.</p>
<p>A range of problems can develop for those using ketamine in higher doses or over a longer period, ranging from mental health problems to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4544340/">incontinence</a>. An overdose of the drug can prove to be fatal.</p>
<p>As with most illicit drugs, combining ketamine with alcohol <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9323326/">increases</a> health risks. Sadly, it is the norm for people to use more than one drug at a time – including alcohol.</p>
<p>Given the widespread availability and <a href="https://www.timeout.com/uk/nightlife/how-ketamine-became-britains-go-to-party-drug">affordability</a> of ketamine in the UK, its use will continue to rise in 2024. Use is concentrated among younger people, many of whom won’t be aware of its potential for harm until it’s too late. </p>
<p>As with cocaine, there has been a distinct lack of health messaging, advice and support for people who use ketamine. Some youth organisations that have tried to do this have faced unhelpful <a href="https://www.thetimes.co.uk/article/how-ketamine-became-the-uks-hidden-campus-killer-9mp3pm6ht">national media backlash</a>. </p>
<h2>4. Benzodiazapines</h2>
<p>Benzodiazepines, more commonly known by brand names such as Valium and Xanax, have proved to be popular and dangerous in equal measure. While medical prescriptions have <a href="https://www.england.nhs.uk/2023/03/opioid-prescriptions-cut-by-almost-half-a-million-in-four-years-as-nhs-continues-crackdown/">fallen</a> in recent years illicit <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/drugmisuseinenglandandwales/yearendingmarch2023">demand</a> and supply has not. </p>
<p>Although doctors have been <a href="https://www.nice.org.uk/sharedlearning/benzodiazepine-hypnotics-deprescribing">encouraged</a> to reduce prescriptions for benzodiazepines, the black market has filled the gap in demand. Unlike legitimate supply, the illicit market has no quality control or reliable information on strength – both of which lead to deaths.</p>
<p>The rapid rise in deaths from <a href="https://www.sciencedirect.com/science/article/abs/pii/S0955395921004308">these drugs</a> in Scotland shows regional differences both in the use of drugs and the risks they pose. Reversing this trend in use and fatalities will prove to be difficult in 2024 as there are few signs of a change in demand for, or supply of these drugs.</p>
<h2>Can we prevent drug harms?</h2>
<p>It is not possible to entirely prevent all the harms relating to drug use and the drugs market, but they can be reduced. 2024 may see the emergence of new drugs or new ways of taking them, but what won’t change will be the continuation of more than 20 years of increasing drug-related harm. </p>
<p>In a year of a general election in the UK, there is the danger that drugs policy will be used for political point scoring – signalling to the electorate how tough on crime one party is, or how soft on crime their opponents are. Whatever the outcome of the election, unless there is a clear commitment to long-term investment in responses to drug use, new records will be set in drug-related deaths.</p><img src="https://counter.theconversation.com/content/220517/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Sumnall receives and has received funding from public grant awarding bodies for alcohol and other drugs research, and consultation fees from (international) not-for-profit organisations, and government Ministries for consultation work. He is an unpaid member of the Scientific Advisory Board of the Mind Foundation.</span></em></p><p class="fine-print"><em><span>Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Synthetic opioids called nitazenes are ones to watch in 2024.Ian Hamilton, Honorary Fellow, Department of Health Sciences, University of YorkHarry Sumnall, Professor in Substance Use, Liverpool John Moores UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2137162023-10-16T21:49:31Z2023-10-16T21:49:31ZThe roots of the North American opioid crisis, and 3 key strategies for stopping it<figure><img src="https://images.theconversation.com/files/554088/original/file-20231016-21-1blzbh.jpg?ixlib=rb-1.1.0&rect=31%2C7%2C4866%2C3210&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Approaching the opioid crisis from a public health perspective includes massively increasing access to care and treatment for patients experiencing substance use disorder.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-roots-of-the-north-american-opioid-crisis-and-3-key-strategies-for-stopping-it" width="100%" height="400"></iframe>
<p>The Netflix series <em><a href="https://www.netflix.com/ca/title/81095069">Painkiller</a></em> recently depicted how the over-prescribing of the medicine OxyContin wreaked havoc on American society. </p>
<p>Today the grim reality is that opioid-related deaths in North America reached a record level in 2022, with more than <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">109,000 fatalities in the United States</a>. The same year in Canada, <a href="https://www.statista.com/statistics/812260/number-of-deaths-from-opioid-overdose-canada-province/">deaths exceeded 7,400</a>, a number equivalent to 20 opioid-related deaths every day, and this is <a href="https://www.thelancet.com/infographics-do/opioid-crisis-north-america">likely to continue to increase over the coming years</a>.</p>
<p>The opioid overdose crisis has been ongoing for over two decades in Canada and the U.S. The current mortality rate is greater than the <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5021a2.htm">worst years</a> of the <a href="https://www.jstor.org/stable/41994093">HIV/AIDs epidemic</a> in these <a href="https://doi.org/10.14745%2Fccdr.v43i12a01">countries</a>. </p>
<p><a href="https://www.canada.ca/en/health-canada/services/opioids.html">Opioids</a> are drugs primarily used to treat severe pain, such as after surgery. When prescribed responsibly they are an effective medication, but if over-prescribed or used recreationally they can lead to an addiction (known as <a href="https://www.canada.ca/en/health-canada/services/opioids/opioids-use-disorder-treatment.html">opioid use disorder</a>) that can result in overdose death and wider community problems.</p>
<h2>The roots of the crisis</h2>
<p>After introduction of the opioid painkiller OxyContin in 1996, <a href="https://doi.org/10.2105%2FAJPH.2007.131714">Purdue Pharma marketed the drug aggressively</a>, underplaying its potential for addiction. Prescriptions increased and many patients became addicted. Purdue Pharma eventually <a href="https://www.justice.gov/opa/pr/justice-department-announces-global-resolution-criminal-and-civil-investigations-opioid">pleaded guilty to criminal charges in 2020</a>.</p>
<p>To address addiction, <a href="https://store.samhsa.gov/sites/default/files/d7/priv/sma16-4997.pdf">prescription monitoring programs</a> aimed to limit supply but many patients then sought illicit opioids, leading to large heroin markets in the 2010s. </p>
<p>From 2015 onwards, illegally made <a href="https://www.canada.ca/en/health-canada/services/substance-use/controlled-illegal-drugs/fentanyl.html">fentanyl</a> — a very strong opioid that is easy to manufacture — became widely available, and rapidly replaced the heroin market. Fentanyl is extremely toxic — up to 100 times stronger than heroin — and is largely responsible for the increase in overdose deaths. </p>
<p>Now North Americans face an urgency on how to end the suffering. There is no single solution given the complexity of the problem, but we explain three potential strategies for treating patients and managing this epidemic.</p>
<h2>1. Treat substance use disorders as a public health problem</h2>
<p>The traditional “<a href="https://www.lse.ac.uk/ideas/publications/reports/ending-drugs">war on drugs</a>” approach that focuses only on criminalization has been unsuccessful. In reality the data shows that illegal drug prices have fallen whilst purity and deaths have increased. <a href="https://www.themarshallproject.org/2021/07/15/inside-the-nation-s-overdose-crisis-in-prisons-and-jails">Overdose deaths have also increased in prisons</a> showing that places with even the highest level of security are vulnerable to drug smuggling.</p>
<p>Focusing on the opioid crisis through a public-health approach includes massively increasing access to care and treatment for patients experiencing substance use disorder. It requires more evidence-based services such as addiction clinics, psychotherapy harm reduction strategies and education for both patients and families about treatments that are available to them. </p>
<p>Beyond initial treatment there should be continued professional social support and a wider national effort to address the <a href="https://doi.org/10.2105%2FAJPH.2017.304187">socioeconomic causes</a> in disadvantaged communities. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/HHiN7JftdcY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Scott McFadden, an addictions counsellor in recovery from opioid use, shares his own journey and the impact of stigma and shame.</span></figcaption>
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<p>Just as there is <a href="https://www.youtube.com/watch?v=HHiN7JftdcY">stigma associated with addiction</a> that stops people from seeking help, there also appears to be stigma at the political and community level, as there is reluctance to fully acknowledge community drug problems. This <a href="https://doi.org/10.1371/journal.pmed.1002969">stigma needs to be reduced</a> so patients can get help.</p>
<h2>2. Find better treatments through research</h2>
<p>There are currently three main medicines approved for <a href="https://www.canada.ca/en/health-canada/services/opioids/opioids-use-disorder-treatment.html">treating patients with opioid use disorder</a> in Canada and the U.S.: methadone, buprenorphine/naloxone and extended-release naltrexone.</p>
<p>Although these are effective when used, there are barriers to access and long-term engagement with these treatments. <a href="https://thetyee.ca/News/2023/10/06/Catastrophe-No-Sense-Crisis/">Less than 10 per cent of overdose survivors have access to meaningful care.</a> The limited number of medications available does not work for everyone. We need more innovation to rapidly increase access to care and to find better therapies that suit the needs of different patients.</p>
<p>For example, our <a href="https://www.bccsu.ca/about/">research centre in Vancouver</a>, is evaluating a slow-release formulation of morphine compared to methadone, which has been the dominant treatment for the past 40 years. This study will generate real-world evidence on the effectiveness of novel treatments in contexts of increasing fentanyl use.</p>
<p>Other research is exploring <a href="https://classic.clinicaltrials.gov/ct2/show/NCT05985850">cannabis-based therapy</a> and the <a href="https://www.bccsu.ca/road-to-recovery-study/">best pathways patients can access for recovery</a>. These research initiatives aim to increase the number of evidence-based treatments that can be used to enhance patient recovery and quality of life.</p>
<h2>3. Stop the international spread of the epidemic</h2>
<p>Currently the epidemic is contained within North America but there is the real <a href="https://doi.org/10.1007/s40429-018-0231-x">concern of the crisis spreading</a> to other countries. There is a steady <a href="https://theconversation.com/over-the-counter-opioids-does-britain-have-a-codeine-problem-205331">increase in prescription</a> and illicit opioid use in the United Kingdom and other European countries, which should be an early warning sign that they do not follow the same trajectory. Clinicians must remain actively vigilant on how they prescribe these drugs. </p>
<p>There should be <a href="https://doi.org/10.1016/S0140-6736(21)02252-2">greater international regulation</a> in the marketing and operational strategies of pharmaceuticals, and oversight of the “<a href="https://www.science.org/content/article/fda-s-revolving-door-companies-often-hire-agency-staffers-who-managed-their-successful">revolving door</a>” between industry and regulator employment. There is a potential conflict of interest when pharma companies hire the government employees who oversee their applications. As shown in <em>Painkiller</em>, the FDA regulator who initially had issues with the drug’s approval, and then later approved it, subsequently went on to work for Purdue.</p>
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Read more:
<a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">‘Benzo-dope’ may be replacing fentanyl: Dangerous substance turning up in unregulated opioids</a>
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<p>Another concern is that the current increase in overdose deaths is coinciding with increased deaths where other illicit recreational drugs, such as cocaine and benzodiazepines, are <a href="https://www.bccsu.ca/blog/news/fentanyl-laced-cocaine-appears-in-b-c-amid-calls-for-safe-supply/">contaminated with fentanyl</a> unknown to the users. More effort should be made towards the public awareness of the dangers of an increasingly toxic drug market.</p>
<p>Speaking at a health-care summit in June, Rahul Gupta, the <a href="https://www.politico.com/news/2023/06/07/gupta-opioid-crisis-deaths-00100756">director of the U.S. Office of National Drug Control Policy</a>, said, “There is almost no other area today (that) affects our public health, national security and economic prosperity.”</p>
<p>Valuable knowledge has been gained in confronting this crisis. Governments and communities should support evidence-based recommendations to help patients. There are still many challenges, but they are not beyond solving.</p><img src="https://counter.theconversation.com/content/213716/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Smith Foundation for Health Research/ St. Paul’s Foundation Scholar Award.
Peer-review grants from the Canadian Institutes of Health Research and Vancouver Foundation.
Partial funding from Indivior for an investigator initiated study.
</span></em></p><p class="fine-print"><em><span>Rohan Anand does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There were more than 100,000 opioid-related deaths in North America in 2022. How the crisis grew to such proportions, and three potential paths to ending it.Rohan Anand, Post Doctoral Fellow, British Columbia Centre on Substance Use, University of British ColumbiaM. Eugenia Socias, Assistant Professor, Dept of Medicine, University of British Columbia and Research Scientist with the BC Centre on Substance Use, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2046122023-05-24T12:17:56Z2023-05-24T12:17:56ZAnesthesia can cause disturbing sexual hallucinations, leading to lasting psychological trauma<figure><img src="https://images.theconversation.com/files/527119/original/file-20230518-17-zdnrt1.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2119%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Having witnesses or recording devices during procedures requiring anesthesia could help prevent opportunities for sexual assault.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/anaesthetist-placing-mask-on-patient-royalty-free-image/1178748279">Science Photo Library/Getty Images</a></span></figcaption></figure><p>Some patients can have vivid and detailed <a href="https://doi.org/10.1002/jcph.2233">sexual hallucinations during anesthesia with sedative-hypnotic drugs</a> like propofol, midazolam, diazepam and nitrous oxide. Some make suggestive or sexual comments or act out, such as grabbing or kissing medical professionals or touching themselves in a sexual way. Others awaken erroneously believing they were sexually assaulted. Why does this happen? </p>
<p>Doctors have long known that <a href="https://www.britannica.com/science/sedative-hypnotic-drug">sedative-hypnotic drugs</a>, which slow down brain activity to induce calm or sleep, can affect a patient’s perception of reality. A 1984 review of the drugs midazolam, ketamine and thiopental found that 18% of patients receiving anesthesia for a dental or medical procedure had a <a href="https://www.accessdata.fda.gov/drugsatfda_docs/nda/pre96/018654Orig1s000rev.pdf">hard time distinguishing reality from fantasy</a> during and shortly after administration. Similarly, a 1980 study found that around 14% of patients report some <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2516323/">sexual dreaming or arousal</a> while under anesthesia. It’s no surprise that together these two features of anesthesia could sometimes manifest in sexual hallucinations.</p>
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<figcaption><span class="caption">Propofol is a commonly used anesthetic.</span></figcaption>
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<p>There have been rare cases in which medical professionals <a href="https://www.rollingstone.com/culture/culture-news/coma-birth-woman-arisona-hacienda-healthcare-776902/">used a patient’s unconscious state</a> to commit sexual assault. For instance, in 1991, a health professional <a href="https://doi.org/10.1016/0140-6736(91)90890-2">sexually assaulted a university student</a> under anesthesia. Although the case was initially dismissed on the grounds that the patient could have had a drug-induced sexual hallucination, genetic evidence the health professional left behind later led to his conviction. It cannot be assumed that all cases of reported sexual assault under anesthesia are due to a sexual hallucination. </p>
<p>We are <a href="https://scholar.google.com/citations?user=lWAD9d8AAAAJ&hl=en">pharmacology researchers</a> who recently <a href="https://doi.org/10.1002/jcph.2233">reviewed the medical literature</a> on sexual assault or sexual fantasy during anesthesia from the earliest documented case to February 2023, finding 87 reported cases from 17 published papers. Better understanding what triggers unpleasant or sexual dreams under anesthesia could help researchers figure out how to reduce the risk of hallucinations to keep both patients and providers safe.</p>
<h2>Reports of sexual hallucinations</h2>
<p><a href="https://doi.org/10.1002/jcph.2233">Sixteen of the individual cases</a> we found in our review involved patients reporting sexually amorous behavior or perceived sexual assault. In these cases, observers like health professionals or family members were also present during the procedure, reducing the chance that the sexual behavior actually occurred versus being hallucinated.</p>
<p>We also found a striking match between the anatomic location of the procedure and where the patient perceived inappropriate sexual contact. Procedures involving the mouth were perceived as oral sex, squeezing a ball to make a vein more accessible as squeezing a penis, chest procedures as breast fondling and groin procedures as vaginal penetration. </p>
<p>This may explain why <a href="https://doi.org/10.1111/j.1365-2044.1988.tb05529.x">one assessment of 200 patients</a> found no cases of sexual hallucination for those undergoing gallbladder or appendix procedures involving the abdomen, but around 12% of those undergoing vaginal procedures noted amorous or sexually disinhibited behavior.</p>
<h2>Trauma for both patients and providers</h2>
<p>These anesthesia effects can have major real-world impacts on patients and providers that last long after the surgery.</p>
<p>The <a href="https://doi.org/10.1002/jcph.1995">emotional turmoil</a> a patient undergoes is likely the same whether actually experiencing sexual assault under anesthesia or having vivid hallucinations of the event. And practitioners too can experience distress: <a href="https://doi.org/10.14219/jada.archive.1980.0343">Some medical professionals</a> accused of real or perceived sexual assault have been brought before regulatory boards or the courts and lose their license to practice.</p>
<p>It is possible that if patients knew a hallucination of sexual assault is a rare but possible adverse effect of anesthesia before they receive it, and were aware of the steps medical providers are taking to reduce that risk, they would be less likely to believe their sexual hallucinations were real. But this would not lessen the trauma of the hallucination. In one case, an anesthesiology student <a href="https://pubmed.ncbi.nlm.nih.gov/3469766/">volunteered in a study</a> where she experienced sexual hallucination after taking sedative-hypnotics. Although she knew her vivid memories of the sexual assault weren’t real, the distress she felt over them led her to withdraw from the study.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/527121/original/file-20230518-24-wwrsrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Patient sitting on hospital bed looking out window" src="https://images.theconversation.com/files/527121/original/file-20230518-24-wwrsrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/527121/original/file-20230518-24-wwrsrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/527121/original/file-20230518-24-wwrsrl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/527121/original/file-20230518-24-wwrsrl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/527121/original/file-20230518-24-wwrsrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/527121/original/file-20230518-24-wwrsrl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/527121/original/file-20230518-24-wwrsrl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An experience of sexual assault can lead to significant psychological trauma.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/patient-sitting-on-hospital-bed-waiting-royalty-free-image/493991213">Portra Images/Stone via Getty Images</a></span>
</figcaption>
</figure>
<p>In our review of the literature, we found <a href="https://doi.org/10.1002/jcph.2233">71 individual cases</a> in which the medical professional was alone with the patient at the time of the alleged sexual assault or sexual behavior. For the safety and well-being of both patients and medical professionals, having witnesses in the room or recording devices during dental or medical procedures could help prevent an opportunity for sexual assault and reassure patients that the hallucinations they may experience are not real.</p>
<p>However, the health care system needs to go further to protect patients. Patients struggling with the trauma of hallucinated sexual assault, even if there is evidence that it did not occur in reality, should be referred to counseling and supported just like someone who was physically harmed during a medical or dental procedure.</p>
<h2>Many unknowns remain</h2>
<p>What makes some people more likely to recall their dreams while under anesthesia is unclear. A 2009 study of 97 patients receiving propofol reported that those who <a href="https://doi.org/10.1097/EJA.0b013e32832c500c">frequently remember their dreams</a> after anesthesia received higher doses of anesthetics, were younger than 50 years old and took longer to recover from anesthesia. A 2013 study of 200 patients receiving propofol found that men were more likely to <a href="https://doi.org/10.1097/WNR.0b013e3283644b66">remember dreams after anesthesia</a> but women were more likely to remember unpleasant dreams. While dreaming and hallucinations are related experiences, people experiencing hallucinations believe they could plausibly be real.</p>
<p>While we reviewed all published cases of sexual hallucinations in the medical literature, the actual incidence of anesthesia-induced sexual hallucinations remains unknown. Given the decades that have passed since the first reported cases, more work needs to be done. Data from a very large sample size of patients will be required to understand the prevalence of sexual hallucinations under anesthesia. However, drug companies are reluctant to spend money on research that may show that their drugs cause adverse side effects.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/527122/original/file-20230518-27-rp4r6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two white pills in one hand and glass of water in the other" src="https://images.theconversation.com/files/527122/original/file-20230518-27-rp4r6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/527122/original/file-20230518-27-rp4r6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/527122/original/file-20230518-27-rp4r6k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/527122/original/file-20230518-27-rp4r6k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/527122/original/file-20230518-27-rp4r6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/527122/original/file-20230518-27-rp4r6k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/527122/original/file-20230518-27-rp4r6k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A number of prescription sedative-hypnotic drugs can cause hallucinations.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/close-up-view-of-hands-holding-pills-and-water-royalty-free-image/1171196510">Grace Cary/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p>Finally, though we limited our review to reports of sexual hallucinations during anesthesia, millions of Americans use other prescription sedative-hypnotic drugs. <a href="https://doi.org/10.1177/070674370204700823">Benzodiazepines</a> like alprazolam (Xanax) and temazepam (Restoril) are used to treat anxiety and induce sleep. <a href="https://doi.org/10.1007%2Fs13181-013-0294-y">Z-drugs</a> like zolpidem (Ambien) and eszopiclone (Lunesta) as well as suvorexant (Belsomra) and sodium oxybate (Xyrem) are also used to induce sleep. <a href="https://doi.org/10.1213%2FANE.0000000000001417">Opioids</a> like morphine and oxycodone and <a href="https://doi.org/10.2146/ajhp150136">gabapentinoids</a> like gabapentin (Neurontin) and pregabalin (Lyrica) are used to treat pain. <a href="https://doi.org/10.4088%2FPCC.14l01773">Muscle relaxers</a> like carisoprodol (Soma) and cyclobenzaprine (Flexeril) are used for muscle spasms. All of these drugs have had reported cases of patients experiencing hallucinations while taking them.</p>
<p>In a review of the <a href="https://www.fda.gov/drugs/surveillance/questions-and-answers-fdas-adverse-event-reporting-system-faers">FDA Adverse Events Reporting System</a>, which public health officials and researchers use to monitor drug safety, 30,728 cases of “abnormal dreaming” were reported from 1974 through 2022. Most involved sedative-hypnotic drugs treating insomnia, anxiety, pain and muscle spasms. The reports do not specify the nature of these dreams, or how they affected the patient’s own perceived well-being. </p>
<p>It is important for patients to be aware that abnormal dreaming is a possibility when starting a sedative-hypnotic medication, and to inform their health professional if they experience hallucinations. These symptoms could indicate that the drug is not the right choice for you or that the dose may be too high.</p><img src="https://counter.theconversation.com/content/204612/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sedative-hypnotic drugs can distort a patient’s perception of reality. Some patients wake up from a procedure believing they have been sexually assaulted.Melody White, Ph.D. Candidate in Pharmaceutical Sciences, University of ConnecticutC. Michael White, Professor of Pharmacy Practice, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1992392023-02-06T20:53:55Z2023-02-06T20:53:55ZWhy the drug poisoning crisis in B.C. won’t be addressed by the new decriminalization policy<p>On the same day that British Columbia began a new era in drug policy with the <a href="https://www2.gov.bc.ca/gov/content/overdose/decriminalization">decriminalization of simple possession of some drugs</a>, the province’s chief coroner provided a <a href="https://www2.gov.bc.ca/gov/content/life-events/death/coroners-service/statistical-reports">devastating update</a> about the number of lives lost to illicit drugs during the previous year. </p>
<p>On Jan. 31, 2023, B.C. began a <a href="https://www2.gov.bc.ca/assets/gov/overdose-awareness/decriminalization_factsheet.pdf">three-year pilot project</a> under which simple possession of some drugs (opioids, methamphetamine, cocaine and MDMA) can no longer lead to criminal prosecution or even seizure of the drugs by police. The policy applies to possession of up to 2.5 grams of substance for personal use.</p>
<p>While a major step in the right direction, decriminalization does nothing to tackle what is fuelling the drug-poisoning crisis: the makeup of a toxic and unregulated drug supply. </p>
<p>In fact, imposed carry restrictions of 2.5 grams could theoretically lead to unintended consequences as drugs become more potent to fit within legal limits. </p>
<p>The stated goal of the decriminalization policy change is to <a href="https://theconversation.com/decriminalizing-drug-use-is-a-necessary-step-but-it-wont-end-the-opioid-overdose-crisis-162497">remove the stigma associated with drug use</a> to encourage people to seek help when they need it. </p>
<p>While the effects that decriminalization may have on the stigma of drug use remain to be seen, what it won’t affect is the toxicity of the drug supply that is killing thousands of Canadians each year.</p>
<h2>Inconsistent and unreliable drug supply</h2>
<p>Chemical analysis of drugs (such as from <a href="https://drugcheckingbc.ca/video/">drug checking</a> or police investigations) can tell us what is circulating in the supply, but <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">toxicology results</a> from those who have died from overdoses tell us what is actually causing death. </p>
<p>These data sources describe how increases in adulteration of drugs with fentanyl analogues, <a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">benzodiazepines</a> and animal tranquilizers like <a href="https://substance.uvic.ca/blog/xylazine/">xylazine</a> are driving the drug poisoning crisis. </p>
<p>Fentanyl has been the main opioid sold on the unregulated market for several years. It is typically sold mixed into other powders like caffeine or sugars to make a final product. </p>
<p>Drug supply monitoring has shown that fentanyl concentration in these powders sold on the street can range from zero to nearly 100 per cent, with a standard sample in B.C. being <a href="https://drugcheckingbc.ca/wp-content/uploads/sites/2/2023/01/Drug_Checking_BC_Nov_20224.pdf">around 10–15 per cent</a>. </p>
<p><a href="https://doi.org/10.1093/aje/kwab129">Research conducted in Vancouver</a> has described how fentanyl concentration in these samples was somewhat consistent between 2018 and early 2020, with variability between samples even decreasing over that period. What that may speak to is producers of fentanyl reaching a sort of “sweet spot” that satisfies their customers. People who sell drugs have described how they <a href="https://doi.org/10.1016/j.drugpo.2020.102845">listen to feedback</a> from their regulars and adjust the product to meet their customers’ needs. </p>
<p>However, following the start of the COVID-19 pandemic, <a href="https://epiresearch.org/wp-content/uploads/2022/06/2022-Abstract-Book.pdf#page=77">variation in potency between fentanyl samples rose dramatically</a>, leading to further unpredictability. These changes to the fentanyl supply around the spring of 2020 coincided with rates of drug poisonings previously not seen in the province. </p>
<p>Under B.C.’s decriminalization framework, possession for personal use caps at 2.5 grams of substance. While 2.5 grams may be more than enough MDMA for a night out, it may not be enough heroin to last a single day for someone who has a high opioid tolerance. People who use drugs say that to abide by these limits, they will be forced to make <a href="https://vancouver.citynews.ca/2022/05/31/bc-decriminalization-drugs/">more frequent, smaller purchases.</a> With the drug supply as volatile and unpredictable as it is, every new purchase puts someone at risk. </p>
<h2>Legal limit may affect potency</h2>
<p>Since we know that the drug supply is dynamic, it raises a question: Will the imposed legal carry limit of 2.5 grams result in increased potency of fentanyl to fit within the new 2.5-gram threshold? </p>
<p>Increases in average potency of fentanyl has been <a href="https://www.inhsu.org/resource/fentanyl-concentration-in-drug-checking-samples-and-risk-of-drug-related-mortality-during-an-illicit-drug-toxicity-crisis-in-vancouver-canada-a-time-series-analysis/">shown to be linked to increased drug poisonings</a> in the same geographic area. If the unregulated fentanyl market adjusts to fit more active ingredient into a smaller package, there will be downstream effects on people lives. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cropped image of a person holding a hand-lettered sign reading 'Every death is a drug policy failure'" src="https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An advocate holds a sign at a demonstration in Victoria in April 2022. Decriminalization alone may have little effect on drug deaths without changes to the addiction treatment system.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Chad Hipolito</span></span>
</figcaption>
</figure>
<p>The provincial and federal governments have <a href="https://www.theglobeandmail.com/canada/british-columbia/article-federal-minister-promises-data-on-impact-of-decriminalization/">committed to a data-driven approach</a> to decriminalization. Ongoing drug supply monitoring will help public health professionals characterize what changes occur to the unregulated drug supply as a result of the policy change. Yet the act of decriminalizing drugs for personal use does not have any direct effect on the cause of the ongoing poisoning crisis. </p>
<p>The <a href="https://news.gov.bc.ca/releases/2023PSSG0008-000109">consensus among experts</a> has consistently pointed to unpredictable drugs from an unregulated supply and the absence of a functioning addiction treatment system. For those who want to seek treatment, the lack of available space leaves people waiting, once again left to rely on the toxic drug supply. </p>
<p>If B.C. is serious about confronting the leading cause of unnatural death in the province, it is going to take far more than decriminalizing simple drug possession. People who use drugs require an alternative to the toxic unregulated supply to not be risking their lives every time they use drugs. </p>
<p>Increasing access to a safer supply of drugs through a <a href="https://theconversation.com/safer-supply-of-opioids-saves-lives-providing-alternatives-to-toxic-street-drugs-177925">variety of formats</a> and providing meaningful funding for accessible treatment options are some examples of ways the province can take immediate steps to make an impact. </p>
<p>In the meantime, <a href="https://bc.ctvnews.ca/illicit-drug-death-toll-surpasses-2-000-in-b-c-for-a-2nd-consecutive-year-1.6253605">six more people will die today</a> from a drug poisoning in B.C. And another six will die tomorrow. How many more days can this go on?</p><img src="https://counter.theconversation.com/content/199239/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Tobias does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As British Columbia begins a new era in drug policy, the drug poisoning crisis continues without an end in sight.Samuel Tobias, PhD Student, School of Population and Public Health, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1779252022-03-11T16:31:22Z2022-03-11T16:31:22ZSafer supply of opioids saves lives: Providing alternatives to toxic street drugs<figure><img src="https://images.theconversation.com/files/450317/original/file-20220307-109224-rux7pe.jpg?ixlib=rb-1.1.0&rect=710%2C486%2C5059%2C3288&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Methamphetamine, heroin and cocaine distributed by the Drug User Liberation Front, a grassroots organization proving a safe supply of illicit drugs, in Vancouver, in April 2021.
</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span></figcaption></figure><p>Over 25,000 Canadians have died from opioid overdose since 2016 — with <a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/">6,306 people dying in 2020</a> alone. </p>
<p>The overdose crisis is driven by an unregulated drug supply made up mostly of fentanyl, increasingly potent fentanyl analogues such as carfentanil, and more recently, <a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">unregulated benzodiazepines</a>. Early in the COVID-19 pandemic, fentanyl directly contributed to <a href="https://odprn.ca/research/publications/opioid-related-deaths-and-healthcare-use/">89 per cent of all overdose deaths</a> in Ontario. </p>
<p>The volatility and toxicity in the unregulated drug supply continues to lead to more deaths. The British Columbia coroner’s report shows that <a href="https://news.gov.bc.ca/releases/2022PSSG0010-000188">more people died in 2021</a> from suspected illicit toxic drugs than ever before. In 2021, there was a 26 per cent increase in overdose deaths compared to 2020. </p>
<p>The Public Health Agency of Canada recently estimated that without new interventions, <a href="https://www.canada.ca/en/health-canada/services/opioids/data-surveillance-research/modelling-opioid-overdose-deaths-covid-19.html">another 8,000 overdose deaths will occur in 2022</a>. Addressing this devastating crisis requires bold action that includes expanding current evidence-based harm reduction and treatment services, alongside new interventions to prevent overdose deaths.</p>
<h2>Safer supply</h2>
<p><a href="https://www.canada.ca/en/health-canada/services/opioids/responding-canada-opioid-crisis/safer-supply.html">Safer supply</a>, the practice of providing a medical prescription for pharmaceutical drugs of known quality, is one of those new interventions. In Ontario, safer supply programs are run mostly by community health centres that specialize in providing care to our most marginalized community members. These small pilot programs are a low-barrier first step alternative to the toxic drug supply.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Orange signs with black block lettering instructions on how to pick up safe supply of illicit drugs." src="https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Safe supply programs are run mostly by community health centres.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>There are several <a href="https://www.canada.ca/en/health-canada/services/substance-use/canadian-drugs-substances-strategy/funding/substance-use-addictions-program.html">research studies funded across Canada</a> to evaluate different parts of these pilot safer supply programs. We are public health researchers involved in some of these studies, and initial results are promising.</p>
<p>At London’s Intercommunity Health Centre, close to 250 clients are prescribed pharmaceutical opioids as a daily-dispensed prescription that they take home and use at their discretion. <a href="https://lihc.on.ca/wp-content/uploads/2022/01/2021-SOS-Evaluation-Full.pdf">A recent evaluation of this program</a> reported decreased use of fentanyl and other street-acquired drugs, reduced hospitalizations and a dramatic decrease in overdoses among clients.</p>
<p>Importantly, clients reported that the program was saving their life and helped them to take steps to improve their health. </p>
<h2>Addiction treatment models</h2>
<p>Unfortunately, there has been <a href="https://www.theglobeandmail.com/opinion/article-as-a-doctor-i-was-taught-first-do-no-harm-thats-why-i-have-a-problem/">opposition to safer supply programs</a> from some in the addiction treatment community. Such opposition has the potential to undermine public support for people who use drugs and the expansion of lifesaving interventions that are urgently needed. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A hand holding a small box labelled 'Ingredients: Cocaine. Please see insert. NOT FOR SALE. Keep away from children and pets.'" src="https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A client of the Drug User Liberation Front in Vancouver holds safe supply cocaine.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>Current interventions to respond to opioid use don’t work for everyone. Opioid agonist treatments (OAT) like methadone and buprenorphine, are intended to reduce cravings for opioids and manage withdrawal symptoms, but they do not produce euphoria or the high associated with other opioids. </p>
<p>There are issues with both access and retention in OAT. Fewer than <a href="https://doi.org/10.1111/add.14947">70 per cent</a> of people who are diagnosed with an opioid use disorder ever start OAT. And although retention rates vary, an Ontario study found that after one year, <a href="https://doi.org/10.1097/adm.0000000000000156">less than half</a> of people who do start are still using OAT. Although there isn’t a set rule for how long someone should stay on OAT, generally <a href="https://www.camh.ca/-/media/files/professionals/canadian-opioid-use-disorder-guideline2021-pdf.pdf">longer treatment is associated with better outcomes</a>.</p>
<p>Despite low retention rates, addiction medicine has been reluctant to address the barriers to care that people who use drugs have been <a href="https://doi.org/10.1016/j.drugpo.2021.103364">attempting to call attention to for years</a>. </p>
<p>People who use drugs have highlighted for a long time how restrictions around take-home doses reduce people’s ability to stay in methadone programs. And they are right — when restrictions on taking home doses of methadone were loosened during the COVID-19 pandemic to facilitate physical distancing, <a href="https://doi.org/10.1001/jama.2022.1271">retention to methadone improved</a> without increased negative outcomes like overdose. </p>
<h2>Listening to drug users</h2>
<p>To address the toxic drug poisonings that are killing Canadians at such an alarming rate, we need to start listening to people who use drugs when they tell us what’s not working with the current system. </p>
<p>The war on drugs has so demonized people who use drugs that they are mostly dismissed by addiction medicine experts when they have tried to say <a href="https://sway.office.com/UjvQx4ZNnXAYxhe7?ref=Link&loc=play">what will help their communities</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People holding signs in support of safer drug supply marching in a street" src="https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People march in the Downtown Eastside to call on the government to provide a safe supply of illicit drugs in April 2021.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>Groundbreaking grassroots work being done by organizations such as the <a href="https://www.dulf.ca/">Drug User Liberation Front</a> (DULF) in Vancouver has highlighted the demand for <a href="https://filtermag.org/compassion-clubs-vancouver/">a non-medicalized model for a safer supply</a> of drugs. </p>
<p>DULF has organized in its community to distribute tested drugs to keep people alive during a crisis; contrast this to prominent members of the addiction medicine community attempting to use their social power to <a href="https://filtermag.org/people-who-use-drugs-safer-supply/">deliberately undermine</a> their efforts. </p>
<p>Opposition to safer supply often misrepresents both the aim and benefits of safer supply. Safer supply is intended to keep people alive — and it works. </p>
<h2>Building new models</h2>
<p>We need new options. Both for people for whom current addiction treatment models have not worked and for those who simply don’t need or want treatment. </p>
<p>People are dying from using a toxic drug supply. Building models of care that listen to the voices of people who use drugs and centre their needs is critical and should not be dismissed based on the fears of doctors who act as gatekeepers of the status quo. The status quo did not prevent, and it will not address, the overdose crisis. </p>
<p>Urgent actions — like decriminalization and access to a regulated drug supply — are part of the policy changes needed to address the toxic drug crisis in Canada. But for the people at risk of drug poisoning today, and for their friends, families and loved ones, safer supply represents a real chance at preventing more tragedy.</p><img src="https://counter.theconversation.com/content/177925/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rose A Schmidt is employed as a research coordinator at the University of Toronto on a project that receives funding from The Ontario HIV Treatment Network about Safer Supply programs in Ontario.</span></em></p><p class="fine-print"><em><span>Gillian Kolla receives funding from a Canadian Institutes of Health Research Banting Postdoctoral Researcher Award and a Canadian Network on Hepatitis C (CanHepC) Postdoctoral Fellowship. She has consulted for Parkdale Queen West Community Health Centre, London Intercommunity Health Centre, The Neighbourhood Group, Street Health, and The Working Centre. </span></em></p><p class="fine-print"><em><span>Nat Kaminski is part of the University of Toronto research project on Safe Supply in Ontario, and is president of The Peel Drug Users Network & Ontario Network of People who use drugs and secretary of the Canadian Association of People who use drugs. They reviewed the guidelines for safe supply in Ontario and advocate for the expansion of services medically prescribed safe supply.</span></em></p>People are dying from using a toxic drug supply. Safer supply and other approaches that listen to the needs of people who use drugs are critical to saving lives and addressing the opioid crisis.Rose A Schmidt, PhD candidate, Dalla Lana School of Public Health, University of TorontoGillian Kolla, Postdoctoral research fellow, Canadian Institute for Substance Use Research, University of VictoriaNat Kaminski, Research assistant, School of Public Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1642862021-08-11T19:29:30Z2021-08-11T19:29:30Z‘Benzo-dope’ may be replacing fentanyl: Dangerous substance turning up in unregulated opioids<figure><img src="https://images.theconversation.com/files/415383/original/file-20210810-13-9vnesq.jpg?ixlib=rb-1.1.0&rect=92%2C29%2C3140%2C2004&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Naloxone can prevent deaths from opioid overdose, but there is no way to reverse the effects of benzodiazepine overdose without risk.</span> <span class="attribution"><span class="source">(THE CANADIAN PRESS/Jonathan Hayward)</span></span></figcaption></figure><p>Canada has seen a drastic shift in the unregulated drug supply with the emergence of benzodiazepine-adulterated opioids (also known as “benzo-dope”). Benzodiazepines have been detected in as many as <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">60 per cent of overdose deaths in British Columbia</a>.</p>
<p>Recent data from B.C. has observed a steady rise in opioids testing positive for benzodiazepines between August 2020 and April 2021, <a href="https://drugcheckingbc.ca/monthly-reports/">from a low of five per cent to a high of 25 per cent</a>.</p>
<p>British Columbia is not alone in seeing this trend: data from Toronto has shown that this issue is even more prominent. During the same time period, there was an increase from <a href="https://drugchecking.cdpe.org/">45 per cent to 57 per cent</a> in samples containing etizolam, a specific benzodiazepine-like compound.</p>
<p>Commonly prescribed benzodiazepines include drugs like Xanax and Valium. These medications treat a variety of conditions such as anxiety and insomnia and have been used since the 1960s. </p>
<p>However, what is being detected in opioids in Canada are not pharmaceutical drugs. They are drugs from the benzodiazepine class that are neither prescribed nor used in medicine in Canada, meaning they may possess unknown strengths or side-effects. Since benzodiazepines are sedatives, combining them with another type of depressant, like opioids, significantly increases the risk of overdose.</p>
<p>As researchers in substance use, we questioned whether the increasing supply of benzo-dope in the unregulated drug market would saturate the opioid supply in a similar way fentanyl did to heroin years ago. The data seem to suggest we should be prepared for the unregulated drug supply to adjust to a new normal.</p>
<p>In this context, there are significant public health issues that need to be considered. </p>
<h2>Emergence of ‘benzo-dope’</h2>
<p>The increasing availability of benzo-dope is cause for concern given that when taken together, the combined effects of benzodiazepines and opioids can result in overdose and death. According to the B.C. Coroner’s Service, there has been a substantial increase in benzodiazepines detected in illicit drug toxicity deaths, <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">from 15 per cent in July 2020 to 60 per cent in May 2021</a>. </p>
<p>Most people do not intend to consume benzodiazepines with their opioids. As a consequence, people wanting to use opioids may unknowingly increase their risk of overdose from benzodiazepine adulteration. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A test strip in a paper cup" src="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drug checking services can provide people with timely information about the contents of their unregulated drugs using things like the fentanyl test strip shown here. However, benzodiazepine test strips may miss detecting the drug.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Benzodiazepines are also slower to take effect compared to opioids, meaning someone can experience delayed overdose symptoms. Thefts and sexual assaults have also been reported after people were given benzodiazepine-adulterated opioids without their knowledge and consequently knocked into an unresponsive state.</p>
<p>The reason behind the adulteration of benzodiazepines in opioids is unclear. Some suggest they may be added to opioids to produce similar effects at a lower total cost to drug suppliers, or intentionally used to prolong or enhance the desirable effects of opioids. Regardless, there is growing evidence that co-use and dependence on opioids and benzodiazepines is occurring in parallel to the rising supply of these drugs. </p>
<p>Deaths from opioid overdose can be prevented with <a href="https://towardtheheart.com/naloxone">naloxone, which counteracts the effects of opioids</a>. However, there is no evidence-based antidote to reverse the effects of benzodiazepines without potential consequences such as withdrawal or seizures.</p>
<p>Additionally, due to the complications of benzodiazepine withdrawal, many addiction treatment providers will not admit individuals who test positive for benzodiazepines. As a result, people may not be able to access substance use treatment because of an imposed adulterant to their drugs.</p>
<h2>Challenges detecting benzo-dope</h2>
<p><a href="https://drugcheckingbc.ca/">Drug checking services</a> have been implemented across Canada to monitor the unregulated drug supply and provide people with timely information about the contents of their drugs. In many settings in B.C., benzodiazepine test strips are used alongside a technology called <a href="https://drugcheckingbc.ca/what-is-drug-checking/overview-of-technologies/">Fourier-transform infrared</a> spectroscopy to detect the presence of benzodiazepines. However, limitations of these technologies sometimes cause benzodiazepines to be missed when present in small concentrations. </p>
<p>Etizolam, the most common benzodiazepine-like compound found in opioids, is particularly difficult to detect using point-of-care drug-checking technologies because of its chemical structure. Thus, there may be an under-reporting of how pervasive this issue really is in B.C. and elsewhere in Canada. </p>
<h2>A new wave of the overdose epidemic?</h2>
<p>There have been a number of crucial life-saving responses to address the fentanyl-driven overdose epidemic, such as <a href="http://www.bccdc.ca/our-services/programs/harm-reduction">supervised consumption sites and expanded distribution of naloxone</a>. However, less attention has been paid to the growing issue of benzo-dope and its associated health harms. As this public health emergency worsens, it is important that we incorporate a broader understanding of overdose risk that goes beyond opioids in our efforts to prevent, treat and respond.</p>
<p>It’s too soon to know whether benzo-dope will saturate the unregulated opioid market. As long as there remains a lack of any legal framework to promote a safer supply of drugs (safe supply and <a href="https://theconversation.com/decriminalizing-drug-use-as-we-contain-the-coronavirus-is-the-humane-thing-to-do-136165">decriminalization</a>), there will always be a level of unpredictability in the unregulated opioid supply that can harm people’s health.</p><img src="https://counter.theconversation.com/content/164286/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lianping Ti receives funding for her research from the Michael Smith Foundation for Health Research and Health Canada.</span></em></p><p class="fine-print"><em><span>Samuel Tobias does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Fentanyl adulteration led to the replacement of heroin in the unregulated drug supply of British Columbia. Now that benzodiazepines are present in many opioids, are we headed towards a ‘new normal?’Lianping Ti, Assistant Professor, Department of Medicine, University of British ColumbiaSamuel Tobias, Research Data Coordinator, British Columbia Centre on Substance Use, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1253462019-10-18T11:25:13Z2019-10-18T11:25:13ZWhere is my Xanax Rx? Why your doctor may be concerned about prescribing benzodiazepines<figure><img src="https://images.theconversation.com/files/297596/original/file-20191017-98670-1fz706i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Xanax, sold generically as alprazolam, is a popular drug to treat anxiety -- and to sell on the street.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/september-3-2017-ogden-utah-xanax-714836047?src=Xf9c3aT8gmECixAW1xnBUg-1-3">PureRadiancePhoto/Shutterstock.com</a></span></figcaption></figure><p>As an <a href="https://www.starclab.org/members/arash-javanbakht">academic psychiatrist who treats people with anxiety and trauma</a>, I often hear questions about a specific class of medications called benzodiazepines. I also often receive referrals for patients who are on these medications and reluctant to discontinue them.</p>
<p>There has been increasing attention into long-term risks of benzodiazepines, including potential for addiction, overdose and cognitive impairment. The <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Cohort+Study+of+the+Impact+of+High-Dose+Opioid+Analgesics+on+Overdose+Mortality">overdose death rate</a> among patients receiving both benzodiazepines and opioids is 10 times higher than those only receiving opioids, and benzo misuse is a serious concern.</p>
<h2>What are benzodiazepines?</h2>
<p>Benzodiazepines are a class of anti-anxiety medications, or anxiolytics, that <a href="https://www.aafp.org/afp/2000/0401/p2121.html">increase the activity of the gamma-aminobutyric acid</a> receptors in the brain. GABA is a neurotransmitter, a molecule that helps brain cells, or neurons, communicate with each other. GABA receptors are widely available across the brain, and benzodiazepines work to reduce anxiety by enhancing GABA inhibitory function.</p>
<p>The benzo family includes diazepam, or Valium; clonazepam, or Klonopin; lorazepam, or Ativan; chlordiazepoxide, or Librium; and the one most commonly known to the pop culture, alprazolan, or Xanax, among others. </p>
<p>Different benzos have similar effects, but they differ in strength, how long it takes for them to work and half-life, a measure of how long the drug stays in your system. For example, while <a href="https://www.rxlist.com/valium-drug.htm#clinpharm">diazepam</a> has a half-life of up to 48 hours, the half-life of <a href="https://www.rxlist.com/xanax-drug.htm#clinpharm">alprazolam can be as short as six hours</a>. This is important, as a shorter half-life is linked with higher potential for addiction and dependence. That is one reason physicians typically are not excited about prescribing Xanax for long periods of time.</p>
<h2>When are they used?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297429/original/file-20191016-98636-1t09kde.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Benzos are often prescribed to treat short-term anxiety.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-sad-depressed-black-afro-american-1159789150?src=UUPgoCwuIcGIXa856ZIftg-1-38">TheVisualsYouNeed/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>When benzos were introduced to the market in the 1950s, there was excitement as they were considered safer compared to <a href="https://www.drugs.com/drug-class/barbiturates.html">barbiturates</a>, which had been used to treat anxiety. By the 1970s, benzos made it to the list of the <a href="https://www.ncbi.nlm.nih.gov/pubmed/24007886">most highly prescribed medications</a>.</p>
<p>Benzos are mainly used to treat anxiety disorders, such as phobias, panic disorder and generalized anxiety disorder. They are mostly used for <a href="https://www.ncbi.nlm.nih.gov/pubmed/30454582">a short period</a> at the beginning of the treatment. That is because it may take a few weeks for the main pharmacological treatment for anxiety, antidepressants, to kick in. During that time, if anxiety is severe and debilitating, benzodiazepines may be prescribed for temporary use. </p>
<p>Benzos are also prescribed for occasional situations of high anxiety, such as that caused by phobias. The main treatment of phobias, such as excessive fear of animals, places and social interactions, is <a href="https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610">psychotherapy</a>. Sometimes, however, phobias can interfere with one’s functioning just sporadically, and the person may not be interested in investing in therapy. For example, a person with fear of flying who may fly on a plane once or twice a year may choose to take a benzo before flying. However, for a businessman or woman who flies several times a months, psychotherapy is recommended. </p>
<p>Benzos may also be used for situations of short-term stress, such as a stressful job interview. </p>
<p>Benzos are also used for other medical conditions, such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/25323468">treatment of seizures</a> or alcohol withdrawal in the hospital. There is <a href="https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGClinicianSummaryFinal.pdf">no good evidence for use of benzos in post-traumatic stress disorder</a>.</p>
<h2>So why the worry?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297597/original/file-20191017-98632-df4e6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Doctors often are reluctant to prescribe benzodiazepines, and many prefer to talk to their patients about the risks and also about other potential treatments, such as psychotherapy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asian-doctor-talking-middle-aged-woman-769470607?src=H24N3M5KnjChVCHoWtmrpA-1-23">Pormezz/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Now we get to the part about why I and other doctors are not eager to prescribe benzodiazepines for long-term use: We have a Hippocratic oath to “first do not harm.” I sometimes tell patients who insist on getting benzos: “I am not paid differently based on the medication I prescribe, and my life would be much easier not arguing with you about this medication. I do this because I care about you.” </p>
<p>A major risk of long-term use of benzos is <a href="https://www.ncbi.nlm.nih.gov/pubmed/21714826">addiction</a>. That means you may become dependent on these meds and that you have to keep increasing the dose to get the same effect. Actually benzos, especially Xanax, have street value because of the pleasant feeling they induce. In 2017, there were more than <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">11,000 deaths involving benzos</a> alone or with other drugs, and in 2015, a <a href="https://www.drugabuse.gov/drugs-abuse/opioids/benzodiazepines-opioids">fifth of those who died of opioid overdose</a> also had benzos in their blood. </p>
<p>Benzos to anxiety can be seen like opioids to pain. They both are mostly for short use, have a potential for addiction and are not a cure. Benzo overdose, especially when mixed with alcohol or opioids, may lead to slowing of breathing, and potentially death. Benzo misuse can also lead to lack of restraint of <a href="https://www.ncbi.nlm.nih.gov/pubmed/30454581">aggressive or impulsive behavior</a>. </p>
<p>As benzos are sedating medications, they also <a href="https://www.ncbi.nlm.nih.gov/pubmed/28448593">increase the risk of accidents and falls</a>, especially in the elderly. This is worse when they are mixed with other central nervous system suppressants like alcohol or opioids.</p>
<p>Recently, we have been learning more about the <a href="https://www.ncbi.nlm.nih.gov/pubmed/21714826">potential cognitive, memory and psychomotor impairment</a> in long-term use of benzodiazepines, especially in older adults. Cognitive functions impacted may include <a href="https://www.ncbi.nlm.nih.gov/pubmed/15762814">processing speed and learning</a> among others. <a href="https://www.ncbi.nlm.nih.gov/pubmed/15841867">Such effects may persist</a> even after discontinuation of long-term use of the benzos.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/7841856">Stopping benzos abruptly</a>, especially if high dose, can cause withdrawal symptoms, such as restlessness, irritability, insomnia, muscle tension, blurred vision and racing heart. Withdrawal from high doses of benzos, especially those that are shorter acting, may be dangerous, leading to seizure, and getting off of these medications should be done under supervision of a physician.</p>
<h2>Safer options abound</h2>
<p>There are safer effective treatments for anxiety, but they require patience to work. A first line treatment for anxiety disorders is psychotherapy, mainly <a href="https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610">cognitive behavioral therapy</a>. During therapy, the person learns more adaptive coping skills, and corrects cognitive distortions to reduce stress. </p>
<p>Exposure therapy is an effective treatment for phobias, social phobia, obsessive compulsive disorder and PTSD. During exposure therapy, the person is gradually exposed to the feared situation under the guidance of the therapist, until the situation does not create anxiety anymore. Importantly, the skills earned during therapy can always be used, allowing better long-term outcome compared to medications.</p>
<p><a href="https://adaa.org/finding-help/treatment/medication">Medications are also used</a> for treatment of anxiety disorders. The main group of such medications is selective serotonin reuptake inhibitors, commonly known as antidepressants. Examples of such medications are fluoxetine, sertraline and citalopram. Especially when combined with psychotherapy, these medications are effective and are safer options than the benzos, and without a risk of addiction.</p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/125346/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arash Javanbakht does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Benzodiazepines, or benzos, are some of the most widely prescribed drugs in the US. They are meant to be used only short-term, but thousands use them long-term. That’s a big worry.Arash Javanbakht, Assistant Professor of Psychiatry, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1023432018-09-18T20:34:28Z2018-09-18T20:34:28ZI can’t sleep. What drugs can I (safely) take?<figure><img src="https://images.theconversation.com/files/236593/original/file-20180917-177935-1k5b32x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are many pharmacological options available for insomnia. But they will mostly make you reliant upon them for sleep. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>If you’re having trouble sleeping, <a href="https://theconversation.com/some-reasons-why-you-should-avoid-sleeping-pills-10054">medicines</a> shouldn’t be your first option. Exercise regularly, cut back on coffee (and other caffeinated drinks) after midday, eat less in the evening, ease up on “screen time” before, and in, bed, practise meditation and try to have a quiet, dark bedroom dedicated mostly to sleep.</p>
<p>But what if you’ve tried everything and are still struggling with sleep? Many people will want to turn to a medicine for help. Navigating the various options for effectiveness, safety and the potential to become habit-forming can be difficult.</p>
<p>Long-term regular use of medicines to promote sleep should be avoided, as initial effectiveness declines rapidly over a few weeks and dependence and adverse effects become <a href="https://www.nejm.org/doi/full/10.1056/NEJMra1611832">problematic</a>. But in the short <a href="https://www.nps.org.au/australian-prescriber/articles/the-management-of-insomnia-an-update">short term</a>, sleep medications do have their place. Unfortunately they are often <a href="https://link.springer.com/content/pdf/10.1007%2Fs40271-016-0182-z.pdf">over-used, especially in older</a> people.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-getting-enough-sleep-should-be-on-your-list-of-new-years-resolutions-88007">Why getting enough sleep should be on your list of New Year's resolutions</a>
</strong>
</em>
</p>
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<h2>Benzodiazepines</h2>
<p>Benzodiazepines are drugs such as <a href="https://theconversation.com/weekly-dose-valium-the-safer-choice-that-led-to-dependence-and-addiction-59824">Valium</a>, also used to treat anxiety. They are the most commonly prescribed <a href="https://www.nps.org.au/australian-prescriber/articles/management-of-benzodiazepine-misuse-and-dependence-5">sleeping pills</a>.</p>
<p>Their effects, which include some muscle relaxing properties, are achieved by enhancing the effect of <a href="https://www.wikiwand.com/en/Gamma-Aminobutyric_acid">GABA</a>, an inhibitory neurotransmitter operating throughout the brain. Rarely, some people experience the opposite and become over-excited and more anxious. </p>
<p>As benzodiazepines depress brain function (they depress the central nervous system), their effects add to other central nervous system depressants including alcohol, sedating antihistamines and opioid analgesics such as oxycodone (<a href="https://www.healthdirect.gov.au/endone">Endone</a>). This can be very dangerous, and when combined can lead to respiratory failure, coma and even death.</p>
<p>Physiological and psychological dependence on the drug can develop after only a few days in some people, or weeks in most. Unfortunately, far too many people are <a href="https://www.nps.org.au/news/benzodiazepine-dependence-reduce-the-risk">dependent</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-valium-the-safer-choice-that-led-to-dependence-and-addiction-59824">Weekly Dose: Valium, the 'safer choice' that led to dependence and addiction</a>
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<p>Importantly, the effectiveness for inducing sleep wears off after a few weeks. It can be very hard to stop taking benzodiazepines as insomnia and often anxiety returns. The duration of “<a href="https://theconversation.com/weekly-dose-valium-the-safer-choice-that-led-to-dependence-and-addiction-59824">withdrawal</a>” is related to the length of time these are taken.</p>
<p>Stopping suddenly after long-term use can be dangerous, with violent withdrawal reactions possible, including epileptic seizures. <a href="https://theconversation.com/weekly-dose-valium-the-safer-choice-that-led-to-dependence-and-addiction-59824">Ceasing</a> these medicines needs to be managed by your doctor. Essentially, a gradual reduction in dose is needed with support and counselling to assist with the temporary increase in insomnia and perhaps anxiety.</p>
<p>Side effects include a “dulling” of cognitive function, memory impairment and the increased risk for accidents, especially unsteadiness and falls in older people. </p>
<p>Benzodiazepines should only be used for two to four weeks, or intermittently, and only in addition to <a href="https://www.nps.org.au/medical-info/consumer-info/how-to-sleep-right">good sleep hygiene</a> (that is, practising the measures listed in the first paragraph).</p>
<p>Temazepam (brand names Normison, Temaze, Temtabs) and lorazepam (brand name Ativan) are reasonable choices from the many benzodiazepines available. That’s because they have a faster onset and short duration of effect so as to avoid a “hangover” the next day.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-how-to-soothe-yourself-to-sleep-83154">Health Check: how to soothe yourself to sleep</a>
</strong>
</em>
</p>
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<h2>Z-drugs (hypnotics)</h2>
<p>Zopiclone (brand names Imovane and Imrest) and zolpidem (brand name Stilnox) are similar in their pharmacology and effects to the benzodiazepines. These prescription-only medicines also enhance the actions of GABA to depress brain activity and have the same hazards related to excessive sedation and dependence. </p>
<p><a href="https://www.tga.gov.au/alert/zolpidem-stilnox">Bizarre</a> behaviours and symptoms, for example hallucinations and sleep-walking that can be dangerous, are more likely than with benzodiazepines.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/236595/original/file-20180917-177947-18nirlm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/236595/original/file-20180917-177947-18nirlm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/236595/original/file-20180917-177947-18nirlm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/236595/original/file-20180917-177947-18nirlm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/236595/original/file-20180917-177947-18nirlm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/236595/original/file-20180917-177947-18nirlm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/236595/original/file-20180917-177947-18nirlm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/236595/original/file-20180917-177947-18nirlm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Medications for sleep can’t be used long term.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Antihistamines</h2>
<p>Older antihistamine medicines, now known as sedating antihistamines, induce drowsiness through their central nervous system-depressing properties. These are available over the counter from pharmacies. Common examples include diphenhydramine (brand name Unisom Sleep Gels), doxylamine (brand name Restavit) and promethazine (branded Phenergan). </p>
<p>Especially in those with allergies such as hay fever disturbing their sleep, these may be a reasonable short-term option. Dependence on these medications to sleep is a hazard. </p>
<p>These medicines have <a href="https://www.veteransmates.net.au/VeteransMATES/documents/module_materials/M39_TherBrief.pdf">side effects</a> including dry mouth, blurred vision, constipation, confusion, dizziness and urinary retention in men with prostrate problems. All side-effects are worse in older people.</p>
<p>By contrast, over-the-counter antihistamines commonly used to treat hay fever (such as brand names Telfast, Zyrtec and Claratyne) are non-sedating, and therefore not likely to make you drowsy.</p>
<h2>Analgesics</h2>
<p>Any opioid-containing medicine, all now requiring a prescription, will induce drowsiness (depending on the dose) because they also depress our central nervous system. Codeine (in Panadeine, Panadeine Forte or Nurofen Plus), tramadol, tapentadol, morphine or oxycodone will make us sleepy, but they’re not recommended to treat insomnia. </p>
<p>These powerful medicines are best reserved for judicious use in pain relief, given the severe <a href="https://www.mja.com.au/journal/2011/195/5/prescription-opioid-analgesics-and-related-harms-australia">hazards of dependence and overdose</a>. Older people are more sensitive to the central nervous system-depressing effects and also to constipation.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-five-ways-to-get-a-better-nights-sleep-43700">Health Check: five ways to get a better night's sleep</a>
</strong>
</em>
</p>
<hr>
<h2>Melatonin</h2>
<p>Our sleep-wake cycle is dependent on the hormone melatonin released cyclically from a gland in our brain. <a href="https://www.nps.org.au/radar/articles/melatonin-prolonged-release-tablets-circadin-for-primary-insomnia-in-older-people">Melatonin</a> administered orally helps induce sleep in some people, but is <a href="https://www.nps.org.au/australian-prescriber/articles/melatonin">not as effective as other sedatives</a>.</p>
<p>However, a <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002587">recent Australian study</a> tested melatonin in people with sleep problems caused by delayed melatonin release in their brains. These people have trouble falling asleep and waking at times appropriate for proper functioning.</p>
<p>Taken one hour prior to bed time, melatonin (0.5mg) accompanied by a behavioural intervention (such as learning how to meditate) helped the participants get to sleep and improved common accompanying impairments such as low mood, anxiety and difficulty concentrating. </p>
<p>You need a <a href="https://tga-search.clients.funnelback.com/s/search.html?query=melatonin&collection=tga-artg&start_rank=1">prescription for melatonin</a> in Australia. It’s best to avoid alcohol as it interferes with sleep, thereby reducing any effect of melatonin. It is worth trying as it is generally well tolerated, although some people experience back pain. It may work in other types of sleep disturbances, not due to delayed release of melatonin. A dose of 2mg, controlled release one to two hours before bedtime is <a href="https://www.nps.org.au/radar/articles/melatonin-prolonged-release-tablets-circadin-for-primary-insomnia-in-older-people">most commonly</a> used.</p>
<h2>Antipsychotics</h2>
<p><a href="https://www.nps.org.au/australian-prescriber/articles/concerns-about-quetiapine-3">Antipsychotic medicines</a> (such as quetiapine) have been increasingly used to treat insomnia. </p>
<p>Typically used at a lower dose, quetiapine can induce sleep but carries a significant burden of possible harmful effects. These include a fast heart rate, agitation, <a href="https://www.nps.org.au/australian-prescriber/articles/concerns-about-quetiapine-3">low blood pressure and unsteadiness</a>. These make quetiapine not appropriate for treating common sleep problems.</p>
<h2>Antidepressants</h2>
<p>Antidepressants are typically prescribed at a low dose for insomnia, but the supporting <a href="https://www.ncbi.nlm.nih.gov/pubmed/29761479">evidence</a> of efficacy (despite the wide use) is low quality and there is the <a href="https://www.nps.org.au/medical-info/consumer-info/antidepressant-medicines-explained?c=antidepressant-medicine-side-effects-a38bd490">risk of adverse effects</a> such as confusion, dry mouth and blurred vision.</p>
<h2>Herbal and complementary medicines</h2>
<p>Herbal remedies such as valerian, lavender, passiflora, chamomile, hops and catnip are widely promoted to promote “sleep health”. Research to support their efficacy is <a href="https://www.ncbi.nlm.nih.gov/pubmed/20965131">limited</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-possible-to-catch-up-on-sleep-we-asked-five-experts-98699">Is it possible to catch up on sleep? We asked five experts</a>
</strong>
</em>
</p>
<hr>
<p>Many <a href="https://www.ncbi.nlm.nih.gov/pubmed/29487083">newer and emerging medicines</a> are being tested for insomnia, so in the future more options should be available. </p>
<p>For now it’s important to remember none of the options listed above is without side effects, and most will cause dependence if used long term, meaning falling asleep without them will be even harder than it was before. </p>
<p>Improve your sleep hygiene, and if that hasn’t worked for you, speak with your doctor about what’s keeping you up at night. She’ll be able to prescribe the best type of medication for you to use in the short term.</p><img src="https://counter.theconversation.com/content/102343/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With so many different types out there, it’s hard to know what sleep medications are safe to use. Here’s a guide.Ric Day, Professor of Clinical Pharmacology, UNSW SydneyAndrew McLachlan, Head of School and Dean of Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/945942018-04-11T13:15:12Z2018-04-11T13:15:12ZXanax: how does it work and what are the side effects?<figure><img src="https://images.theconversation.com/files/214290/original/file-20180411-592-17j2le2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/deanslife/1270344046/sizes/l">Dean812/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>More teenagers and young people use drugs than any other age group: <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/642738/drug-misuse-2017-hosb1117.pdf">in 2017</a>, 16.5% of 16- to 19-year-olds and 21.2% of 20- to 24-year-olds across England and Wales said they had taken drugs in the past year. And although drug use has declined over the past decade, new and potentially life-threatening trends continue to appear. Most recently, doctors <a href="https://www.theguardian.com/society/2018/feb/05/xanax-misuse-uk-dark-web-sales-health">have warned</a> of an “emerging crisis” relating to Xanax use among young people. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=514&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=514&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=514&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=646&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=646&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214285/original/file-20180411-587-1gs5wa3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=646&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Alprazolam (Xanax) is a short-acting anxiolytic of the benzodiazepine class of psychoactive drugs.</span>
<span class="attribution"><span class="source">Igor Petrushenko / www.shutterstock.com</span></span>
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<p>Xanax is a brand of alprazolam – a <a href="https://www.mind.org.uk/information-support/drugs-and-treatments/sleeping-pills-and-minor-tranquillisers/about-benzodiazepines/#.Ws3ks9PwalM">benzodiazepine</a> drug, or “benzo” – which is marketed as an alternative to Valium (diazepam) and used to treat anxiety, panic attacks and problems associated with depression. It works by affecting the way that the brain functions, to increase feelings of pleasure and reduce stress and anxiety. </p>
<p>Doses range from 0.25mg to a maximum of 3mg per day (by comparison, a teaspoon of sugar is about 1,300 times this amount). A dose can take up to an hour to have an effect, which then typically lasts for between five and 12 hours, depending on the formulation of the drug. It can take four or five days to clear the drug from the body. </p>
<h2>Here to stay</h2>
<p>While it is the most frequently prescribed benzodiazepine in the US, Xanax is not available in the UK, but it can be obtained on private prescriptions and online. Recent data suggests that <a href="https://www.theguardian.com/society/2018/feb/05/xanax-misuse-uk-dark-web-sales-health">the UK is the second largest market for Xanax on the dark web</a>, after the US. Its widespread availability on the internet has made the situation around this drug especially perilous. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214282/original/file-20180411-540-wtry47.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A bottle of prescription alprazolam pills.</span>
<span class="attribution"><span class="source">PureRadiancePhoto/Shutterstock</span></span>
</figcaption>
</figure>
<p>To be clear, there is no such thing as a “safe” drug. A drug – whether swallowed, smoked, inhaled, injected – is going to have an effect on the physiology and, potentially, the mental state of the person who takes it. Every person is different, and will react differently to different drugs, doses and ingredients. It is never clear exactly what is actually in the recreational drugs that people take which is why we should be so concerned about the effects that they might have. </p>
<p>But we can’t pretend that recreational drugs are going to go away. People have used drugs for thousands of years; whether for religions reasons, as a way of life, due to peer pressure, to experiment, or to escape from reality. Some are legal, while others carry severe fines, prison sentences or penalties as harsh as the death sentence in some parts of the world. People will use drugs such as Xanax regardless of legal controls, so it’s best to be clear how it works, and why it presents a health risk.</p>
<p>When people use Xanax regularly, they build up a tolerance to the drug, which means they need to take larger and more frequent doses for the drug to have the desired effect. Eventually, this results in a physical dependence – where the brain needs the drug to function “normally”. People can also develop a psychological dependence – they feel like they “need” the drug. Together, these effects lead to what we understand as addiction. </p>
<h2>Know the risks</h2>
<p>If someone becomes addicted to prescription drugs, including Xanax, then the effect of the drugs has to be reversed - normal functioning of the brain cells must be restored and this is a long, slow and often painful process. Under the influence of the drug, there are <a href="https://drugabuse.com/library/the-effects-of-xanax-use/">side effects</a> – apathy, sleepiness, decreased cognitive functioning, as well as the possibility of slurred speech or violent outbursts. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214288/original/file-20180411-566-y0h123.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Unhealthy combination.</span>
<span class="attribution"><span class="source">Burlingham/Shutterstock</span></span>
</figcaption>
</figure>
<p>Like any other benzodiazepine drugs, Xanax should not be taken with alcohol. This can increase the drug’s effects, potentially leading to loss of consciousness and coma. What’s more, Xanax levels could build up in the body, which increases the chance of an overdose the next time the drug is taken. All of these effects present risks to the user’s health, or to their livelihood and future aspirations. </p>
<p>The drug market contains products manufactured legally and illegally. Some drugs are diverted onto the black market from legal pharmaceutical sources, while others are powders imported from overseas and pressed into tablet form. In our work as forensic chemists, we have seen this with many other drug types over the years through our <a href="http://pubs.rsc.org/en/content/articlelanding/2014/ay/c3ay41020j#!divAbstract">casework and research</a> on MDMA, piperazines and cathinones. There is always a risk that the drug in the powder is not what it seems – even if the pill looks legitimate. </p>
<p>Drugs which are legally manufactured and sold undergo quality control procedures - for example controlling the amount of drug in each pill and its purity. On the black market, these processes are completely missing. Most users can’t determine the materials and processes used to make illegal drugs, so there is no way of knowing the toxicity of the drugs or of the chemicals made from the side reactions of the drug making process. </p>
<p>Drug testing kits are available on the internet, but at best, these will only tell you the group of drugs that a pill may contain - not which of the many possible drugs are present. They won’t accurately tell you how much drug is present, or how the drug was made or what impurities the pill might contain. Some employers use drug testing in the workplace: these tests are accurate, and employees who test positive for drugs often face dismissal. The best way to avoid the risks associated with recreational drugs is to avoid taking them altogether.</p><img src="https://counter.theconversation.com/content/94594/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Cole has received funding from the EPSRC, EU (Framework V), EU AGIS programme, Botswanan Government and South African Police Service for carrying out research on the analysis and profiling of controlled substances.</span></em></p><p class="fine-print"><em><span>Agatha Grela and Lata Gautam do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More young people are using Xanax – but overdose, addiction and side effects present serious risks.Michael Cole, Professor of Forensic Science, Anglia Ruskin UniversityAgatha Grela, Postdoctoral researcher, Anglia Ruskin UniversityLata Gautam, Senior Lecturer in Forensic Science, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/725712017-03-21T20:28:22Z2017-03-21T20:28:22ZHow to reduce dependency on drugs like Valium with alternative therapies<figure><img src="https://images.theconversation.com/files/160124/original/image-20170309-21026-4k6vx7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Benzodiazepines are prescribed for anxiety, but can cause more problems than they solve. </span> <span class="attribution"><span class="source">Pavel Kubarkov/Shutterstock</span></span></figcaption></figure><p>Benzodiazepines (such as Valium and Xanax) are <a href="http://adf.org.au/drug-facts/benzodiazepine/">depressant prescription drugs</a> used most commonly for anxiety. But evidence suggests dependence on these medications is increasing and side effects are common, so we increasingly need to look to alternative therapies.</p>
<p>Benzodiazepines <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002798.pub2/full">cause sedation</a> by slowing down nerve activity in the central nervous system and the messages <a href="http://adf.org.au/drug-facts/benzodiazepine/">travelling between the brain and the body</a>. They became a popular prescription drug for treating anxiety in the US, and many Western countries, after their creation in 1955. </p>
<p>They’re <a href="http://www.racgp.org.au/afp/201111/44792">prescribed for</a> managing panic attacks, excessive worry or fear and other signs of stress and anxiety, and to help with sleep. Other conditions treated with benzodiazepines include <a href="http://www.cochrane.org/CD005063/ADDICTN_benzodiazepines-for-alcohol-withdrawal">alcohol withdrawal</a>, relief from muscle stiffness and tightness <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684331/">caused by central nervous system pathology</a>, and epilepsy.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919169/">Concern about risks and problems</a> associated with benzodiazepines has increased in recent years. Around seven million scripts for benzodiazepines <a href="http://www.racgp.org.au/your-practice/guidelines/drugs-of-dependence-b">have been written each year</a> in Australia since 2002. <a href="http://www.coronerscourt.vic.gov.au/home/coroners+written+findings/finding+-+finding+without+inquest+into+the+death+of+frank+edward+frood">Benzodiazepines contributed to over half</a> of all pharmaceutical drug overdose deaths in Victoria in 2015.</p>
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Read more:
<a href="https://theconversation.com/weekly-dose-valium-the-safer-choice-that-led-to-dependence-and-addiction-59824">Weekly Dose: Valium, the 'safer choice' that led to dependence and addiction</a>
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<p>Evidence also suggests people are <a href="http://www.nps.org.au/publications/health-professional/health-news-evidence/2015/reduce-benzodiazepine-dependence-risk">using benzodiazepines in the long term</a>, for which they’re generally <a href="http://www.racgp.org.au/your-practice/guidelines/drugs-of-dependence-b">not recommended</a>. And benzodiazepines were the pharmaceutical drug associated with the <a href="https://www.ncbi.nlm.nih.gov/pubmed/21545557">highest rates of ambulance attendances in Melbourne</a> between 2000 and 2009.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/160126/original/image-20170309-21022-v1mb2s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/160126/original/image-20170309-21022-v1mb2s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=565&fit=crop&dpr=1 600w, https://images.theconversation.com/files/160126/original/image-20170309-21022-v1mb2s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=565&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/160126/original/image-20170309-21022-v1mb2s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=565&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/160126/original/image-20170309-21022-v1mb2s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=710&fit=crop&dpr=1 754w, https://images.theconversation.com/files/160126/original/image-20170309-21022-v1mb2s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=710&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/160126/original/image-20170309-21022-v1mb2s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=710&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Advertisement for Librium® (chlordiazepoxide) from the early 1960s.</span>
<span class="attribution"><span class="source">Francisco López-Mu˜noz, Cecilio Álamo and Pilar García-García</span></span>
</figcaption>
</figure>
<h2>What are the health risks?</h2>
<p>Many risks and harms are associated with taking benzodiazepines. The risk of <a href="http://adf.org.au/wp-content/uploads/2017/02/ADF-PreventionResearch-Nov16.pdf">developing dependence on benzodiazepines</a> is higher the longer the drug is used. <a href="https://adf.org.au/family/supporting-a-loved-one/withdrawal/">Dependence</a> can occur quickly and be difficult to treat. <a href="http://nceta.flinders.edu.au/files/6113/2823/3742/EN448_Nicholas_2011.pdf">Withdrawal from benzodiazepines</a> is challenging, too.</p>
<p>More <a href="http://nceta.flinders.edu.au/files/6113/2823/3742/EN448_Nicholas_2011.pdf">research is needed</a> to determine how many people are dependent on benzodiazepines in Australia. However, evidence of prescriptions written for benzodiazepines and ambulance attendances and overdose deaths associated with their use suggest more people need to know benzodiazepine use carries a risk of side effects, including dependency.</p>
<p>Other <a href="http://adf.org.au/drug-facts/benzodiazepine/">side effects include</a> drowsiness, depression, headaches, tiredness but difficulty sleeping, irritability, personality changes, impaired thinking, paranoia, reduced sex drive and fertility problems.</p>
<p>While <a href="http://www.racgp.org.au/afp/201111/44792">violence and aggression associated with benzodiazepines</a> is rare, it can be of a high severity. Mixing benzodiazepines with alcohol and other drugs <a href="https://www.ncbi.nlm.nih.gov/pubmed/21545557">can lead to overdose and death</a>. In the US, for instance, <a href="http://www.bmj.com/content/356/bmj.j760">nearly 30% of fatal overdoses</a> from opioids (such as codeine) involve benzodiazepines.</p>
<h2>What treatments can be used instead?</h2>
<p>The <a href="http://www.racgp.org.au/your-practice/guidelines/drugs-of-dependence-b">Royal Australian College of GPs recommends</a> benzodiazepines be used only in the short term and after a comprehensive medical assessment. The assessment should include consideration of risks and benefits from using the drug, as well as alternative approaches. More work could be done during assessments by both patients and doctors to consider alternative approaches given recent evidence of harms associated with benzodiazepine use.</p>
<p>Non-drug-based alternatives are recommended as the first option for treating stress, anxiety <a href="http://www.racgp.org.au/your-practice/guidelines/drugs-of-dependence-b">and trouble sleeping</a>. Having a well-balanced diet, exercising regularly and using cognitive behaviour therapy are proven to be more effective at treating <a href="http://www.nps.org.au/publications/health-professional/health-news-evidence/2015/reduce-benzodiazepine-dependence-risk">stress, anxiety and difficulty sleeping than benzodiazepines</a>. Non-drug-based alternatives don’t have the negative side effects of benzodiazepines, either.</p>
<p>For some people, use of benzodiazepines with supervision by a doctor could better meet their health needs. Some mental health conditions are severe and likely to be short-term.</p>
<p>Alternatives are best explored when a person reviews their need for help managing stress, anxiety or insomnia with a health professional. This discussion should also consider ways of handling the health condition in the long term.</p>
<p><strong>Cognitive behaviour therapy</strong></p>
<p>Cognitive behaviour therapy (CBT) is very effective for helping people to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/">manage anxiety and stress and to sleep better</a>. People use the therapy to develop practical skills for more <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/cognitive-behaviour-therapy">helpful ways of thinking, feeling and behaving</a>. Dealing differently with sources of stress and anxiety helps to reduce worry and improve wellbeing.</p>
<p>Cognitive behaviour therapy for insomnia (CBT-i) was <a href="https://www.ncbi.nlm.nih.gov/pubmed/24138364">developed specifically for helping people sleep</a>. CBT-i uses stimulus control (stopping things like watching television and use of computers in bed), sleep restriction, relaxation techniques, cognitive therapy and sleep hygiene education.</p>
<p>In sleep hygiene education, people learn about habits and behaviours that help with better sleep. These include avoiding long naps in the day time, exercising regularly, having a regular wake-up time throughout the week and limiting alcohol consumption.</p>
<p>People can try CBT through sessions with a counsellor, group education <a href="https://www.ncbi.nlm.nih.gov/pubmed/23459093">and self-help materials</a>. Normally, consultation with a GP is the <a href="https://www.beyondblue.org.au/get-support/who-can-assist/getting-support-how-much-does-it-cost">first step for a referral to a counsellor or mental health specialist</a>.</p>
<p>Online platforms <a href="http://focus.psychiatryonline.org/doi/abs/10.1176/appi.focus.12.3.299">are promising for reaching and supporting people with anxiety and depression</a> who might not otherwise receive help.</p>
<p><strong>Exercise</strong></p>
<p>Regular physical activity can help improve <a href="https://www.beyondblue.org.au/get-support/recovery-and-staying-well/staying-well">energy levels, sleep and moods</a>.</p>
<p><a href="https://www.beyondblue.org.au/get-support/online-forums">Beyondblue forums</a> offer suggestions for people experiencing anxiety and depression who may find it difficult to start exercising and stay motivated.</p>
<p><strong>Dietary changes</strong></p>
<p>Magnesium relaxes muscles. When vitamin B and calcium are at low levels in the body, increasing magnesium can help to relax tight muscles and <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/anxiety-treatment-options">reduce the risk of anxiety and difficulty sleeping</a>. Green vegetables, such as spinach and broccoli, and nuts, seeds and unprocessed cereals are <a href="https://www.ncbi.nlm.nih.gov/pubmed/26404370">foods rich in magnesium</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/160129/original/image-20170309-21050-izro8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/160129/original/image-20170309-21050-izro8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/160129/original/image-20170309-21050-izro8q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/160129/original/image-20170309-21050-izro8q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/160129/original/image-20170309-21050-izro8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/160129/original/image-20170309-21050-izro8q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/160129/original/image-20170309-21050-izro8q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Examples of food in a balanced diet.</span>
<span class="attribution"><span class="source">margouillat/Shutterstock</span></span>
</figcaption>
</figure>
<p>Consuming less nicotine, caffeine and stimulant drugs also <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/anxiety-treatment-options">helps reduce stress</a> as these trigger the adrenal gland. (The adrenal gland releases hormones that can help the body react rapidly and move fast away from danger.)</p>
<p>A <a href="http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00051-0/abstract">well-balanced diet</a> with plenty of vegetables, fruits, legumes, lean proteins like fish, and whole grains is important for good mental health. Kimchi, sauerkraut, pickles and similar foods may also have a <a href="http://www.health.harvard.edu/blog/nutritional-psychiatry-your-brain-on-food-201511168626">positive impact on mood and energy levels</a>. These foods are fermented and therefore contain bacteria that can affect mood and energy levels.</p>
<hr>
<p><em>Dr Shauna Sherker from the Alcohol and Drug Foundation co-authored this article.</em></p><img src="https://counter.theconversation.com/content/72571/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben O'Mara is affiliated with the Alcohol and Drug Foundation where he works as a science writer.</span></em></p>Benzodiazepines are used by many people despite their associated risks and harms.Ben O'Mara, Adjunct Research Fellow, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/649722016-09-09T10:26:46Z2016-09-09T10:26:46ZDrugs fatalities overtake car fatalities for the first time<figure><img src="https://images.theconversation.com/files/137080/original/image-20160908-25249-1ct7wc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-276472910/stock-photo-man-injecting-himself-with-a-small-hypodermic-needle-possibly-administering-medication-for-a-disease-such-as-diabetes.html?src=NLK3gv9RXwwEBCFGAW-lgA-1-0">NAS CREATIVES/Shutterstock.com</a></span></figcaption></figure><p>Seven years ago, <a href="http://articles.latimes.com/2011/sep/17/local/la-me-drugs-epidemic-20110918">fatalities from opiates</a> overtook fatalities due to road accidents in the US. Sadly, the same phenomenon is now playing out in England. The latest figures from the Office for National Statistics (ONS), show that last year, 1,732 people died in <a href="https://www.gov.uk/government/statistics/reported-road-casualties-in-great-britain-main-results-2015">traffic accidents in the UK</a> compared with <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015registrations">1,989</a> who died due to opiates in England alone.</p>
<p>New psychoactive substances, referred to as “legal highs”, have <a href="https://theconversation.com/stories-about-legal-high-deaths-are-bound-up-in-media-hysteria-24360">received significant media attention</a>, and deaths due to these drugs have risen by 40%, but opiate deaths now outnumber legal-high deaths by 19 to 1, despite a <a href="https://www.gov.uk/government/statistics/drug-misuse-findings-from-the-2015-to-2016-csew">steady decline</a> in opiate use in England and Wales over the last decade.</p>
<p>Of course, opiates are not the only problem – deaths due to cocaine have reached the highest on record at 320, increasing by nearly 30% since last year – but opiates are what we should really be focusing on. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=377&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=377&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=377&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=474&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=474&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=474&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Drug deaths.</span>
<span class="attribution"><span class="source">Office for National Statistics</span></span>
</figcaption>
</figure>
<h2>Premature and preventable</h2>
<p>Drug-related deaths of males outnumber those of females by three to one and 60% of deaths occur in 30- to 49-year-olds – compared with an <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/lifeexpectancyatbirthandatage65bylocalareasinenglandandwales/2015-11-04">average life expectancy</a> for the rest of the population of 80. </p>
<p>Health complications resulting from drug use do not entirely explain this inequality in life span. A range of factors are likely to be involved. Purity and quality of heroin are not as critical, borne out by <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13516/full">decades of research</a>. Rather it is the risk of accidental overdose by more experienced and tolerant heroin users. Equally, combining heroin with alcohol and or a benzodiazapine such as diazepam <a href="http://www.sciencedirect.com/science/article/pii/S0376871612002785">increases the risk of death</a>. In 1993, one in four deaths were attributed to combining alcohol with opiates; this has now reached one in two. </p>
<p>In 2010, the newly elected Conservative government introduced a <a href="https://www.gov.uk/government/publications/drug-strategy-2010">new treatment strategy</a>. The policy emphasised the importance of achieving abstinence from drugs rather than merely reducing the harm they can cause. This recovery agenda may have inadvertently contributed to the rise in drug deaths. Unfortunately, even if abstinence is achieved, the <a href="http://bit.ly/2cbURiS">odds of relapsing</a> are high. Abstinence <a href="http://www.bjmp.org/files/2013-6-1/bjmp-2013-6-1-a601.pdf">reduces the ability</a> to tolerate previously manageable doses of heroin, resulting in an overdose for some. </p>
<h2>Treatment risk</h2>
<p>Treatment does reduce mortality. A <a href="http://www.nta.nhs.uk/uploads/trendsdrugmisusedeaths1999to2014.pdf">recent report</a> showed that most opiate deaths were of people not in treatment. Treatment usually involves providing a substitute drug with the aim of weaning the individual off heroin. Methadone and buprenorphine are commonly used to do this. But there are two critical factors, retaining people in treatment and what happens when treatment finishes. The month following treatment is particularly important as a person’s tolerance to opiates will have reduced, increasing the risk of overdose <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13087/full">if the person relapses</a>. Following up people at this critical stage could help reduce the risk of fatality. </p>
<p>But the challenge is how to engage those who are not in treatment. Attracting this group requires a more radical approach. <a href="https://theconversation.com/why-australia-needs-drug-consumption-rooms-53215">Drug consumption rooms</a> provide a safe place for people to use their drugs, providing clean syringes for those who inject heroin. These facilities have an impressive record of reducing fatalities due to drug use. And, just as important, they are the first step towards engaging a marginalised group into health and social care. We don’t need any more evidence as to their value – we need what politicians crave: <a href="http://www.tandfonline.com/doi/abs/10.3109/14659891.2016.1143049">public support</a>.</p>
<p>Naloxone can also temporarily reverse the effects of an opiate overdose. Making this drug available to opiate users and their families offers the potential to reduce fatalities. Scotland has pioneered this by implementing a <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13265/pdf">national naloxone policy</a> and new regulations in England have <a href="https://www.gov.uk/government/publications/widening-the-availability-of-naloxone/widening-the-availability-of-naloxone">allowed this approach to be mirrored</a>. This development gives workers and heroin users access and permission to administer naloxone when an overdose occurs.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Naloxone can reverse the effects of an opiate overdose.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-418417357/stock-photo-layton-utah-march-11-2016-vial-of-naloxone-drug-which-is-used-for-opiate-drug-overdose-it-is-now-available-to-patients-without-a-prescription-or-over-the-counter.html?src=HeShWLVmobUTJtghilzrNw-1-0">PureRadiancePhoto/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>A glimpse into the future?</h2>
<p>The US has witnessed a 200% rise in prescription-opiate deaths since the millennium, driven by <a href="http://onlinelibrary.wiley.com/doi/10.1111/ajt.13776/full">increasing availability and lower costs</a>. The regulatory and marketing environments differ in the US and the UK. In the UK, open marketing of opiates is prohibited and there are stricter controls and monitoring of prescribing. But current drug control measures are outdated and <a href="http://www.tandfonline.com/doi/abs/10.3109/14659891.2014.980861">easily circumvented by the internet</a>.</p>
<p>So we need to carefully monitor the use and misuse of a range of prescription drugs such as tramadol. Tramadol is an analgesic used for moderate to severe pain. Prescriptions for tramadol rose dramatically over the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015registrations">last decade</a>, as did deaths thought to be the result of misusing the drug. This prompted new regulations which came into force last year with the aim of curbing tramadol-related deaths. This year’s ONS data shows that one year after the introduction of these regulations deaths have reduced, but we will need to see if this trend continues.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=366&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=366&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=366&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=460&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=460&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=460&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tramadol deaths.</span>
<span class="attribution"><span class="source">Office for National Statistics</span></span>
</figcaption>
</figure>
<p>A clear measure of the UK government’s ambition to reduce inequality is <a href="http://www.huffingtonpost.co.uk/clare-bambra/theresa-may-health-inequalities_b_11716312.html">halting the rise in drug overdoses</a>. Avoidable fatalities due to drugs serve as a barometer of how equal our society is and how we respond to individual vulnerability. We all lose out when an individual dies this way.</p>
<p>Public Health England has responded to the trend in drug fatalities, publishing <a href="http://www.nta.nhs.uk/uploads/phe-understanding-preventing-drds.pdf">several recommendations</a>. There are some welcome aims but they could be bolder. The time has come to introduce drug consumption rooms – it’s a life or death decision.</p><img src="https://counter.theconversation.com/content/64972/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Hamilton is affiliated with Alcohol Research UK.. </span></em></p><p class="fine-print"><em><span>Mark Monaghan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Opiates have emerged as a significant threat to public health in the UK.Ian Hamilton, Lecturer in Mental Health, University of YorkMark Monaghan, Lecturer in Crimimology and Social Policy, Loughborough UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/598242016-07-13T05:20:03Z2016-07-13T05:20:03ZWeekly Dose: Valium, the ‘safer choice’ that led to dependence and addiction<figure><img src="https://images.theconversation.com/files/130301/original/image-20160712-9307-usxl64.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Long-term use is not recommended because of the known side effects. But it took two decades, after its release in the 1960s, to recognise this.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/-dear-diary/4852660461/">3 0 d a g a r m e d a n a l h u s Follow/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>Valium is a brand name for diazepam, which belongs to a group of drugs called <a href="http://www.nps.org.au/medicines/brain-and-nervous-system/anxiety-medicines/diazepam/valium-tablets">benzodiazepines</a>. Also included in this class are temazepam, oxazepam, nitrazepam, clonazepam, alprazolam, midazolam and flunitrazepam.</p>
<p>Benzodiazepines remain among the <a href="http://www.nps.org.au/medicines/brain-and-nervous-system/anxiety-medicines/diazepam/valium-tablets">most widely prescribed psychotropic medications</a> – that is, drugs that affect brain function. <a href="http://www.racgp.org.au/yourracgp/news/media-releases/benzodiazepines-guide/">Nearly 7 million prescriptions</a> are issued for benzodiazepines in Australia each year, with diazepam the <a href="http://onlinelibrary.wiley.com/doi/10.1111/imj.12315/abstract">most common</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/130350/original/image-20160713-12353-8429qv.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/130350/original/image-20160713-12353-8429qv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/130350/original/image-20160713-12353-8429qv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=703&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130350/original/image-20160713-12353-8429qv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=703&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130350/original/image-20160713-12353-8429qv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=703&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130350/original/image-20160713-12353-8429qv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=884&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130350/original/image-20160713-12353-8429qv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=884&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130350/original/image-20160713-12353-8429qv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=884&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<h2>How does it work?</h2>
<p>Benzodiazepines <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.1994.tb03743.x/abstract">bind to specific receptors</a> to strengthen the effect of an amino acid called Gamma-aminobutyric acid (GABA) in nerve cells. This reduces the turnover of other neurotransmitters, therefore depressing the central nervous system.</p>
<p>The dampening of the nervous system reduces anxiety and causes muscles to relax. This leads to sedation, reduced cognition and motor function, and sleep. </p>
<p>Benzodiazepines, like alcohol, are depressant drugs. These are sometimes referred to as “downers” as they make people feel relaxed, sleepy, less coordinated and generally slowed down.</p>
<h2>How is it used?</h2>
<p>Benzodiazepines have been used for insomnia, anxiety, reducing muscle tension and other situations where there is a need to calm the central nervous system. </p>
<p>There is little controversy about using benzodiazepines in acute psychiatric emergencies, anaesthesia, intensive care, palliative care at the end of life, and in the treatment of seizures and alcohol withdrawal. But its use in long-term situations has been <a href="http://www.racgp.org.au/afp/200711/21023">increasingly questioned</a>. </p>
<p>Diazepam is an effective and low-cost drug – at <a href="http://www.pbs.gov.au/medicine/item/3162K-5072Y-5356X">A$11.67 to $17.19</a> for a pack of 50 in Australia – and therefore remains on the <a href="http://www.who.int/medicines/publications/essentialmedicines/en/">World Health Organisation List of Essential Medications</a>.</p>
<h2>Side effects</h2>
<p><a href="http://www.australianprescriber.com/magazine/38/5/152/5">Benzodiazepines can cause</a> confusion, cognitive impairment and falls, resulting in considerable disruption and socioeconomic costs. This is particularly problematic given that use is more common among older age groups.</p>
<p>Benzodiazepines are also sold as street drugs, can impair driving and are associated with overdose. </p>
<p>Continued use even at low dose for a few weeks can lead to physiological dependence (tolerance and withdrawal). Tolerance means that, over time, the effect of the drug wears off and a higher dose is needed for the same effect. <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.1994.tb03743.x/abstract">When the drug is stopped</a>, users can experience severe withdrawal symptoms such as insomnia, irritability, tension, panic attacks, tremor, sweating, poor concentration, nausea, palpitations, headache, muscle aches and sometimes even seizures and psychotic reactions. </p>
<p><a href="http://www.nps.org.au/publications/health-professional/health-news-evidence/2015/reduce-benzodiazepine-dependence-risk">Long-term use is generally not recommended</a> because of the known side effects. </p>
<p>But withdrawal can be difficult since the initial symptoms for which the drug was prescribed might return, made worse by the symptoms from the withdrawal itself. Some people are therefore reluctant to stop the drug. For these reasons, <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03563.x/abstract">withdrawal should be gradual</a> and guided by clinicians, who can help patients cope with any symptoms. </p>
<h2>History</h2>
<p>Up to the mid-1950s, barbiturates were widely used to treat insomnia and anxiety. But the incidence of dependence, severe withdrawal reactions, overdose and death had become a great concern. </p>
<p>In the <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03563.x/abstract">quest for a safer alternative</a>, American chemist Leo Sternbach created the first compound in the benzodiazepines class of drugs, methaminodiazepoxide. </p>
<p>This led to the release of diazepam (Valium) in 1963, considered to be <a href="http://www.bmj.com/content/309/6946/3">safer</a> than barbiturates. Over the next decade, it became the <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03563.x/abstract">most prescribed drug in the United States</a>. </p>
<p>Negative effects were <a href="http://www.nejm.org/doi/full/10.1056/NEJM199305133281907">slow to be recognised</a> and widely acknowledged. This took nearly two decades after the description of the withdrawal syndrome. Only then did prescription rates begin to fall. </p>
<p>The good news is there is now <a href="https://hal.archives-ouvertes.fr/hal-00571435/document">greater caution</a> and questioning about the potential unintended effects of new drugs.</p>
<h2>Current use</h2>
<p>Despite the clear evidence and widespread acceptance that benzodiazepines cause harm, they have a <a href="http://www.racgp.org.au/afp/200711/21023">legitimate place in therapeutics</a>, such as in acute emergencies. </p>
<p>Yet despite international and national guidelines recommending that the use of benzodiazepines should be <a href="http://www.nps.org.au/publications/health-professional/health-news-evidence/2015/reduce-benzodiazepine-dependence-risk">limited to two to four weeks</a>, these drugs continue to be prescribed beyond these time frames. </p>
<p>The reasons for this are complex. As the largest medical workforce, GPs have the greatest contact with patients and therefore prescribe the most medications. They are often seen as responsible for the benzodiazepine problem. </p>
<p>But GPs may <a href="https://hal.archives-ouvertes.fr/hal-00571435/document">not always be the initiator</a>. They often take over the care of patients who have been started on benzodiazepines by psychiatrists or during hospital admissions. Psychiatrists <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03563.x/abstract">commonly prescribe</a> these medications as an add-on to antidepressant treatment to reduce anxiety and to increase the likelihood that patients will adhere to treatments and respond early. </p>
<p>In Australia, the modest <a href="http://onlinelibrary.wiley.com/doi/10.1111/imj.12315/abstract">decline in the amount of benzodiazepines prescribed</a> between 1992 and 2011 reflects an awareness of risks and GPs’ reluctance to prescribe the drugs, especially to those who have not previously had them. </p>
<p>Today there is a <a href="http://nceta.flinders.edu.au/files/6113/2823/3742/EN448_Nicholas_2011.pdf">broad spectrum of people and contexts</a> where benzodiazepines are used, from the clearly legitimate short-term situations in known patients to deliberate drug misuse and sale in people with chaotic and sometimes aggressive behaviour. </p>
<p>GPs are aware that benzodiazepines may be obtained through <a href="https://ama.com.au/ausmed/national-system-urgently-needed-counter-doctor-shopping-drug-deaths">deliberate “doctor shopping”</a> to obtain medications from multiple medical practitioners under false pretences. </p>
<p>Further, with an increasingly internationally networked world, benzodiazepines can now be <a href="http://thecircular.org/ireland-asleep-in-the-dangers-of-benzodiazepine/">purchased on the internet</a> without a prescription. </p>
<p>The promotion of the <a href="http://www.healthdirect.gov.au/healthy-sleep-habits">dangers of inadequate sleep</a> also results in people seeking medications to reach the goal of seven to nine hours of sleep. In some cases, there are underlying causes that can be treated or healthy sleep habits can improve sleep. In other cases, a person may feel well and simply need less sleep. </p>
<p>New guidelines now recognise individual variations with a broader range of <a href="http://www.sleephealthjournal.org/pb/assets/raw/Health%20Advance/journals/sleh/NSF_press_release_on_new_sleep_durations_2-2-15.pdf">possible appropriate sleep</a> durations of six to ten hours in adults aged 26-64 years, and five to nine hours in those aged 65 years and over.</p>
<p>Clinicians need to discuss the potential side effects of sedative drugs with patients, emphasising the risk of dependence and cognitive decline. They also need to promote non-drug approaches for managing stress, insomnia and anxiety, such as cognitive behavioural therapy, and reinforce that sedative drugs do not work in the long term.</p><img src="https://counter.theconversation.com/content/59824/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Moira Sim does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Benzodiazepines, like alcohol, are depressant drugs, sometimes referred to as “downers” as they make people feel relaxed, sleepy, less coordinated and generally slowed down.Moira Sim, Professor and Dean of School, Medical and Health Sciences, Edith Cowan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/128972013-03-19T03:52:17Z2013-03-19T03:52:17ZWhy the TGA should make it harder for people to get Xanax<figure><img src="https://images.theconversation.com/files/21410/original/9jnghy6d-1363657382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This class of drug poses significant risks of misuse and dependence, paradoxical reactions, disinhibition, amnesia and intoxication.</span> <span class="attribution"><span class="source">Jacek Becela</span></span></figcaption></figure><p>The body responsible for regulating drugs in Australia, the Therapeutic Goods Administration (TGA), is poised to decide whether to restrict access to benzodiazepines, such as Xanax, Valium and Normison. </p>
<p>The drugs are commonly – <a href="http://dx.doi.org/10.1111/j.1360-0443.2011.03563.x">but controversially</a> – used to treat anxiety and insomnia. However, there is a growing body of evidence that they’re increasingly being misused. </p>
<p>A TGA committee meeting on Wednesday will consider <a href="http://www.tga.gov.au/newsroom/consult-scheduling-acmcs-1303.htm">rescheduling benzodiazepines</a> to restrict their use. </p>
<p>More than 7.5 million benzodiazepine prescriptions were dispensed across Australia in 2010 - including more than 680,000 for alprazolam (AKA Xanax). The proposal is to move benzodiazepines from Schedule 4 to the more restrictive <a href="http://www.australianprescriber.com/magazine/20/1/12/3">Schedule 8</a>. Medicines on Schedule 8 are considered potentially addictive, and have an additional layer of monitoring and control to support quality prescribing, and reduce drug dependence and diversion. </p>
<p>Benzodiazepines are not <a href="http://jop.sagepub.com/content/19/6/567.short">first-line treatments</a> for anxiety and there’s limited medical evidence of their efficacy beyond two to four weeks. In fact, they’re only approved and recommended for short-term use. </p>
<p>There’s good evidence that, in most cases, non-pharmaceutical treatment of <a href="http://www.biomedcentral.com/1471-2296/13/40">insomnia</a> <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1614.2004.01423.x/full">and</a> <a href="http://journals.lww.com/co-psychiatry/Abstract/2009/01000/Current_use_of_benzodiazepines_in_anxiety.16.aspx">anxiety</a> are as effective as these drugs. And that their benefits are more enduring, with less risk of adverse effects. </p>
<h2>What’s the harm?</h2>
<p>There’s been growing concern about the misuse and harms of <a href="http://www.health.vic.gov.au/aod/pubs/benzoresponse.htm">benzodiazepines</a> in recent years. The drug poses significant risks of misuse and dependence, paradoxical reactions, disinhibition, amnesia and intoxication. </p>
<p>There’s particular concern about <a href="http://www.mjainsight.com.au/view?post=alprazolam-linked-to-heroin-deaths&post_id=12343&cat=issue-7-4-march-2013">alprazolam</a>, a potent, fast-acting benzodiazepine that has been associated with <a href="http://au.news.yahoo.com/sunday-night/features/article/-/14207856/expressInstall/">serious</a> <a href="http://www.theage.com.au/national/experts-warn-xanax-usage-may-reach-epidemic-proportions-20120713-2223j.html">health risks</a>, such as misuse, dependence and crimes including <a href="http://www.theage.com.au/victoria/tranquilliser-use-causing-accidents-20121120-29o1j.html">traffic injuries</a>, <a href="http://ecite.utas.edu.au/74824">violence</a>, property damage, <a href="http://abcnews.go.com/US/xanax-defense-utah-woman-allegedly-mowed-husband-suv/story?id=16975190">blackouts</a>, theft and <a href="http://www.mjainsight.com.au/view?post=alprazolam-linked-to-heroin-deaths&post_id=12343&cat=issue-7-4-march-2013">overdoses</a>. Alprazolam has also been implicated in a number of celebrity drug-related deaths, including Heath Ledger’s.</p>
<p>Benzodiazepines were responsible for <a href="http://www.turningpoint.org.au/site/DefaultSite/filesystem/documents/Ambo%20Project%20Annual%20Trends%20Report%202010-11%20edit.pdf">3,135 ambulance attendances</a> in Victoria alone in 2010-11. In terms of all alcohol and drug related attendances, they were second only to alcohol, and there was a disproportionate increase in involvement of alprazolam compared to all benzodiazepines in ambulance attendances. </p>
<p>Health-care professionals, including general practitioners, needle syringe program workers and forensic workers, have experienced incidents of <a href="http://www.racgp.org.au/afp/2011/november/benzodiazepines/">extreme violence and aggression</a> resulting from Xanax misuse; this drug is often described as “angry pills”.</p>
<p>People who inject drugs or use opioids may take benzodiazepines for insomnia or anxiety, or to enhance the intoxicating effects of opioids. But benzodiazepine use causes particular problems for opioid dependent people. </p>
<p>One <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2005.01051.x/abstract">study</a> found people using a benzodiazepine within 12 hours of using heroin were at 28 times the risk of overdose compared with those who did not. Several studies have found that opioid users who also take benzodiazepines have poorer health and are at greater risk of contracting <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1465-3362.2012.00514.x/abstract">HIV</a>.</p>
<p>A <a href="https://www.mja.com.au/journal/2013/198/4/recent-increase-detection-alprazolam-victorian-heroin-related-deaths">study we recently published</a> investigated prescription rates of alprazolam and its detection in heroin-related deaths over the past 21 years. We found there was a disproportionate increase in the supply of the high-dose two milligram formulation of alprazolam (compared to other formulations). We also found a significant increase in the detection of alprazolam in heroin-related deaths since 2005. </p>
<p>The relationship between the increase in supply and increasing detection in deaths was linear. While we can’t definitively know whether alprazolam contributed directly to the deaths, we know that opioids and benzodiazepines (and alcohol) are central nervous system depressants, meaning that it’s easier to overdose if they’re taken together. That people who inject drugs are increasingly using this potent benzodiazepine is a huge concern.</p>
<h2>What’s the source?</h2>
<p>While some prescriptions are provided directly to opioid users, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22141578">recent research</a> shows most (81%) people who inject drugs in Melbourne obtained alprazolam from illicit sources. Users pay between $3 and $5 for one tablet. A concessional prescription for 50 alprazolam tablets subsidised by the Pharmaceutical Benefits Scheme (PBS) costs $5.90, yielding a potential street value between $150 to $250. </p>
<p>This is a considerable profit for those on-selling their medication. And there’s been a considerable increase in reports of forged and altered prescriptions to obtain Xanax, which is the preferred brand name of alprazolam. </p>
<p>A 2012 Victorian review of reports of forged benzodiazepine prescriptions found 65% were for Xanax. This is the main reason why alprazolam should be rescheduled to S8. Before dispensing S8 drugs, pharmacists are required to recognise the prescriber’s handwriting or check whether she actually wrote the prescription.</p>
<p>Pharmacists report that it’s not uncommon for them to see prescriptions for 100 or 200 tablets. This is worrying for a product that has no proven benefit beyond short-term use.</p>
<h2>Would restrictions help?</h2>
<p>The proposed rescheduling of benzodiazepines could have significant infrastructure and workforce implications for already stretched addiction and <a href="http://www.agedcare.org.au/national-report/acsa-national-report-issue-297-24-january-2013/tga-proposal-to-reschedule-benzodiazepines">aged care</a> sectors. Still, many health professionals <a href="http://www.mjainsight.com.au/view?post=alprazolam-linked-to-heroin-deaths&post_id=12343&cat=issue-7-4-march-2013">support</a> a selective rescheduling of alprazolam because of the problems stemming from its higher potency.</p>
<p>The effectiveness of this kind of rescheduling is well demonstrated by the case of flunitrazepam (Rohypnol). This drug was rescheduled to S8 in 1998, leading to a significant drop its detection in heroin-related deaths. </p>
<p>Similarly, in May 2001, the PBS started to require authority for temazepam gel capsules, which became favoured for injection in the late 1990s (causing serious injection wounds and gangrene). This resulted in a <a href="https://www.mja.com.au/journal/2004/181/6/effects-restricting-publicly-subsidised-temazepam-capsules-benzodiazepine-use">reduction in its use</a> by people who inject drugs. And the product was eventually <a href="http://www.ncbi.nlm.nih.gov/pubmed/18264874">withdrawn</a> and remaining stocks destroyed by the manufacturer in 2004.</p>
<p>Given the success of the restrictions applied to flunitrazepam and temazepam, and the substantial harm resulting from the increased supply of alprazolam, we hope the TGA’s scheduling committee will acknowledge the evidence of its significant harms and make it more diffuclt for people to access alprazolam.</p><img src="https://counter.theconversation.com/content/12897/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Nielsen does not work for, own shares, or consult for any company or organisation that would benefit from the article. She is the current recipient of an NHMRC Early Career Fellowship. </span></em></p><p class="fine-print"><em><span>Angela Rintoul and Louisa Degenhardt do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The body responsible for regulating drugs in Australia, the Therapeutic Goods Administration (TGA), is poised to decide whether to restrict access to benzodiazepines, such as Xanax, Valium and Normison…Angela Rintoul, Doctor of Public Health Candidate, Monash UniversityLouisa Degenhardt, Professor of Epidemiology, NDARC, UNSW SydneySuzanne Nielsen, NHMRC Early Career Research Fellow Addiction Medicine, University of SydneyLicensed as Creative Commons – attribution, no derivatives.