Benzodiazepine addiction

January 2018: Interesting evidence session in the Scottish Parliament

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See also benzact.info

To the Daily Mail: Congratulations

A few days ago the Daily Mail published an article on the prescription of benzodiazepines. It starts

Countless thousands of Britons have become addicted to pills that have been prescribed by their doctors for pain, anxiety, sleeplessness and depression.

Tranquillisers such as benzodiazepines (also used as muscle relaxants for pain) are highly addictive, yet many medics continue to hand them out for longer than they should.

actionagainsttranquiliseres.org.uk (2003-2016)

The  article in the Daily Mail prompts me to re-post an item from an old website, actionagainsttranquiliseres.org.uk  started in 2003 -but the problem is rather older:  The Independent reported in 2010 in Drugs linked to brain damage 30 years ago. Now that’s 37 years ago.

Anyway, here is something from 2003. It’s a submission that a voluntary organisation made to government when there was even less public awareness of the benzo issue. The document was written as background information which in the late ’90s/early 2000s was still very scarce. It was one of several compiled by grassroots organisations intended to inform Government.  A Hidden Epidemic was submitted to Home Office Minister Caroline Flint in 2003.

Dependence

“It is more difficult to withdraw someone from benzodiazepines than it is heroin” “the withdrawal symptoms are so intolerable that people have a great deal of problem coming off”. Lader M.1999

Cognitive impairment

“Most benzodiazepines impair and compromise a wide range of basic skills which are absolutely necessary for coping with the intellectual and psychological demands of everyday living.” Hindmarch I. 1999

Agoraphobia

Cognitive and other coping mechanisms are vital for negotiating busy streets etc. With these abilities impaired by BZs, many long-term users find themselves increasingly housebound with agoraphobic-type symptoms.

Co-ordination

the benzodiazepine tranquillizers and hypnotics, more than double the risk of injurious accidents/ the use of the most frequently prescribed impairing medication, the benzodiazepine tranquillizers and hypnotics, more than double the risk of injurious accidents 32 De Gier 1998/9.

Benzodiazepine misuse

– Increased drug-related deaths

– Risks to the unborn child

– Crime and criminal behaviour

Next time I get a chance, I will ask Caroline Flint whether A Hidden Epidemic got through the departmental filter and she got a chance to read it.

After 37 years it’s good to see the Daily Mail on the case. The problem hasn’t disappeared.

A Hidden Epidemic.

Introduction

A group of drugs which are responsible for an increase in drug-related deaths and unsafe for use in pregnancy, continue to be prescribed and are now flooding the illicit drugs market.

Benzodiazepines (most tranquillisers and sleeping pills, e.g. Valium, Mogadon, Ativan, Librium etc.), are safe drugs when used short-term and according to the guidelines, but their ‘safe’ image may be their greatest danger.

40 years of benzodiazepine prescribing has brought a catalogue of problems in its wake and these are being compounded by their misuse.

As well as increased drug-related deaths and hazards to the unborn child, the immediate dangers of benzodiazepines include increased road traffic accidents, increased falls in the elderly and involvement in crime and criminal behaviour.

Longer term, benzodiazepines use can cause severe addiction and the deterioration of physical and mental health.

Much has been written, but little done, to address the problem of benzodiazepines, although the cost of not doing so, must outweigh that of tackling the issue.

Most facts about benzodiazepines are available, but have failed to reach public awareness.

The purpose of this document is to bring some of those facts together and highlight what has become, a hidden epidemic.

Incidence of Benzodiazepine use

GLOBAL CONSUMPTION RISING
1.5 MILLION LONG-TERM UK USERS
RISING MISUSE

“You have this huge problem, with a huge number of people involved and yet
we seem as a society to be incapable of acting on it” – Phil Woolas MP, 2000 ¹³⁷

Worldwide

Fig.2 Global diazepam consumption, 1991-2000, in billions of defined daily doses (adapted). 1

Global benzodiazepine (BZ) consumption rose between 1991 and 2000, with Europe the highest consumer.¹

Several European countries report high BZ consumption rates, Ireland being one of the highest. Belgium, Spain and Portugal also have high BZ consumption.²

In Ireland, 10% of all adults take prescribed BZs, 20% of whom are elderly. Of these, 70% are long-term BZ users.³

BZ-related problems are common worldwide and one international study indicates that long-term prescribing is still accepted practice⁴, for example, in The Netherlands, an estimated 50,000 long-term prescribed BZ users are created annually. ⁵

“The optimistic idea that chronic benzodiazepine users would soon die out, cannot be confirmed” – Van der Vaals F, 2001 ⁵

UK consumption

Figure 1 Benzodiazepine anxiolytic consumption 1990-2000, average national consumption in selected countries by region, in defined daily doses (DDDs) per 1,000 inhabitants per day. 1

In the UK, there are at least 13 million prescriptions for BZs per year, 8 with 1 – 1.5 million people currently taking them. ⁹

Long-term BZ users

Available figures show at least 1 million people currently on long-term BZ prescriptions (> 4 months) in the UK,¹⁰ some of whom have been on their drugs for up to 40 years.

GP Practices

GP practices in the UK average 100 – 200 patients on long-term BZ prescriptions.11A recent audit in one UK health care trust found around 3.5 thousand prescribed BZ users amongst 29 GP practices; (average 125 patients per practice). Of these, almost 70% were long-term BZ users (>2years).

Another UK study estimated that in one District Health Authority, there are an estimated 14 thousand patients on long-term BZ prescriptions (>6 months).¹²

Benzodiazepine misuse

BZ misuse is widespread. In Hong Kong BZs were rescheduled as a ‘dangerous drug,’ which halved prescribing and their subsequent supply to the illicit market.⁶ Results from a questionnaire issued by the Pompidou Group in 2001, revealed that no country questioned could provide figures on the prevalence of BZ abuse or their illegal consumption, although all countries agreed that BZs posed a public health hazard. ⁷

The prevalence of BZ misuse in the UK has been reported by the Department of Health variously, as 16% ¹⁵ and 90% ¹³, ¹⁴ for England, 55% ¹⁵ for Scotland and 23% ¹⁵ for Wales.

Benzodiazepine Effects

• DEPENDENCE
• DIFFICULT WITHDRAWAL
• GENERAL HEALTH PROBLEMS
• LONG-TERM PROBLEMS

A short-term drug

Benzodiazepines (BZs) are effective drugs used Short-term, but long-term use brings problems with side effects, dependence and deterioration in health.
In 1988, the Committee on the Safety of Medicines issued guidelines regarding BZs and recommended that they should only be prescribed for 2-4 weeks, due to the risk of dependence. ²¹

“There is increasing evidence that long-term prescribing of benzodiazepines may cause harm.” SMMGP, 1998. ¹⁶

How benzodiazepines ‘work’

A major effect of benzodiazepines (BZs) is the enhancement of the GABA (gamma amino butyric acid) neurotransmitter system present throughout the brain and nervous system. ¹⁷

The function of the GABA system is to regulate and ‘damp down’ reactions to stimuli and excitation throughout the system. The enhancement of GABA is why BZs ‘work’ so effectively as tranquillisers and sleeping pills. BZs are also used as anti-epileptics, muscle relaxants and in hospital procedures (where their amnesic qualities/side-effects are an additional benefit). ¹⁸

Side-effects

Many BZ side-effects are also their ‘therapeutic’ sedative effects, such as drowsiness, ataxia, fatigue, confusion, weakness, dizziness, vertigo, fainting etc. ¹⁹

Dependence

“Symptoms such as persistent tinnitus, involuntary movements, paraesthesia, perceptual changes, confusion, convulsions, abdominal and muscle cramps, and vomiting may be characteristic of benzodiazepine withdrawal syndrome.” Wyeth Laboratories. 1990 ²⁰

Altered brain chemistry

The changes in brain chemistry caused by BZ use become harder to reverse over time, ²²increasing the risk of protracted withdrawal syndrome.

Withdrawal

“It is more difficult to withdraw someone from benzodiazepines than it is heroin” “the withdrawal symptoms are so intolerable that people have a great deal of problem coming off”. Lader M.1999 ²³

Dependence on BZs can occur after 3 weeks of continuous use, and after 3 months in nearly half of users. ²⁴ The BZ withdrawal syndrome lasts from four weeks to a year or more ²⁵ (British National Formulary, 2002) and can be severely disabling.

Nervous system effects

Multiple neurological symptoms are associated with BZ use, particularly during withdrawal. These include disturbances of perception, sensation, co-ordination and consciousness.

Cognitive impairment

“Most benzodiazepines impair and compromise a wide range of basic skills which are absolutely necessary for coping with the intellectual and psychological demands of everyday living.” Hindmarch I. 1999 ²⁶

A major effect of BZ use, is cognitive impairment, with memory functions such as information processing, specifically impaired.²⁷ Memory “blackouts” are also common; the sufferer may have performed complex tasks such as driving a car but have no recall. ²⁸ The consequences of this impairment can be a deterioration in behaviour and day-to-day functioning, which tends to reverse after withdrawal of BZs. ²⁹, ¹³⁵.

‘Agoraphobia’

Cognitive and other coping mechanisms are vital for negotiating busy streets etc. With these abilities impaired by BZs, many long-term users find themselves increasingly housebound with agoraphobic-type symptoms. This has a significant impact on both the sufferer and those around them.
In one study, 20% of long-term BZ users developed incapacitating agoraphobia, which largely disappeared after withdrawal from the drug. ³¹

Co-ordination

the benzodiazepine tranquillizers and hypnotics, more than double the risk of injurious accidents/ the use of the most frequently prescribed impairing medication, the benzodiazepine tranquillizers and hypnotics, more than double the risk of injurious accidents ³² De Gier 1998/9.

Psychomotor impairment caused by BZs increases the risk of falls (particularly in the elderly)³³ and road traffic accidents. ³²,³³

Emotional/behavioural effects

“Striking deterioration in personal care and social interactions has been reported ” [with BZ use]. WHO, 1985 ³⁴

Depression, aggression, irritability, mood swings, impaired response to stress, excess anxiety, general dysphoria – all are adverse effects of BZ ¹⁸ use and may be mistaken for mental health problems.

“This hatefulness was of a peculiar type. The patients were unhappy with it; they realised that it was unnatural and without basis, but were impotent to do anything about it “Feldman P., 1962. ³⁵

Risk of suicide

An increase in suicidal thoughts and tendencies associated with BZ use has been reported since the early 1960s. ³⁶,³⁷.

General health problems

” even small anatomical, biochemical, or physiological insults to the nervous system may result in adverse effects on human health”. Environmental Protection Agency, 1997 ³⁸

Long-term BZ use is associated with an overall deterioration in general health, reflected in increased use of health services ³⁹ and increased prescribing for other health problems.

In 1989, findings from a large UK survey revealed high rates of ill health amongst long-term BZ users. These users were prescribed on average 3 types of other medication. The medications most commonly prescribed were for pain relief, gastrointestinal problems and heart problems.¹³⁶

In 2001, a report from The Netherlands, reflecting the above, showed long-term BZ users being prescribed twice the amount of medications for other complaints as short-term BZ users. ⁵

An improvement in general health after withdrawal from BZs reflected in reduced use of health services has been reported. ⁴⁰

BZ-related problems can manifest in all bodily systems including the endocrine ⁴¹ and immune system. ⁴²

Long-term effects

“PWS (post withdrawal syndrome) is likely to be a genuine iatrogenic complication of long-term benzodiazpine treatment” Higgitt A, 1990 ⁴³

Symptoms persisting long after withdrawal from BZs; a ‘Post-withdrawal syndrome,’ has been identified by several authors, indicating that these symptoms are not a return of the original problem. ⁴³,⁴⁴.

The drug flumazenil, a BZ antagonist (‘antidote’) has been found to eliminate or reduce many ‘post withdrawal symptoms’. ⁴⁵,³⁰.

Recovery from BZ withdrawal can continue over months or years in some patients. ³⁹,⁴⁰. 135.

Neurotoxicity

“repeated insult to the nervous system could lead to an adaptation. There are, however, limits to this capacity, and… further exposure could lead to frank manifestations of neurotoxicity at the structural or functional level” Environmental Protection Agency, 1999.³⁸

Reports are increasing in some long-term BZ users of problems consistent with the Environmental Protection Agency’s criteria for functional neurotoxicity listed below: ³⁸

• Alterations in sensations of sight, hearing, or touch;
• Alterations in simple or complex reflexes and motor functions;
• Alterations in cognitive functions such as learning, memory, or attention;
• Changes in mood, such as fear or rage, disorientation as to person, time, or place, or distortions of thinking and feeling.

Adverse effects in somatic/autonomic, sensory, motor and cognitive function, together with measurable alteration in BZ receptor function in the brain, ²² suggest that BZs can cause neurotoxicity with long-term use.

Benzodiazepines in Pregnancy

• DRUG WITHDRAWAL AT BIRTH
• RISK OF COT DEATH
• DEVELOPMENTAL PROBLEMS
• IMPAIRED METABOLISM

“Exposure of our most valuable resource, our children, to harmful developmental effects of drugs is a problem of staggering proportion.” Huestis M. ⁴⁶

It is accepted that there are dangers to newborn babies exposed to ‘dangerous’ drugs such as alcohol and opiates during pregnancy, but the risks of prescribed drugs during pregnancy are rarely examined. In 1978, the Australian National Drug Information Service stated that benzodiazepines (BZs) were contraindicated during pregnancy. ⁴⁷

Category ‘X’

Benzodiazepines are classified by the US Food and Drug Administration (FDA), as pregnancy category ‘D’, ⁴⁸, ⁴⁹. which should not normally be taken during pregnancy and category ‘X’,⁵⁰which should never be taken during pregnancy (opiates are category ‘B’ or ‘C’). *See FDA categories below.

BZs readily cross the placenta reaching high levels in the foetus ⁵¹,⁵² and are also present in breast milk. ⁵³.

Incidence

Worldwide, an estimated 85% of all psychotropic medicines prescribed to pregnant women are for BZs. ⁵⁴ The incidence of BZ use during pregnancy is unclear and figures varying from 1-3%, ⁵⁵ to 40% ⁵⁶ have been suggested. These figures do not include women who misuse BZs, 90% of whom are of childbearing age ⁵⁷.

1 in 6 newborn infants

BZs were detected in 18% of infants born between October and November 2000 at a Glasgow maternity hospital ⁵⁸

“We noted a high rate of prescribing of benzodiazepines to pregnant women in spite of documented evidence that this may lead to the so-called “floppy baby syndrome” of neonatal drowsiness, hypotonia and withdrawal symptoms” O’ Shaughnessy P., IMJ, 1993 ⁵⁹

Fig.1. Anxiolytic & hypnotic prescribing to women aged 15-44 in the UK, 1994-1998 (adapted), source, General Practitioner Database.17

Prescribing

It is a legal requirement that all prescribed medicines in the UK are dispensed with an attached Patient information leaflet. ⁶⁰Information leaflets for BZs state that they should not be taken during pregnancy, but not all women receive this warning. Although illegal, some prescriptions are currently issued without leaflets. ⁶¹ The Committee on Safety of Medicines issued a reminder warning of the dangers of BZ use in pregnancy in 1997, ⁵³ but prescribing of hypnotics and anxiolytics to women of childbearing age rose between 1994 and 1998 (fig. 1). ⁶²

Dangers at birth

Babies exposed to BZs during pregnancy are at risk of the following:

• Low birth weight. ⁶³
• Breathing difficulties. ^64,65
• “Floppy” muscles. ⁶⁴
• Unstable body temperature. ⁶⁴
• Alteration in heart rate/function. ^51,64
• Altered EEG measurements.⁶⁶
• Withdrawal syndrome (can be protracted) with irritability, convulsions etc. ^64,67

Prenatal BZ exposure can cause toxicity and/or withdrawal effects at birth. Affected babies may need months of treatment, sometimes in special care, ^68,69,70 whereas the adverse effects of prenatal opiate exposure lasts 2-4 weeks. ⁷⁰

Flumazenil, a BZ antagonist (‘antidote’) that can reverse many effects of BZs (licensed for use in surgical procedures and overdose), has been used in emergencies (outside of license) in some BZ-exposed neonates, successfully reversing most of the above adverse effects. ^71,72,73,74

Risk of Cot death

“The baby might have died on a postnatal ward of an apnoeic episode had he not been admitted to a special care nursery.” The Lancet, 1977 ⁷⁰

BZs are a risk factor in cot death as they can interfere with breathing regulation ^64,65. and the drug can remain active in the baby’s system for long periods. ^51,56

No specific investigation appears to have been done into prenatal BZ use and cot death.75 Instances of cot death in BZ-exposed infants have been reported ^76,77 and in one study the use of nitrazepam has been implicated in sudden unexpected deaths in children. ⁷⁸

Long-term problems

“Diazepam should be avoided in pregnant or lactating animals… in humans, it has been shown to be teratogenic when used during the first trimester of pregnancy. Diazepam crosses the placenta and is present in milk.” Veterinary advice, 2001 ⁸⁹.

Malformations

Conflicting reports of the incidence of cleft palate and other malformations have continued to emerge since the 1970s; the results remain unclear. A recent meta-analysis (2000) of 13 studies showed no increased risk of BZ-induced malformations from cohort studies and slight increased risk from case-controlled studies. ⁷⁹

Developmental effects

Animal studies show that BZs can interfere with foetal development including neurodevelopment, ^{17, 80} and development of the immune system. ^81,82

Current human research ^83,84 reflects many animal findings, as do the growing anecdotal reports.

An informal study amongst self-reported parents of 63 BZ-exposed children ⁸⁵ revealed high rates of neonatal and later developmental problems; e.g. 30% needed treatment in special care at birth and 31% developed learning difficulties. Unexposed siblings were reported to be unaffected, indicating that further research is needed.

Parenting and the next generation

Cognitive and other health problems due to parental BZ use can impair parenting skills ⁸⁶ with negative consequences for the children and the family. Research shows a direct link between parental BZ use (mainly maternal), and subsequent BZ use/misuse in their adolescent children. ^87,88

Category X benzodiazepines include: Flurazepam, Estazolam, Temazepam, Quazepam, Triazolam

Definition of FDA pregnancy categories: The FDA-assigned pregnancy categories as used in the Drug Formulary:

Benzodiazepine Misuse

• INCREASED DRUG-RELATED DEATHS
• INCREASED RISK TO THE UNBORN CHILD
• HIV INCREASED RISK OF HIV

New problem – Old drug

Harder to withdraw from than heroin, ¹⁶ benzodiazepines (BZs) are also more dangerous to the newborn, ⁹⁰ and can cause more cognitive impairment during use. ⁹¹

Largely unrecognised as “dangerous drugs,” the BZ group of drugs have encroached the illicit market, becoming major drugs of misuse worldwide and the low priority given to this problem has compounded it. ⁹²

BZ dependence can underlie many drug misuser’s problems, which may be being wrongly attributed to more notorious ‘hard’ drugs.

Incidence

High rates of BZ misuse are reported worldwide, but accurate figures are scarce. In a questionnaire on the prevalence of illicit BZ use issued by the Pompidou Group for the Council of Europe, no country questioned could provide accurate figures.⁷

Diazepam and flunitrazepam are the main BZs abused worldwide, ⁹² but it has been shown that all BZs have the potential for misuse. When prescription of temazepam was restricted in 1996, misuse of this drug reduced, but there was a corresponding increase in the prescribing and misuse of diazepam. This was reported in both Scotland ⁹³ and North West England. ⁹⁴

In England, official figures for BZ misuse range from 16% ⁹⁵ to 90% ^13,14 There are probably over 100,000 illicit benzodiazepine abusers in the U.K., and the number is still rising. ⁹⁶

A ‘secondary’ drug

Misuse of BZs is endemic throujghout the illicit drugs scene, being used mainly as a ‘secondary drug’. ⁹⁴ BZs are used by drug misusers with alcohol, opiates, methadone, amphetamines, cocaine, and ecstasy, ⁹⁷ for many reasons, including:

• Low cost on the ‘streets’ (between 50p -Ł1.50 per tablet/capsule) ⁹³
• To ‘tide over’ between doses of primary drug (particularly opiates).⁹⁷
• To enhance the effect of other drugs, (particularly opiates). ^97,98
• To ‘come down’ or ‘chill out’ after amphetamine/cocaine/ecstasy use. ^3,98
• To cope with withdrawal symptoms from other, (usually ‘primary’) drugs. ^97,98.
• To relieve anxiety and dysphoria due to drug use.⁹⁷
• To facilitate crime ^99,100
• Used alone in high doses to achieve a ‘high’. ^3,97

Combined opiate/ benzodiazepine use

“benzodiazepine abuse caused considerable harm among the illegal drug-using population, opiate users suffered the most serious harm.” Department of Health & Children, Ireland, 2002.³

with increased risk of heroin overdose,¹⁰¹ higher levels of HIV risk-talking behaviour, ¹⁰²poorer physical health and psychological functioning. ¹⁰³ BZs are used with opiates for several reasons including:

• To ‘ tide over’ between opiate doses or when supplies are scarce. 97
• To enhance the effects of opiates. ^97,98
• To relieve opiate withdrawal symptoms. ^98,3

Several countries report high levels of BZ/opiate use:

• Geneva: 70% opiate users use BZs 1999) ¹⁰⁴
• Toronto: 62.5% of opiate users use BZs ¹⁰⁵
• Ireland: 45% of opiate users (1997- ‘8) ⁹⁹

Injecting drug users

“Benzodiazepine abuse is common among injecting drug users as indicated by studies in Europe, USA, UK, Australia and India and is associated with markedly worse outcomes.” SAHAI Trust, India ¹⁰⁸

High rates of BZ use are also common amongst injecting drug users. In Australia for instance, up to 78% of injecting drug users use BZs (2000). ¹⁰⁶ In the UK, Up to 49% of attendees at drug misuse centres had injected BZs. ¹⁰⁷

Treatment of other addictions with BZs

“Benzodiazepines are a major contributor to drug deaths and are not a safe substitute for methadone.” Keen J., 2001 ¹⁰⁹

BZs are commonly prescribed to treat addiction to other drugs and alcohol, particularly in combination with methadone, creating further problems and addiction.

In 1988/89, 24.9% of prescribed opiate users in the Northwest of England, used BZs, and 89.6% of those had been prescribed them. ¹¹⁰

BZs are the drug of choice during alcohol withdrawal, but if continued long-term, can cause dependence and compromise therapy due to cognitive side effects. ³ 30 – 50% of alcoholics use illicit BZs. ¹¹¹.

Sources of illicit benzodiazepines

The primary sources of illicit BZs are from legitimate supplies, such as diverted prescriptions, warehouse and pharmacy thefts and prescription forgeries. ^92,97.

Problems caused by benzodiazepine misuse

• Increased drug-related deaths
• Risks to the unborn child
• Physical problems
• Social problems
• Psychological problems
• Crime and criminal behaviour

Drug-related deaths

“Polydrug deaths contributed to the overall rise in heroin deaths, especially benzodiazepines.” Keen J. 2001 ¹⁰⁹

BZs are involved in a large proportion of drug-related deaths. Taken alone in overdose, BZs can cause death, but more commonly, it is their effect in combination with other drugs, which is responsible for most of the deaths.

Children born to benzodiazepine misusers

Over 90% of women attending for drug treatment in the UK are of childbearing age. ¹¹² These children face the same risks as children of prescribed BZ users, but they are compounded by increased dosage and other drug use, particularly opiates; a mixture known to be lethal in adults. ¹¹³

An increased incidence of cot death in babies born to opiate users is well established; ¹¹⁴ A risk compounded by the addition of BZs, which can cause multiple problems at birth, including apnoea (stopping breathing). ¹¹⁵

Physical problems

Drug misusers who use BZs have poorer general health, ⁹⁸ increased incidence of hepatitis C, ¹¹⁶ increased HIV risk-taking behaviour ¹⁰² and greater risk of heroin overdose. ¹⁰¹ Where BZs are being injected, BZ users risk venous/arterial damage and amputations. ⁹⁸

Psychological problems

Amnesia, disturbed behaviour, aggression, depression, anxiety and general psychological impairment. ⁹⁸

Social problems

Educational failure, unemployment, imprisonment, poor social functioning. ⁹⁸

Crime

BZs are implicated in a wide range of criminal behaviour, due to their behavioural effects, they can induce criminal behaviour in the user and be used against the victim to disable them, e.g. ‘date rape.’ ¹⁰⁰ (section 6).

Drug-related deaths

“As in England and Wales, opiates and benzodiazepines were the types of drug most often mentioned on death certificates in recent years” Drugscope Report, 2001 ¹¹⁷

Figure 1. Selected drugs mentioned in drug-related deatvhs in Scotland, 1996-2000, (adapted) 118 Key: HRN= Heroin, MNE=Morhine, DZ=Diazepam, TZ=Temazepam.

In 1999, the Advisory Council on the Misuse of Drugs (ACMD), noted that sub-lethal amounts of BZs and opiates when taken together are a fatal cocktail, acting on different respiratory mechanisms in the brain and that this was responsible for an increase in drug-related deaths. ¹¹³

High rates of BZ involvement in drug-related deaths, particularly in combination with opiates are widespread. Fig.1, shows drugs involved in drug-related deaths in Scotland, 1996-2000.¹¹⁸

Figure 2. Health Statistics Quarterly, spring 2002. (adapted) 11 Key HNE=heroin, MNE=morphine,TDN=Temazepam, diazepam, nitrazepam.

In England and Wales, similar high rates of BZ involvement in drug-related deaths were recorded, until 1998, when opiate-related deaths escalated and BZ involvement fell (fig.2). ¹¹⁹ The reason for this is not known; possibly, the habits of opiate users in England and Wales differ from those in other countries.

Combined benzodiazepine /opiate-related deaths

Fig.3. Drugs involved in opiate-related deaths in Dublin City, 1998 & ’99, E Keenan, 2001.

In Victoria, New South Wales, BZs were found in 50% of all deaths involving heroin use from 1997 to 2000. ¹²⁰

A breakdown of the drugs implicated in opiate-related deaths in Dublin City is given in Figure 3. In the years 1998 and 1999, the most common drugs involved in opiate-related deaths were BZs. ¹²¹

Crime and Aggression

• INDUCE CRIMINAL BEHAVIOUR
• USED TO FUEL CRIME
• USED AGAINST VICTIMS
• HIGH LEVELS OF USE IN PRISONERS

Behavioural disturbance

Benzodiazepines (BZs) can cause violent aggression, memory loss, disinhibition and suggestibility and they are implicated in a wide range of criminal behaviour ¹²³

“The implications of the combination of anti-anxiety agents and aggressiveness are astounding.” Canadian Family Physician, 1975.¹²²

Unlike most other sedatives, BZs alter behaviour and memory without causing loss of consciousness ²⁸ and users can perform complex tasks, but have no recall.²⁷

“Instead of prompting the appearance of delusions and/or hallucinations, many of the patients themselves deliberately used the term “hate”. Feldman P., 1962 ³⁵

Violent crime

Violent crimes, including murder, have been attributed to the adverse behavioural effects of BZs. In 1980, a woman who stabbed her husband to death was acquitted, due to the effects of the diazepam that she had been prescribed. ¹²⁴

“Professor Michael Rawlins said that he believed the tragedy [murder] was probably precipitated by the excessive amount (30mg prescribed diazepam which the defendant had consumed in the preceding twelve-hour period before her husband’s death” Law Society Gazette, 1987. ¹²⁴

Use of benzodiazepines to perpetrate crime

For ‘Dutch courage’

BZs are used to enhance/fuel the mood of perpetrators of crime, as ‘Dutch courage,’ the loss of inhibition, sedation and disassociation imparting a sense of invulnerability. ⁹⁹

To incapacitate victims

“As soon as I took the drink- I’d say within three minutes- I didn’t remember anything that happened, until I woke up during the rape.” victim of ‘date rape, 1996 ¹²⁵

BZs are used against the victims of crime such as, physical assaults (indecent assault, rape, incest) and violation of property (swindling, theft etc), ²⁸ as they induce amnesia, disinhibition and suggestibility. ¹²⁶ Usually the victim’s drink is spiked with a BZ. ¹²⁵

The amnesia caused by BZs makes it difficult for the victim to recall events, which protects the perpetrator from detection. ^28,125

Benzodiazepine use in the prison population

“Benzodiazepines were the commonest drug found by health care staff urine screening new receptions to Swansea” HMIP Swansea Prison,1999.¹²⁷

High levels of BZ use amongst arrestees and prisoners are common. Figures in the UK range from 13% of arrestees in England and Wales testing positive for BZs (’99-2000) ¹²⁸ to 45% of prisoners entering Scottish prisons (2000). ¹²⁹

Many prisoners, typically young prisoners, were coming into the prison with a history of high levels of benzodiazepine use some of whom were the result of GP prescribing.” Chelmsford Prison, ¹³⁰

Link to violence in inmates

“9 out of 12 suicides at HMP Greenock were connected to heroin or benzodiazepine abuse”. ¹³¹

A direct connection between BZ consumption and aggressive behaviour in prison inmates has been reported since the ’70s. High levels of riots, stabbing, cuttings, murders, self-mutilation and attempted suicide in inmates were attributed to BZ consumption in a Utah prison.¹³²

In 1995, clonazepam (a BZ) was restricted by the New South Wales prison service, as it was causing emotionally reactive aggression, self-harm and suicide attempts in inmates. ¹³³

Reduced BZ use – reduced aggression

“the conventional view that symptoms of violent disorders should be tackled by increasing medication has been stood on its head” ¹³⁴ In 1975, a Canadian prison reported less aggressive incidents on days when inmates were off diazepam medication.¹²²

“81% of inmates involved in aggressive incidents had taken diazepam (Valium) and 3.6 times as many acts of aggression occurred in inmates while on these drugs.”. ¹²²

A study at Parkhurst Special Unit also showed a direct correlation between the reduction of sedative consumption (mainly BZs) by inmates and the reduction of physical assaults from between 1990 and 1995. ¹³⁴

REFERENCES

1.	International Narcotics Control Board (INCB), Commentary
on global statistics, 2001.

2.	Infarmed Instituto Nacional de Farmacia e do
medicamentes, Boletim de Farmaco Vigilancia, Vol 5 - No 1-
1st Quarter, 2001.

3.	Report of the Benzodiazepine Committee, August 2002,
Department of Health and Children, Ireland, August 2002.

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