SCOTLAND is in the middle of a drug crisis. The number of drug-related deaths in the country . Today, it has the highest drug-related death rate in the European Union.
Though smaller in scale, the problem has been compared to the US opioid crisis. There, huge numbers of people became addicted to prescription opioid painkillers and graduated to illegal opioids. It seems a similar sort of pattern is unfolding in Scotland, but with a different sort of drug.
Opioid drugs like heroin and morphine are implicated in the largest number of Scotland’s drug-related deaths. But a less well known class of drugs called benzodiazepines is the second biggest cause. These tranquilisers, often used to treat anxiety disorders, are implicated in 67 per cent of such deaths.
Advertisement
And here’s the real trouble: we are beginning to learn how to tackle the opioid epidemic, but the same solutions probably won’t work with benzodiazepines.
When they were first prescribed in the 1960s, benzodiazepines (often called benzos) were seen as a safe alternative to barbiturates, a class of sedatives that had been responsible for several high-profile fatal overdoses, such as that of Marilyn Monroe.
One example is the drug diazepam, sometimes sold as Valium. It can bring on sleepiness, relax muscles and the mind, and can help treat anxiety disorders. “They were introduced as wonder drugs with no downsides,” says at Stanford University in California. “Doctors were giving them out like candy.”
But they did have a downside. It became apparent during the 1970s that people taking the drugs came to depend on them. Benzos were implicated in drowsiness-induced car accidents and falls. It was also easy to overdose. “In the 1970s, diazepam was one of the most common reasons for hospital admissions,” says Humphreys.
Then, in the 1990s, benzos started to become a drug of choice for people in Scotland who took heroin. They eased the withdrawal effects when people were coming off a high or struggling to maintain their supply, says Andrew McAuley at Glasgow Caledonian University. The drugs were available on prescription, but they were then being sold on to heroin users illegally.
As doctors in Scotland became aware of this onward sale they cut back on prescriptions. But this made things worse as many of those who had been taking prescribed benzos then turned to illegal alternatives that tend to be much stronger. One of the most commonly taken in Scotland is etizolam. Possession of this drug is illegal in the UK, though it is often made to look like diazepam.
Deaths resulting from overdoses of illegal benzos have shot up in Scotland in the past few years (see Graph). Etizolam was first implicated in a single such death in Scotland in 2012. In 2017, it was involved in 299 deaths. By 2018, the figure was 548.
Not only is etizolam stronger than benzos like diazepam, its effects wear off more quickly, so people tend to take it more frequently. The low cost of illegal benzos makes that easy to do. “They can be purchased for as little as 15p per tablet,” says McAuley. “When we talk to drug users about how they consume these drugs, they don’t talk about taking one or two, they talk about taking them in handfuls.”
At the end of 2018, a group of men were found to be . A ÂŁ20,000 pill-pressing machine (pictured below) enabled them to produce 250,000 tablets per hour.
Benzos are far less of a problem in the rest of the UK, but they are an issue in the US, where some people warn that they are becoming the country’s next prescription drug crisis. An estimated , both legally and illegally. Research has shown that the number of people in the US visiting outpatient doctors for health matters related to benzos .
There are stark parallels with the opioid crisis, says Humphreys. “In both cases, the drugs were produced perfectly legally, given out by physicians and then a large, addicted base looks for illegal sources,” he says. “It’s following a similar trajectory, but in terms of awareness, we’re at least five to 10 years behind.”
What can we do? Humphreys and his colleagues are calling for doctors in the US to reduce the number of benzo prescriptions and look for alternative treatments for sleep and anxiety disorders. Physical therapies and cognitive behavioural therapies are both possibilities.
Safe spaces
This may help, but it won’t solve the problem, especially for people who are already addicted.
One widespread response to the opioid crisis has been to make available a drug called naloxone, which reverses the effects of opioid overdoses. Scotland’s , launched in 2011, offers training and drug kits to people at risk of overdose – . The British Columbia Centre for Disease Control in Canada has supplied over 100,000 naloxone kits, and the organisation estimates that these prevented in 2016.
Unfortunately, there is no equivalent drug to combat benzos. A drug called flumazenil can prevent the fatal effects of an overdose in some cases, but it isn’t recommended if the person has taken other substances or has a tolerance to benzos.
A better alternative may be to provide safe spaces for people addicted to benzos to take them. That is the argument made for supervised consumption sites, which also offer access to healthcare and advice. The evidence suggests that this can work: supervised drug use centre Insite opened in Vancouver in 2003 and has had over 3.6 million clients. Not one of them has died from an overdose and .
Plans for the first safe drug use site in the US, in San Francisco, were thwarted in October last year, when a bill for the site was vetoed by California governor Jerry Brown. Shortly before the veto, Rod Rosenstein, the US deputy attorney general, wrote in that “one obvious problem with injection sites is that they are illegal”. US cities and counties, he wrote, “should expect the Department of Justice to meet the opening of any injection site with swift and aggressive action”.
Glasgow City Council has appealed to the UK government for permission to launch a similar “fix room” in the city. But so far the Home Office has rejected the request on the grounds that such sites enable people to break the law. “The UK government has been clear that there is no legal framework for the provision of drug consumption rooms and there are no plans to introduce them,” a spokesperson for the Home Office said in July.
Another option is to legalise drugs. The concern, however, is that even if this helped people avoid overdoses, it might lead to a surge in drug use more widely. But there is evidence that this might not be the case. Portugal decriminalised the purchase, possession and use of small amounts of any drug in 2001. At the time, there were concerns that doing so would lead to cities in Portugal becoming “drug havens”. But this hasn’t come to pass. Last year, Portugal had , according to the European Monitoring Centre for Drugs and Drug Addiction.
“Drug users don’t talk about taking one or two of these tablets – they take them in handfuls”
In Portugal, decriminalisation was married with investment in treatment for people who use illicit drugs, including offers to wean them off the substances. “They destigmatised drug use, and reframed it as a health issue rather than a criminal one,” says McAuley.
He and his colleagues are advocating for a similar approach across the UK. They hope that financial support and a campaign to destigmatise drug use could ensure that people at risk of drug overdose encounter the health system before the justice system.
