Understanding the lethal interactions between benzodiazepines and opioids to develop new harm reduction strategies

A multidisciplinary project to understand why taking benzodiazepines or z-drugs and opioids together leads to so many deaths, brought together qualitative researchers with other specialists. Two papers from the study have now been published in the Harm Reduction Journal and a third paper on beliefs around risk reduction is underway. Here the qualitative team discuss their findings.

The number of people dying because of drugs is rising in the UK, especially in Scotland. Many of these deaths involve a combination of opioids (heroin or methadone) and benzodiazepines or z-drugs (sedatives often used to treat anxiety and insomnia), which are either prescribed or obtained illegally.

We set out to understand how benzodiazepines or z-drugs and opioids work together and why this makes a fatal overdose more likely. We aimed to achieve this first by talking to people about their use of benzodiazepines or z-drugs and opioids in Scotland, Bristol, Teesside – the latter being an area of high z-drug use.

We asked the people we spoke to:

• How and why they use the two types of drugs together (alongside any other substances they may take)
• What effects the two types of drugs have on them
• What role both types of drugs have played in their overdose experiences

What did we do?

Even before we started the project, we asked people who use benzodiazepines and opioids for their input on our study idea and the way we planned to carry out the research. We then interviewed 48 people who use opioids (heroin, methadone and buprenorphine) and benzodiazepines or z-drugs in the three locations. Eighteen of the interviews were co-led by trained ‘peer researchers’ with lived experience, alongside an academic researcher. After the interviews were completed, we discussed our findings with our peer researchers to gain more insight from people with lived experience of drug use.

Who did we talk to?

We talked to 37 men and 11 women ranging in age from 25 to 61. Most described themselves as white Scottish, British or English. Most reported to have mental health difficulties, and either had a diagnosis or were receiving medications, for example for anxiety, depression, post-traumatic stress disorder, and psychosis. Most people were also physically unwell, and reported to have chronic breathing problems or recurrent and chronic physical pains from accidents or assaults.

What did we find?

The interviews gave a comprehensive and multi-layered account of how and why people use benzodiazepines or z-drugs with opioids. They also gave us insights into what people do in response to the risks of using these drugs together.

How people use benzodiazepines or z-drugs and opioids

From the people we spoke to we learnt that co-using benzodiazepines or z-drugs and opioids can happen quite separately or simultaneously. It can be accidental or intentional.

Our first analysis suggested six different patterns of benzodiazepines or z-drugs and opioid use. Across all the patterns people described using benzodiazepines to manage neurological and mental health conditions.

To sleep or come down

Co-use in this pattern focussed around use of benzodiazepines or z-drugs in the late afternoon or evening as a tool to come-down from stimulants (ketamine, crack or powder cocaine) or calm racing thoughts (in our study these were a symptom of anxiety, ADHD, Tourette’s) and sleep. Opioids (both opioid drug treatment and heroin) were taken earlier in the day.

Curated co-use

In the context of stable and maintained opioid treatment, some people described adapting what types, and how many benzodiazepines they took and at what time each day, to allow them to change how they feel or achieve a specific task. For example, taking a small amount first thing in the morning to give them the confidence to deal with a difficult meeting or taking a higher dose on another day to “get out of it” at a social event.

Morning and evening benzodiazepines or z-drugs with variable opioid use

People took the same small dose of benzodiazepine every day in the morning and evening. Taking benzodiazepines or z-drugs in the morning helped ease anxiety and feel calmer. Taking benzodiazepines in the evening helped people sleep. The use of opioids in this pattern was not consistent.

Binges

People described using large amounts of benzodiazepines or z-drugs and opioids over a short period of time which often led to blackouts. This pattern of use was experienced as difficult to control and led to more unintentional drug use.

Binges happened at times when people could get access to benzodiazepines (for example, their dealer or friend had some) or when people had the money (such as on payday). Binges also happened at times when people were reminded of sad or difficult times (for example, the anniversary of the death of a friend or relative).

Co-use throughout the day

One of the more common patterns was co-use throughout the day, where people would take benzodiazepines or z-drugs and opioids (prescribed and illicit) repeatedly throughout the day along with a range of other drugs and alcohol.

Benzos or z-drugs throughout the day plus drug treatment

In the context of stable and maintained opioid treatment, people reported taking large amounts of benzodiazepines repeatedly throughout the day with other illicit drugs such as cannabis. Here, people spoke about having routines which stopped them having long binges and avoided the harms of high benzodiazepine use, such as memory blackouts. For example, taking their opioid treatment at the pharmacy, buying other drugs and going straight home before taking them.

Interestingly, most people we interviewed saw the effects and risks of using benzodiazepines or z-drugs and opioids as separate and co-use may not be intentional. Overdoses were mostly reported by those using benzodiazepines or z-drugs throughout the day and binging. These findings have implications for prevention and health promotion work.

Why people use benzodiazepines or z-drugs and opioids

There were two types of connected motivations: functional and experiential.

Functional motivations included wanting to prevent withdrawal, address poor mental health, control emotions and manage pain.

Experiential influences described people’s desires to achieve the ‘glow’ (feeling comforted), the ‘buzz’ (feeling invincible and energised), ‘oblivion’ (forgetting or escaping previous or current trauma and adversity), and feeling ‘gouchy’ (physical and mental sensations of ebbing in and out of glow and oblivion).

In pursuit of these experiences, those typically seeking the glow or buzz described awareness of the risk of overdosing and a wish to avoid or minimise this risk. People aiming to achieve oblivion or to gouch out tended not to prioritise the risk of overdose.

Beliefs around risk reduction

Importantly, people spoke about using benzodiazepines or z-drugs and opioids together as being like playing consumption roulette. This was due to:

• An unregulated drug market
• Unpredictable, fluctuating potency, availability and contents of illegal drugs
• A lack of information about how benzodiazepines or z-drugs and opioids work together

Awareness of the risks of using opioids and benzodiazepines or z-drugs ranged from ‘I can help myself’ to ‘there is nothing I can do’. The absence of tailored support for people using benzodiazepines or z-drugs and opioids reinforced beliefs of helplessness and hopelessness.

In response to the gaps in treatment provision for this marginalised and vulnerable population specifically relating to co-use, some tried to reduce the harms of their co-use. With limited information to draw upon, current strategies used available social and informational cues such as:

• Sticking to known ‘dealers’ or only buying diverted prescription benzodiazepines
• Stockpiling ‘safer’ illegal substances
• Habitual combinations of opioid and benzodiazepines or z-drugs
• Avoiding alcohol
• Engaging with drug treatment programmes such as methadone
• Regulating dosages
• Inspecting the physical appearance of tablets
• Attempts at self-detox

Another strategy people described was only taking drugs at home and when on their own so that they could avoid getting into trouble, such as fights or falling unconscious on the street.

Inadvertently, some strategies increased overall risk. For example, stockpiling behaviour increased the likelihood of ‘megadosing’.

Read the full paper for more.

Next steps

We have gained valuable information on how and why people use benzodiazepines or z-drugs and opioids.

We want to use these findings to develop tailored ways to better support people (for example, health promotion messages) and decrease the risks of using these substances. We’re now speaking to professionals who work with people who use benzodiazepines or z-drugs and opioids to develop new, appropriate ways to reduce the harm of co-use.

Our findings are informing parallel lab-based experiments aimed at understanding the neuronal mechanisms of why benzodiazepine and opioid use has such a high risk of overdose. Together, we want to provide evidence-based solutions to minimise harm and reduce these preventable overdose deaths.