What Should We Do About Benzos?

As far back as 2011, Labour councillor Andrew Montague, then Lord Mayor of Dublin, became aware of growing antisocial behaviour in the city centre due to the illicit trade in prescription drugs such as benzodiazepines.

He had met with a lot of business representatives in the city, particularly in the Abbey Street area, where there was an ongoing problem with the sale of drugs. Contrary to what people might think, he says, what’s being sold there are prescription drugs, not illegal ones.

The hands of the Gardai were tied because possession of these drugs, even without a prescription, was not an offence. “It’s almost a green light for the sale of those drugs,” Montague says.

Montague spoke to the Garda Commissioner and the Minister for Justice. The issue gained political traction and, in May 2012, TD Roisin Shortall, then Minister of State for Primary Care, approved the move to amend the Misuse of Drugs Regulations 1988, which would introduce tighter controls on benzodiazepines.

The proposed changes included tighter restrictions on the import and export of such medicines and stricter prescribing regulations. It also made unauthorised possession (without prescription) an offence.

In July of that year, then Minister for Health James Reilly answered questions raised in the Dail on the issue by TD Dara Calleary. “My Department is consulting with key stakeholders in relation to the proposed amendments and it is anticipated that new legislation will be introduced by early 2013,” he said.

Two years on, the proposed amendments have yet to be enacted. Should they be? After all, the problems associated with benzodiazepine misuse and illicit trading are still with us.

A Huge Market

The trade in benzodiazepines has accelerated in the inner-city area, says Mel Mac Giobuin of the North Inner City Drugs Task Force (NICDTF). “It’s constantly brought to our attention, and very much acknowledged by An Garda Siochana.”

“It’s very hard to prosecute around it,” he says.

It’s an issue that the NICDTF is continually raising, “trying to get some answers and it’s not very satisfactory within the community because there’s so much harm and waste”, he says.

From the level of drug dealing going on, the NICDTF estimates that there are about 500 people in the Dublin’s north inner-city dependent on benzodiazepines and z-drugs, a group of non-benzodiazepines drugs with effects similar to benzodiazapines. “I’ve been told that’s an underestimate.”

It’s not just about the street dealing of course. It’s about the problems that face people who become addicted to these substances.

“They have quite an adverse neurological aspect to them. They’re very difficult to come off, need quite a high level of medical supervision when looking at detox or reduction programmes, little of which are available,” says Mac Giobuin.

Benzodiazepines are a family of drugs that includes alprazolam, diazepam and flurazepam. They are sedatives or “downers”, used to treat anxiety and stress, encourage sleep or relax muscles.

Over short periods, they’re an effective treatment. But after just two weeks of use, they can lose their effectiveness as sleeping pills. After four months of regular use, they no longer dampen anxiety.

And yet a person can become quickly addicted to benzodiazepines – both physically, so their body craves it, and psychologically, so that they find it hard to deal with life without the drugs.

Withdrawal symptoms, which can start from one day to a week after the last dose, can last for several months. Symptoms include confusion, serious convulsions (“benzo fits”), and the condition the medication is prescribed to treat: anxiety.

An Uptick in Addiction

In the last ten years, more and more people have started to seek treatment because they are dependent on benzodiazepines.

In 2005, there were 75 people in some form of drug treatment whose main drug problem was with benzodiazepines, according to a study by the National Drug Treatment Reporting System (NDTRS).

This number shot up almost 300 percent to 293 by 2010. And by 2013, it had more than doubled again to 719 people.

In Dublin, 18 people were seeking treatment in 2005 primarily for benzodiazepine addiction. In 2013, this figure increased twelvefold to 233.

The NDTRS report also found that when opiates were the main problem, benzodiazepine was the second-most-common additional drug being used (after cannabis).

There’s a reason for that.

During spells when opiates like heroin are thin on the ground, benzodiazepines can help alleviate some of the signs of withdrawal, like anxiety. This is why its use has become more popular with opiate and poly-drug users.

However, mixed with other drugs, benzodiazepines can be fatal.

A Fatal Mix

According to figures from the National Drug-Related Deaths Index, in 2004, benzodiazepines were implicated in 64 of the 267 overdoses – about a quarter. In 2012, they were implicated in 123 deaths, over one-third of all drug-related overdoses.

These figures correspond to what’s being seen on the street.

“There’s a huge market for benzos,” according to one garda officer stationed in the city centre.

“There’s a lot of tablets being sold now at the moment,” she says. “You can get them anywhere, but it’s normally around the clinics.”

Heroin addicts are among the most common users of benzodiazepines, she says. “Anyone who’s on gear, chances are they’re on tablets as well.”

Gardai Aren’t Powerless

But she also points out that gardai are not entirely hamstrung when dealing with illicit trading of benzodiazepines. While possession of benzodiazepines is not an offence, selling them is, and gardai do arrest and charge dealers for that.

Under the Medicinal Products (Prescription and Control of Supply) Regulations 2003-2008, a person in possession of a prescription medicine containing a substance controlled under the misuse-of-drugs legislation for the purpose of selling or otherwise supplying it is guilty under the legislation.

Under this legislation, gardai were able to seize 140,171 benzodiazepine tablets worth an estimated €280,000 last year, according to the An Garda Siochana Annual Report 2014.

Further restrictions on benzodiazepine were proposed in the draft of the Misuse of Drugs (Amendment) Regulations, 2013 which was circulated to various stakeholders including the Irish Medical Organisation (IMO) and the Irish College of General Practitioners (ICGP) for a second round of consultations.

As well as a requirement to obtain a licence to import and export benzodiazepines and z-drugs, the draft proposal introduced tighter restrictions on prescribing and dispensing such drugs, and made unauthorised possession an offence.

Doctors’ Concerns

However, while legislation to tackle the issue of dependency and illicit trading in benzodiazepines was welcomed, concerns about the draft were raised by those in the medical profession.

Professor Colin Bradley, head of the Department of General Practice at UCC, says that some of the proposed changes in regulation, “from a GP point of view, were going to create potentially a lot of hassle and not necessarily much change.”

Under the proposed changes, the writing requirements for prescriptions of benzodiazepines would become more like those for methadone.

“Prescriptions will be required to be written on a pro-forma or template prescription form issued by the Minister or on the Minister’s behalf,” the prosposed legislation said.

Says Bradley, who was not involved in the consultation process: “On the one hand, the ICGP recognised that there was a problem and there was a need to do something about benzos, but what was being proposed was perhaps putting more administrative burden on GPs and not necessarily tackling the problem at source.”

Another concern was raised in relation to the proposed amendments to the length of time for which prescriptions will be valid and the frequency of renewals.

In line with more tightly controlled drugs such as methadone, “benzodiazepines prescriptions will no longer ordinarily be of 6 months’ duration, but instead be valid for 14 days (unless there are installments in which case the prescription will be ordinarily valid for up to 2 months),” the draft read.

Says Bradley: “This failed to recognise the reality of how these are used clinically.”

“It was a requirement that became more arduous the longer the person was on the medication, and basically it was felt that that would be problematic for people who were on these medicines legitimately or for long periods of time,” he says.

New New Regulations

The new regulations have been shelved until the Misuse of Drugs (Amendment) Bill is enacted, which should be in early 2016, according to Sean Howlett, press officer from the Department of Health, via email.

The Misuse of Drugs (Amendment) 2015 Bill  was rushed through the Dail last March to “recontrol” substances which had been made legal briefly, following a High Court ruling which found the banning of various drugs including ecstasy and “head-shop” drugs by several governments had been unconstitutional.

The enactement of the Bill also reconfirmed existing ministerial regulations and orders made under the Misuse of Drugs Act 1977, including the Misuse of Drugs Regulations 1988.

Because of this, amendments are still required to the Misuse of Drugs Act before any new regulations can be made, said Howlett, the press officer

“Work is underway on drafting a second Misuse of Drugs (Amendment) Bill to amend sections of the 1977 Act. Once the Bill is enacted it is the intention to bring forward appropriate controls on benzodiazepines and z-drugs,” he said.

What that new legislation will look like is uncertain.

The Department of Health is “considering tighter measures, including the introduction of import and export controls and  tighter prescribing and dispensing rules,” Howlett said.

One thing seems to have been dropped, though, a ban on the unauthorised possession of these drugs.

Because benzodiazepines and z-drugs are legally available on prescription, have a legitimate medical use, and are found in medicine cabinets across the country, “a blanket ban on the possession of these drugs without a prescription could end up criminalising tens of thousands of otherwise innocent people,” Howlett said.

To Legislate or Not to Legislate

Dr Garrett McGovern, a GP and an expert on addiction, questions whether there’s a need to legislate benzodiazepines.

“Making legislation is great, but unfortunately it’s likely to be harmful for the many who are dependent,” he says.

Legislation that jeopardises their ability to obtain the medication legally is likely to prompt them to seek it on the street.

“Traditionally, there are no services for these people, and in GP land it’s very hit-and-miss. Some GPs will prescribe, but a lot of them will say, ‘Well, I’m under instructions I can’t give you these,’” McGovern says.

These people need treatment, McGovern says. At the very least they will need to be provided benzodiazepines in a structured programme with a view to either coming off them over time or getting their levels down.

“There’s this idea that if you don’t give someone a prescription, then you’re a great doctor, you’ve made them better,” he says. “But you haven’t made them better. They’re dependent.”

Another issue McGovern raises in relation to the debate about benzodiazepine use is that of prescription-happy doctors or “rogue doctors”.

“This is the doctor who never sees the patient, prescribes the diazepam on a private script for maybe a month or longer; the person comes in with their sixty quid, goes off with their medication and there’s no review,” he says.

McGovern doesn’t doubt there are some out there, but he doesn’t know who they are and believes they make up a very small number.

“Why are people paying over the odds for this medication on the street? Because the doctors aren’t giving it,” he says. “Drugs on the street is a reflection of restrictive practises, not liberated practices,” he says.

“If everyone gave the patients the prescriptions they needed, nobody would be selling it.”

There needs to be a very sensible approach to the situation of benzodiazepine dependence, McGovern says. Legislation should not be at the forefront of that.

“There are a lot of people dependent on benzos, we need to look at that. We need to have proper treatment facilities for these patients; we need to give them the option of trying to get off this medication. At the moment they don’t exist.”