Benzodiazepines and Benzodiazepines and risk behaviourrisk behaviour

Graham MackintoshGraham Mackintosh

Critical Incidents Training Critical Incidents Training OfficerOfficer

Scottish Drugs ForumScottish Drugs Forum

Overdose: DefinitionOverdose: Definition

““Use of any drug(s) in such Use of any drug(s) in such quantities that acute adverse quantities that acute adverse physical or mental effects occur. It physical or mental effects occur. It can be deliberate or accidental; can be deliberate or accidental; lethal or non lethal”. lethal or non lethal”.

Drug-related deaths, Scotland 1996 - 2005 Source: GRO

336356

317

382

332

292291

249224

244

0

50

100

150

200

250

300

350

400

450

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Dea

ths

Deaths

DrugDrugPositive casesPositive cases

NumberNumber (%)(%)

BZDs (total) BZDs (total) 22 202202 (68.5)(68.5)

DiazepamDiazepam 171171 (58.0)(58.0)

TemazepamTemazepam 8585 (28.8)(28.8)

OxazepamOxazepam 4747 (15.9)(15.9)

Other BZDOther BZD 1010 (3.4)(3.4)

Heroin/morphineHeroin/morphine 178178 (60.3)(60.3)

AlcoholAlcohol 167167 (56.6)(56.6)

Codeine Codeine 33 134134 (45.4)(45.4)

MethadoneMethadone 8383 (28.1)(28.1)

DihydrocodeineDihydrocodeine 5151 (17.3)(17.3)

Cannabis Cannabis 44 3131 (10.5)(10.5)

Antidepressants Antidepressants 55 3131 (10.5)(10.5)

Drugs detected at post-mortem drug Drugs detected at post-mortem drug related deaths 2003related deaths 2003

DRD involving Benzodiazepines DRD involving Benzodiazepines 2002 -2005 Scotland2002 -2005 Scotland

0

50

100

150

200

250

2002 2003 2004 2005

benzodiazepines

Linking benzodiazepines and Linking benzodiazepines and overdoseoverdose

• Reducing drug related deaths, ACMD, 2000Reducing drug related deaths, ACMD, 2000

• National Investigation into Drug Related National Investigation into Drug Related Deaths in Scotland, 2003.Deaths in Scotland, 2003.

• Benzodiazepines and cocaine as risk factors Benzodiazepines and cocaine as risk factors in fatal opiod overdose,NTA 2007.in fatal opiod overdose,NTA 2007.

• Clinical Guidelines Drug Misuse and Clinical Guidelines Drug Misuse and Dependence, draft 2007Dependence, draft 2007

• Know the score campaign materials.Know the score campaign materials.

What are the links?What are the links?

Benzodiazepine Risk Factors

Physical effectsBehavioural effects

Characteristics Of users

Physical effectsPhysical effects

• CNS depressantCNS depressant

• Potential to increase respiratory Potential to increase respiratory depressant effects of heroin, other depressant effects of heroin, other opiates.opiates.

• Low doses > reduce anxiety Low doses > reduce anxiety Higher doses > sedative effects increase.Higher doses > sedative effects increase.

• Decrease level of consciousnessDecrease level of consciousness

Behavioural EffectsBehavioural Effects

• Perception of riskPerception of risk

• Recklessness/ risk taking behaviourRecklessness/ risk taking behaviour

• AmnesiaAmnesia

• Reduction of fearReduction of fear

• Invisible Invisible

• InvincibleInvincible

• Increased suggestibilityIncreased suggestibility

User characteristics?User characteristics?

• Higher levels of depressionHigher levels of depression

• Higher levels of anxietyHigher levels of anxiety

• Traumatic life eventsTraumatic life events

• Poorer social functioningPoorer social functioning

• Poorer coping strategiesPoorer coping strategies

Maybe seeking oblivionMaybe seeking oblivion

Para-suicidal behaviourPara-suicidal behaviour

National Investigation 2003National Investigation 2003

• Of 171 benzo positive at post mortem Of 171 benzo positive at post mortem only 31% were in receipt of only 31% were in receipt of prescription.prescription.

• This suggests illicit manufacture This suggests illicit manufacture and/or diversion of prescribed drugs.and/or diversion of prescribed drugs.

• Issue for policy makers, service Issue for policy makers, service providers, police.providers, police.

Diazepam or is it?Diazepam or is it?

Police seizuresPolice seizures

• Legal diazepam accounts for vast Legal diazepam accounts for vast majority of seizures.majority of seizures.

• Diversion from legitimate markets.Diversion from legitimate markets.

• Unlicensed versions illicitly made Unlicensed versions illicitly made or or legitimately made abroad but quality legitimately made abroad but quality does not meet UK standards.does not meet UK standards.

• Fakes- many originate from India, Fakes- many originate from India, Pakistan, Thailand. Pakistan, Thailand.

““Street valium”?Street valium”?

• Nitrazepam, alprazolamNitrazepam, alprazolam

• Strong antihistamines – Piriton, Strong antihistamines – Piriton, Promethazine. Sedative action, side effects Promethazine. Sedative action, side effects drowsiness, dizziness, confusion. drowsiness, dizziness, confusion.

• Methenamine – antiseptic/antibacterial can Methenamine – antiseptic/antibacterial can cause irritation of stomach or bladdercause irritation of stomach or bladder

• Warfarin – blood thinning medicationWarfarin – blood thinning medication

• Amitriptylene - seizures, heart Amitriptylene - seizures, heart rate,sedation rate,sedation

Unusual reactionsUnusual reactions

• Paradoxical reactionsParadoxical reactions

• Increased excitementIncreased excitement

• Increased anxietyIncreased anxiety

• HyperactivityHyperactivity

• Sexual disinhibitionSexual disinhibition

• HostilityHostility

• RageRage

Who is at risk?Who is at risk?

• Under 18Under 18• Over 65Over 65• Neurological disordersNeurological disorders• Antisocial personality disorderAntisocial personality disorder• Learning disabilitiesLearning disabilities• Impulse control problemsImpulse control problems• Mood – history of aggressionMood – history of aggression• EnvironmentEnvironment• High doses – high potencyHigh doses – high potency• AlcoholAlcohol

Why?Why?

• Anxiolytic / amnesic effects leads to loss of Anxiolytic / amnesic effects leads to loss of restraint of social behaviourrestraint of social behaviour

• Reduces ability to concentrate on external social Reduces ability to concentrate on external social cuescues

• Impaired ability to identify angry facial expression Impaired ability to identify angry facial expression > fail to modify behaviour> fail to modify behaviour

• Aggressive response to mild provocation more Aggressive response to mild provocation more likelylikely

• Dissociation between feelings and behaviour – felt Dissociation between feelings and behaviour – felt more tolerant and friendly but in fact more more tolerant and friendly but in fact more aggresive aggresive

Finally……………Finally……………

• Hepatitis CHepatitis C

• Injecting behavioursInjecting behaviours

• Stimulant usersStimulant users

• DependenceDependence

• WithdrawalWithdrawal

• SeizuresSeizures

• InternetInternet