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AKA: Benzos,
tranx, sleepers, downers. Specific drugs are referred to by their chemical
name, brand name, and some have got slang names.
Name | Brand | Slang |
ALPRAZOLAM | Xanax | Xs |
CHLORDIAZEPOXIDE | Librium | |
DIAZEPAM | Valium | Vallies, Blues |
FLUNITRAZEPAM | Rohypnol | Rohies, Rufies |
NITRAZEPAM | Mogadon | Moggies |
TEMAZEPAM | Normison | Temazies, Jellies, Eggs |
SOURCE: Benzodiazepines are widely prescribed as
sedatives, to combat anxiety, as skeletal muscle relaxants, anti-epileptics and
anti-convulsants. However, some benzodiazepines leak onto the street, and are
quite widely misused.
In
addition to leaked pharmaceuticals, benzos have been illicitly imported in to
the UK. Some have been entering from Eastern Europe and sold on the illicit
markets. Others have been ordered on line from one of the many Internet
Pharmacies. Some of these tablets are fake, or of variable quality.
From 2009,
abandoned experimental benzodiazepines and novel ones appeared on the UK drugs
market including etizolam, pyrazolam and flubromazepam. Whilst legal, they were
sold on-line and via ‘head-shops.” These novel benzos were almost all brought
under the MoDA in May 2017. Any not covered or emerging since then are
automatically covered by the Psychoactive Substances Act 2016.
GPs
are regularly reminded not to over-prescribe benzodiazepines and those on long
term prescriptions are meant to have these reviewed regularly. Despite this,
and prohibition of newer benzos, drugs in this family remain a key feature of
the UK drugs market.
APPEARANCE:
The appearance of each drug varies
widely. Most are distributed as tablets or capsules. A small number of
unregulated compounds are sold as powders. A few also come in preparations for
injection, such as Valium ampoules, which command a higher street value.
Different brands of drug will vary from
company to company. Tablets will vary in colour, shape and markings.
The mainstay of the street benzodiazepine market has, for a number of years,
been diazepam. The most widespread
and popular strength, a 10mg tablet, is often a scored blue tablet. As a
result, people manufacturing tablets to sell as diazepam invariably produce a blue tablet. These
can vary massively in consistency and strength. Some are merely white powders,
dyed blue and compressed in to tablets.
Alprazolam (Xanax) has become
increasingly popular in the UK. As it is not widely prescribed on the NHS,
Alprazolam sold in the UK may be from private prescriptions, overseas
pharmacies of grey-market tablets batched from raw alprazolam powder. These can
vary greatly in strength. Alprazolam is typically sold as white, scored bars
with XANAX printed on them.
COST: At a street level, benzodiazepines have
a very low value, typically around 50p per tablet. Ampoules can cost a pound or
two. Depending on dose and quantity stronger pills like Xanax can sell for
between £2-5 depending on claimed dose.
QUALITY: If pills are genuine pharmacy product, quality
is assured. However, it is difficult to correctly identify all of the drugs in
this family by eye, let alone assay the strength, so mistakes in strength and
name are frequent amongst those purchasing non-medical products.
With so many imported, fake, unlicensed
and novel products entering the market, the risks with non-pharmacy products
will increase. Products could contain something stronger, weaker or different.
METHODS OF USE: Tablets are designed for oral use, though some users
crush and inject tablets. As diazepam has very poor solubility in water
this is damaging and not very effective. There are some reports of snorting,
especially of novel benzodiazepines.
MECHANISM of ACTION: Benzodiazepines interact with the GABA
system in the brain. The regulatory neurotransmitter gamma-amino butyric acid
(GABA) plays a role in moderating electrical activity in the brain. As GABA
levels increase, so electrical activity in relevant neurons goes down.
Some drugs, like GHB and Barbiturates, are GABA agonists (mimics). Benzodiazepines
are not thought to be full GABA mimics. Instead, benzodiazepines bind to Benzodiazepine
Receptors (BZ receptors) and appear to increase the regulatory effect of GABA.
They need GABA, or a GABA-mimic present to work.
Specific benzodiazepines are believed to be more active at different BZ
receptors. This may result in different benzos having greater or lesser
sleep-inducing, muscle relaxing or anxiolytic effects.
Non-medical use follows similar patterns, self-medicating for a range of
conditions including anxiety and insomnia. They are also popular as "come-down"
drugs following use of stimulants. The sense of intoxication when used with
opiates or alcohol is greater, so these combinations are widely used. This
brings a bigger risk of overdose.
STRENGTH: Benzodiazepines vary significantly in strength. They are generally
compared in potency using diazepam (Valium) as a benchmark. So potencies
are expressed in relation to 10mg of diazepam. 5mg of Alprazolam (for example)
is equivalent to 10mg of diazepam. So Alprazolam is around twenty times
the strength of diazepam.
DOSE RANGES: There are a wide range of benzodiazepines available
and the lower dose ranges vary according to the potency of the drug, and
its duration of effect. Medical guidance specifies upper dose ranges for
medical use. In street settings upper dose range will vary massively according
to tolerance. Some people will build up dose tolerance far in excess of
the therapeutic dose range.
INDICATORS of USE: Aside from physical evidence such as packaging,
there are few markers for benzo use. Illicit fake diazepam can cause blue
staining to lips and tongue. Otherwise indicators are simply drowsiness,
relaxation and possibly appearing drunk, but without the smell of alcohol.
Whilst older benzos will show up on urine tests, some of the newer products
such as Etizolam are sufficiently structurally different so won't show up
on urine tests.
ONSET and DURATION: As with strength and dose, benzodiazepines vary
significantly in terms of how fast they start working, and how long their
effects last.
Slow-onset benzodiazepines increase the risk that a person will re-dose
before drugs have started working properly.
Some benzodiazepines produce active metabolites, with very long half-lives.
Some can last 100-200 hours or longer. These long-acting drugs increase
the risk of building up tolerance, and that any later drug use will be taking
place on top of residual benzodiazepines. For example, diazepam used on
Sunday will probably still be in the system on Tuesday or Wednesday. This
means that alcohol use on these days is effectively taking place on top
of benzodiazepines.
EFFECTS: Benzos can cause physical relaxation, reduce stress and
anxiety. Users may become drowsy or fall asleep. They can have a big impact
on memory, causing amnesia. They can also cause slurred speech, clumsiness
and confusion. People report euphoria and some people find benzos disinhibiting,
in the same way that alcohol is. Some users gain a feeling of invulnerability
or invisibility when using benzodiazepines. They may find this useful when,
for example, shoplifting. Some users experience depression and, paradoxically,
a few users become over-excited or violent.
HEALTH IMPLICATIONS: Dependence: When used within a supervised medical regime, benzodiazepines
should not be used for extensive periods as tolerance develops rapidly and
withdrawal can be an unpleasant and, in some cases, dangerous process. After
a few weeks, and certainly within a few months, they cease to be therapeutic,
and use is now primarily to stave off withdrawal symptoms.
For physically dependent users, abrupt withdrawal can cause insomnia, anxiety,
tremors and, in severe cases convulsions.
Withdrawal from Benzodiazepines should always be tapered rather than done
suddenly.
Where there is evidence of high doses, long-term use, or where the person
has a history of illness such as epilepsy, withdrawal should be done under
medical supervision. IT IS POSSIBLE TO DIE DUE TO SEVERE BENZODIAZEPINE
WITHDRAWAL. However this is unusual and most people are able to withdraw
rapidly, through a tapering reduction programme.
Overdose: There is a low risk of fatal overdose when benzodiazepines
are used on their own. They have a very high therapeutic index, and while
there's a risk of unconsciousness or possible coma, the risk of death is
low. This risk is raised through ignorance as to the strength of various
tablets.
However, in combination with other drugs, especially alcohol and opiates,
the risk of fatal overdose is far higher. A large number of dependent drinkers
and people on opiate substitution therapy are also prescribed diazepam,
increasing risk of dangerous polydrug use.
Other risks: When tablets are crushed for injection, this brings
with it a range of associated health risks. Of specific concern were Temazepam
Capsules. These capsules were originally introduced as a response to growing
concern over Temazepam tablets being crushed for injection. The capsules
contained a viscous jelly that was intended to discourage injecting. However,
users found that heating the jelly made it become liquid, and so injected
it. However, at lower temperature, such as at body temperature, the gel
solidifies, and a large number of gruesome injecting injuries were reported.
Gel capsules have not been legitimately available in the UK for over ten
years.
LEGAL STATUS: : Most Benzodiazepines are class C
drugs. The majority are Schedule 4i drugs, meaning that they can only be
supplied, produced and possessed by those authorised to do so. The law on
Schedule 4 drugs changed in 2002; prior to that it was not an offence to
possess benzodiazepines without prescription.
Temazepam and Flunitrazepam (Rohypnol)
were rescheduled, and are Schedule 3 drugs.
Formerly unregulated benzodiazepines (such
as etizolam) were brought under the MoDA in May 2017. The benzos were added as a
list rather than via an “analogue” clause which means that there is scope for developing
new benzos that will not be covered by the MoDA. Any such emergent benzos will automatically
be covered by the Psychoactive Substances Act 2016.
OTHER INFORMATION:
Benzodiazepines were introduced and have largely supplanted the BARBITURATE
group of drugs, which were widely prescribed and widely misused in the seventies.
They were seen as preferential to barbiturates as the risks of overdose,
dependence and side-effects were thought to be less. They are very widely
prescribed; some critics argue that they are over-prescribed, and do not
tackle the causes, merely masking symptoms temporarily.
They are used recreationally in a number of settings. Some people combine
benzodiazepines with alcohol to enhance and increase intoxication. Some
stimulant users take benzodiazepines to alleviate the "come-down"
from speed, Ecstasy or cocaine, and to promote sleep.
It is not uncommon for dependent heroin users to use benzodiazepines when
heroin is unavailable, or to use them to help offset some of the symptoms
of withdrawal. The use of benzos on top of prescribed opiates - such as
with methadone or Subutex - is also common as it can make the effects of
the opiates feel stronger. Such use increases risk of overdose.
Many people self-medicate with benzodiazepines to alleviate mental discomfort
caused by mental health problems, painful memories, or to escape unpleasant
circumstances. For such users, where unsupervised use may be long-term and
extensive, careful assessment of needs, of underlying reason for the drug
use, and comprehensive care plans are likely to be needed to achieve reduction
and cessation of drug use.
Prescribers are very aware of benzodiazepine over prescribing, and in many
areas greater care is now taken to reduce and monitor prescribing. However,
a number of other drugs have been less closely monitored and have increased
in popularity.
Initially, the "Z-Drugs" (Zopiclone, Zimovane, Zaleplon) increased
and of course started to be misused. The law in relation to some of these
has now been tightened and they are now Controlled Drugs.
More recently, Gabapentin and Pregabalin have emerged as the latest of the
sedating drugs to shift from medical to non-medical settings. Although not
benzodiazepines, they work in the same parts of the brain, with similar
risks in terms of tolerance, dependency and overdose.
Whilst the use of prescribed diazepam is undoubtedly lower, levels of benzo-type
drugs (including illicit market, novel psychoactives, and similar prescribed
drugs) means overall use is probably increasing. Workers have reported people
entering treatment with staggeringly high levels of benzodiazepine dependency,
built up exclusively using street benzos.
Alongside opiates, alcohol and strong stimulants, benzos remain a core feature
of the UK drug scene.
[updated 11.17]
Drug Facts:
Other Information: