What are benzodiazepines?
Benzodiazepines are a widely prescribed group of medicines commonly used for treating anxiety seizures and insomnia. They are, however, sometimes used for other therapeutic purposes, including the treatment of alcohol withdrawal and drug-associated agitation. Correspondingly, benzodiazepines may be prescribed to those being treated for drug problems for therapeutic purposes, such as treating anxiety. There are concerns about the health consequences of using benzodiazepines for long periods, particularly in respect to their possible addictive potential. Therefore, for most conditions, benzodiazepines are only prescribed for short periods.

The use of benzodiazepines that is not in accordance with prescribing guidelines or procured illicitly has raised concern. Studies have shown that people who use opioids may use benzodiazepines to self-medicate, for example to treat anxiety or insomnia, or to alleviate opioid withdrawal symptoms or adverse effects following the use of alcohol or cocaine. Some research has also suggested that patients being prescribed sub-optimal doses in opioid agonist treatment may self-medicate with benzodiazepines to reduce withdrawal symptoms.

Benzodiazepines may also be used for their psychoactive properties, often in the context of polydrug use. Benzodiazepines have, for example, been reported to be used to prolong the intensity and duration of the effect of opioids, especially when injected. Benzodiazepines may also be used, especially by young people, together with alcohol. A concern also exists that the combined use of benzodiazepines and other substances may increase the risk of adverse consequences, including fatal and non-fatal overdose, or engaging in self-harm or other risky behaviours.

In recent years, however, the non-medical use of benzodiazepines has been identified as a concern with regard to sizeable groups in the general population, for example women and the elderly, as well as, increasingly, young people. However, the epidemiological data on patterns and trends in the use of benzodiazepines remain weak in comparison to many other substances.

Benzodiazepines appear to be easily available and relatively cheap compared with some other drug classes. They may be obtained from the diversion of prescriptions (through ‘doctor shopping’ for example), on the illicit market or increasingly from the internet, sometimes from companies based outside the European Union.

What problems are associated with their non-medical use?
The non-medical co-use of benzodiazepines and opioids increases the risk of overdose and is associated with a greater danger of HIV risk behaviour, psychopathology (anxiety and depression), poorer treatment outcomes and impaired social functioning. When combined with other substances, particularly alcohol, the use of benzodiazepines may lead to increased risks of accidents, self-harm and, possibly in some individuals, aggressive behaviours. However, the research data in this area is not consistent and further research is required in this area.

Benzodiazepines are commonly identified in post-mortem examinations in cases of drug-related deaths, many of which are linked to opioid use. For example, current EMCDDA data show that benzodiazepines were implicated (that is, they were thought to have played a role in the person’s death), often in combination with opioids, in almost half of the drug-related fatalities in France and around one third in Portugal and Ireland.

What is the evidence on existing responses?
Robust data are needed on effective responses to the non-medical use of benzodiazepines. Evidence reviews suggest that cognitive behavioural therapy with tapered doses is likely to be effective in the short term, but is of unknown effectiveness in the long term. While pharmacological interventions for benzodiazepine discontinuation have been used, the evidence available is insufficient to allow comment on the on effectiveness of this approach.

Prescribing and clinical practice guidelines can have a critical role to play in mitigating the risks faced by those being treated for drug problems who may be prescribed benzodiazepines as part of their treatment or continuing to use benzodiazepines obtained illicitly during their treatment. However, few evidence-based guidelines appear to be available that specifically address the management of benzodiazepine use among opioid users or those being treated for other drug problems, and there is therefore a need for developmental work in this area. For those using benzodiazepine that have not been prescribed to them for therapeutic purposes, important considerations are likely to include highlighting the risks of consumption, exploring harm reduction approaches, discussing safe withdrawal approaches and understanding the reasons that are driving consumption. Regardless of their source, raising awareness that possible interactions between benzodiazepines and other drugs may lead to an increased risk of experiencing overdose or other adverse consequences is likely to be important.  

Good clinical practice, monitoring systems and guidelines can also play an important role in reducing the risk of prescriptions being diverted, or benzodiazepines being diverted from the pharmaceutical supply chain, while ensuring that benzodiazepines remain available to those who need them.

Implications for the future
Concerns exist about the non-medical use of benzodiazepines, with increased consumption reported in a range of populations, including high-risk drug users, people in prison, those who use drugs recreationally and young people. However, our capacity to monitor patterns and trends in the use of this class of drugs and identify possible adverse implications remains limited. Challenges are intensified as some of the adverse consequences associated with the consumption of these drugs are likely to be tied to their co-consumption with other psychoactive substances, particularly opioids or alcohol. Recently, anecdotal evidence suggests that benzodiazepine use is becoming more popular among some youth sub-cultures, suggesting a need for further research and monitoring in this area.  

The widespread availability of benzodiazepines and their relatively low cost increases the potential for the non-medical use of these drugs to pose a serious public health problem, particularly where they are taken by people who use opioids as part of polydrug use repertoires. This situation is complicated in some countries by the emergence of new benzodiazepines on the illicit market, alongside fake versions of authorised medicines, which may increasingly contribute to deaths among people who use opioids.

Prescribing and clinical practice guidelines need to be part of a comprehensive response to polydrug use among those receiving drug treatment. This is a challenge that European treatment systems must address, given that the treatment population is ageing and has an increased risk of serious health complications from their ongoing substance use. Reviewing and strengthening guidelines and regulatory mechanisms that restrict the diversion of benzodiazepines from therapeutic supply chains are also needed. A policy challenge remains, however, on how to respond to the availability of this class of drugs from online sources often based outside the European Union.