Karen Berry talks about prescribing protocols for people who are dependent on benzodiazepines, and why benzodiazepines have been such a prominent feature in drug-related deaths in recent years. [22 minutes]

Dr Karen Berry is a Research Fellow at the University of Stirling, employed by the Salvation Army Centre for Addiction and Substance Research. She joined Rob Calder on Episode 20 of the Addictions Edited podcast to talk about developing an intervention for people who use benzodiazepines. 

At the start of the podcast, Rob recalls that benzodiazepines were “introduced as a safer version of barbiturates and tranquillisers, but then slowly were discovered to be not quite as safe as originally thought”. He asks Karen to describe what benzodiazepines are and what harms led to the shift away from benzodiazepine-prescribing. Karen talks about their function for treating symptoms of anxiety and sleep problems, as well as the risks of physical dependence, withdrawal if the medication is stopped, and ‘respiratory depression’, which can lead to a fatal overdose.

“Benzodiazepines are a group of drugs that were originally prescribed for anxiety and sleep issues. They are supposed to reduce anxiety. I think part of that is that they can be a depressant on respiration, so that’s kind of one of the issues when you’re looking at them in tandem with opiates. And also, they were found to be very prone to patients becoming dependent on them and quite large issues with withdrawing from benzodiazepines as well. So, while they were prescribed for quite a long period of time, they have kind of fallen out of favour in the last ten years or so when prescribing has become less and less. Particularly in England, there is a lot less prescribing. It’s avoided if possible.”

Karen and colleagues designed a package of treatment for people who are dependent on benzodiazepines, including prescribed medication and psychosocial support. A nurse with experience in the field of addiction delivers this intervention; the medication includes up to 30mg of diazepam per day, intended to be used instead of illicit benzodiazepines; and the psychosocial support includes help with problems such as trauma, anxiety and depression, and difficulty sleeping – things that may cause people to use benzodiazepines in the first place.

Karen talks about the dearth of research into prescribing-based interventions for people who are dependent on benzodiazepines, but equally, why it was important to the team to include a component of psychosocial support in the intervention.

“As well as it being a prescribing intervention it’s also a package of psychosocial care. We’re trying to get to the root of the issue rather than hoping that prescribing on its own will do the job.”

Rob and Karen talk more about the target population for this research. While the focus of the treatment is on benzodiazepine use, participants in the study also use opioids, and are in receipt of opioid substitution treatment (e.g. methadone). Rob has worked as both a researcher and a manager in a treatment service, so he knows the difficulty of balancing a robust study design, with designing a robust intervention that can accommodate the full needs of people who use drugs. So, with one foot in each camp, he tentatively asks Karen whether it would have been “simpler to look at people who use benzodiazepines alone”. Karen says ‘yes’, but explains that their reason for taking the more challenging path was the profile of drug-related deaths – people who use both benzodiazepines and opioids make up a large proportion of drug-related deaths (1 2).

“The reason for looking at this group, in particular, is the profile of drug-related deaths in the UK. It’s around the fact that opioids are obviously related to a large percentage of drug-related deaths, but in more recent years, and having had the statistics coming out in the past month or so, it shows that benzodiazepines have been highly implicated along with opiates. So, it doesn’t tend to be that people would just have opiates or just have benzos. It’s the combination of the two that seems to be showing itself as being the issue in drug-related deaths.”
Karen and Rob talk about the known risks of this combination of drugs, and then talk about the unknown risks that come with people taking ‘street’ benzodiazepines, which the Scottish Drug Deaths Taskforce described as “illicit, unregulated copies with terrifying variances in potency”. Karen says:

“Ultimately the issue with the street benzos is that people don’t really know. They talk about getting a strip of blues or yellows. But ultimately you don’t know what’s in them. You don’t know what’s there.”

You can listen to the full episode of Addictions Edited with Karen Berry and Rob Calder, which also delves into issues around cognition, gaining consent from participants, and how that consent can change throughout an intervention.