1. Benzodiazepines and risk behaviour Graham Mackintosh Critical Incidents Training Officer Scottish Drugs Forum

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

4. Drug Positive cases Number(%) BZDs (total) 2 202(68.5) Diazepam171(58.0) Temazepam85(28.8) Oxazepam47(15.9) Other BZD 10(3.4) Heroin/morphine178(60.3) Alcohol167(56.6) Codeine 3 134(45.4) Methadone83(28.1) Dihydrocodeine51(17.3) Cannabis 4 31(10.5) Antidepressants 5 31(10.5) Drugs detected at post-mortem drug related deaths 2003

5. DRD involving Benzodiazepines 2002 -2005 Scotland

6. Linking benzodiazepines and overdose Reducing drug related deaths, ACMD, 2000 Reducing drug related deaths, ACMD, 2000 National Investigation into Drug Related Deaths in Scotland, 2003. National Investigation into Drug Related Deaths in Scotland, 2003. Benzodiazepines and cocaine as risk factors in fatal opiod overdose,NTA 2007. Benzodiazepines and cocaine as risk factors in fatal opiod overdose,NTA 2007. Clinical Guidelines Drug Misuse and Dependence, draft 2007 Clinical Guidelines Drug Misuse and Dependence, draft 2007 Know the score campaign materials. Know the score campaign materials.

7. What are the links? Benzodiazepine Risk Factors Physical effectsBehavioural effects Characteristics Of users

8. Physical effects CNS depressant CNS depressant Potential to increase respiratory depressant effects of heroin, other opiates. Potential to increase respiratory depressant effects of heroin, other opiates. Low doses > reduce anxiety Higher doses > sedative effects increase. Low doses > reduce anxiety Higher doses > sedative effects increase. Decrease level of consciousness Decrease level of consciousness

9. Behavioural Effects Perception of risk Perception of risk Recklessness/ risk taking behaviour Recklessness/ risk taking behaviour Amnesia Amnesia Reduction of fear Reduction of fear Invisible Invisible Invincible Invincible Increased suggestibility Increased suggestibility

10. User characteristics? User characteristics? Higher levels of depression Higher levels of depression Higher levels of anxiety Higher levels of anxiety Traumatic life events Traumatic life events Poorer social functioning Poorer social functioning Poorer coping strategies Poorer coping strategies Maybe seeking oblivion Maybe seeking oblivion Para-suicidal behaviour Para-suicidal behaviour

11. National Investigation 2003 Of 171 benzo positive at post mortem only 31% were in receipt of prescription. Of 171 benzo positive at post mortem only 31% were in receipt of prescription. This suggests illicit manufacture and/or diversion of prescribed drugs. This suggests illicit manufacture and/or diversion of prescribed drugs. Issue for policy makers, service providers, police. Issue for policy makers, service providers, police.

12. Diazepam or is it?

13. Police seizures Legal diazepam accounts for vast majority of seizures. Legal diazepam accounts for vast majority of seizures. Diversion from legitimate markets. Diversion from legitimate markets. Unlicensed versions illicitly made or legitimately made abroad but quality does not meet UK standards. Unlicensed versions illicitly made or legitimately made abroad but quality does not meet UK standards. Fakes- many originate from India, Pakistan, Thailand. Fakes- many originate from India, Pakistan, Thailand.

14. “Street valium”? Nitrazepam, alprazolam Nitrazepam, alprazolam Strong antihistamines – Piriton, Promethazine. Sedative action, side effects drowsiness, dizziness, confusion. Strong antihistamines – Piriton, Promethazine. Sedative action, side effects drowsiness, dizziness, confusion. Methenamine – antiseptic/antibacterial can cause irritation of stomach or bladder Methenamine – antiseptic/antibacterial can cause irritation of stomach or bladder Warfarin – blood thinning medication Warfarin – blood thinning medication Amitriptylene - seizures, heart rate,sedation Amitriptylene - seizures, heart rate,sedation

15. Unusual reactions Paradoxical reactions Paradoxical reactions Increased excitement Increased excitement Increased anxiety Increased anxiety Hyperactivity Hyperactivity Sexual disinhibition Sexual disinhibition Hostility Hostility Rage Rage

16. Who is at risk? Under 18 Under 18 Over 65 Over 65 Neurological disorders Neurological disorders Antisocial personality disorder Antisocial personality disorder Learning disabilities Learning disabilities Impulse control problems Impulse control problems Mood – history of aggression Mood – history of aggression Environment Environment High doses – high potency High doses – high potency Alcohol Alcohol

17. Why? Anxiolytic / amnesic effects leads to loss of restraint of social behaviour Anxiolytic / amnesic effects leads to loss of restraint of social behaviour Reduces ability to concentrate on external social cues Reduces ability to concentrate on external social cues Impaired ability to identify angry facial expression > fail to modify behaviour Impaired ability to identify angry facial expression > fail to modify behaviour Aggressive response to mild provocation more likely Aggressive response to mild provocation more likely Dissociation between feelings and behaviour – felt more tolerant and friendly but in fact more aggresive Dissociation between feelings and behaviour – felt more tolerant and friendly but in fact more aggresive

18. Finally…………… Hepatitis C Hepatitis C Injecting behaviours Injecting behaviours Stimulant users Stimulant users Dependence Dependence Withdrawal Withdrawal Seizures Seizures Internet Internet