ADVERSE EFFECTS CNSDrugs 1996 Feb; S (2): 137-146

1172-7047/96/0002-0137/505.00/0

Adis International Umited. All rights reserved.

Benzodiazepine Abuse
Nature and Extent of the Problem
J. Roy Robertson l and Wilfrid Treasure2
1 Edinburgh Drug Addiction Study, Edinburgh, Scotland
2 Muirhouse Medical Group, Edinburgh, Scotland

Contents
Summary .................. . 137
1. History of Benzodiazeplne Abuse . . . . . . 138
2. Characteristics of Benzodiazepine Abuse 138
2.1 Which Benzodiazepines Are Abused? 138
2.2 Who Abuses Benzodlazepines? . . . 139
2.3 Why Are Benzodlazeplnes Abused? 140
2.4 Adverse Effects . . . . . . . . . . . . 141
2.5 Dependence and Withdrawal . . . 141
3. Management of Benzodlazeplne Abuse 142
3.1 Therapeutic Withdrawal 144
4. Directions for Research 144
5. Conclusion . . . . . . . . . . 145

Summary Benzodiazepines have been available for more than 30 years. At the time of
their introduction, these drugs were heralded as a safe alternative to the widely
prescribed and addictive barbiturates, and were greeted warmly by the medical
profession and by patients. However, the addictive potential of benzodiazepines
has been increasingly recognised, placing growing pressure on prescribers and
patients to limit their use, especially in the long term.
These precautions seem to have been effective, in that prescribing has de-
creased and the eruption of problems arising from addiction among patients on
prescribed drugs appears to have passed its peak. On the other hand, benzo-
diazepines have been taken up by street drug abusers, not only at conventional
doses and by the oral route, but also in larger doses and intravenously.
Alarming new reports from several continents indicate a serious abuse prob-
lem, with major attendant risks in terms of mortality and morbidity in the future.
Our understanding of the effects of large doses of benzodiazepines administered
by the intravenous or oral route is extremely limited, and further clinical research
into the physical, psychological and sociological implications of benzodiazepine
abuse needs to be undertaken.
138
1. History of Benzodiazepine Abuse
Barbiturates, first produced in 1903, had be-
come massively prescribed by the mid-1960s, with
24.7 million prescriptions issued in the UK in 1968
aloneJIJ However, they came to be recognised as a
group of drugs carrying a major risk of misuse.
During the 1970s in North America and Europe,
barbiturates probably caused more serious health
problems and related social problems than dia-
morphine (heroin) or cocaine. During the 1970s,
agencies emerged to cope with the barbiturate cri-
sis in the UK,[21 and the Advisory Council Cam-
paign in this country began to limit prescribing by
doctors.
Benzodiazepines emerged during the 1960s, the
prototype chlordiazepoxide having been synthe-
sised in 1955 and marketed in the US in 1960. This
was followed by diazepam, which was introduced
in 1965. The benefits and many applications of this
new class of drugs were quickly recognised. In ad-
dition, they seemed safe - especially in comparison
with barbiturates - so that by 1975 diazepam had
become the largest selling drug in the world.
In 1973, a drug company inquiry, which became
known as the 'La Roche Affair', highlighted the
enormous use of benzodiazepines in the UK. At
this time, the cost to the UK National Health Ser-
vice of diazepam and chlordiazepoxide gave rise to
a Monopolies Commission report. This recom-
mended that Hoffman-La Roche (a producer of
benzodiazepines) repay a large sum to the National
Health Service because of excessive overcharging.
After an attempt to open legal proceedings against
the British government, Hoffman-La Roche even-
tually paid nearly 4 million to the National Health
Service. As a result ofthis settlement, several Euro-
pean countries started proceedings against this
company.[3 J
Concern about benzodiazepines gathered mo-
mentum in the 1970s and 1980s. The initial con-
cern centred on long term use among patients
prescribed the drugs for minor psychological mor-
bidity. It subsequently became apparent, however,
that these drugs were being used by recreational
drug users and people already misusing other drugs
Adis International Limited. All rights reserved.
Robertson & Treasure
in drug cocktails (by the intravenous as well as the
oral route) and in massive doses.
There were early warnings of the problems that
were emerging with the misuse of benzodiaze-
pines.[4-6J These included a leading article in the
Lancet in 1973,[7J and the 1982 report of the Advi-
sory Council on the Misuse of Drugs (ACMD)[81
on the treatment and rehabilitation of drug users,
which noted the role of benzodiazepines in multi-
drug abuse and expressed concern about inappro-
priate or excessive prescribing. It was not until
1985 that Schedule 3 of the Misuse of Drugs Act
(UK) 1971 controlled barbiturate prescribing. By
then, however, the dangers of benzodiazepines
were being increasingly recognised, and, in 1986,
Schedule 4 of the same act covered benzo-
diazepines.
By 1991, official sources in the UK[91 acknow-
ledged that, since their previous report in 1984,
patterns of drug use had changed, and now in-
volved 'ecstasy' (methylenedioxymethampheta-
mine; MDMA), 'crack' (pre-freebased form of co-
caine), buprenorphine and benzodiazepines.
Warnings and advice were to follow thick and
fast, with numerous reports and short papers pub-
lished over the subsequent 3 or 4 years on the com-
plications and associations of benzodiazepines. In
Scotland, the number of prescriptions for anxio-
lytics and hypnotics decreased from 3.5 million in
1982 to 2.4 million in 1992. However, in the same
10 year period, there was a rapid escalation of, par-
ticularly injected, benzodiazepine drug use. In
1994, it was reported that Glasgow drug users were
using large doses of benzodiazepines (e.g. diaze-
pam 40 to 50 mg/day and temazepam >60 mg/day),
and as many as 50% were injecting temazepam on
a daily basisJIOJ Similar findings have been re-
ported from other centres.[11.12J
2. Characteristics of
Benzodiazepine Abuse
2.1 Which Benzodiazepines Are Abused?
The abuse of drugs depends on availability, and,
consequently, those drugs most likely to be pre-
eNS Drugs 1996 Feb; 5 (2)
Benzodiazepine Abuse
scribed and in most frequent general use are those
most abused. For this reason alone, diazepam and
temazepam are the benzodiazepines most fre-
quently abused by young people.
Partly as a consequence of its abuse potential,
triazolam was withdrawn from the UK market in
1991, where it remains unavailable. However, tri-
azolam has not apparently created a problem in
other countries. It may be that prescribing trends
can give rise to popular abuse of such a medication,
as when a substance becomes widely available
abuse potential arises.
A similar experience is reported, although not
in a published form, from Dublin where the use of
flunitrazepam in prisons gave rise to experience of
this drug and a subsequent widespread problem
similar to that described elsewhere with temaze-
pam. Intravenous and excessive use of a mixture
of flunitrazepam with heroin or methadone led to
behavioural problems and disinhibition and dis-
engagement from reality. These problems led to
amendment of this drug under the Irish regulations
(Misuse of Drugs Act 1977 and 1984, and Misuse
of Drugs Regulations 1988 and 1993). This restric-
tion seems to have had the effect of reducing con-
siderably the use of flunitrazepam (personal com-
munication, M. Burke). Fiunitrazepam abuse has
also been reported in Chile)13]
2.2 Who Abuses Benzodiazepines?
For many reasons, the inappropriate use of
benzodiazepines is likely to be less visible than that
of drugs such as heroin or cocaine, or even canna-
bis and hallucinogens. The benzodiazepines are
available on prescription through legitimate phar-
macological sources and are, therefore, in the per-
ception of the public, and perhaps the medical pro-
fession, 'safe' drugs)141
Until the recent introduction of regional data-
bases in the UK, there has been no recording sys-
tem in any country for those abusing this group of
drugs. Furthermore, perhaps most obviously, the
extent of the use of these drugs by addicts and re-
creational drug users has emerged very rapidly
over a short period of time. Thus, perceptions
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139
about benzodiazepines may lag far behind the re-
ality. It is helpful to look at the different groups of
individuals using these drugs and identify simi-
larities and differences in the patterns of use, the
problems that arise and management strategies.
King l151 has identified 4 groups of long term
benzodiazepine users. The first group comprises
patients with epilepsy or spasticity who have been
started on these drugs and have continued, even
though the initial benefit may not have been sus-
tained. They do not seem to experience depend-
ence on the drugs or withdrawal symptoms on ces-
sation of therapy.
The second group comprises daytime users of
benzodiazepines, while the third and largest group
are night-time users. Patients in these groups are
usually prescribed the drugs for minor symptoms
of anxiety or insomnia, respectively. The number
of daytime users may have decreased since the
peak of benzodiazepine prescribing, and neither
group necessarily exhibits dose escalation or harm-
ful effects.
Whether or not the patients in the second and
third groups are thought to represent a major health
problem depends on the context in which they are
studied. For instance, a hospital-based study in
Sydney, Australia, suggested that benzodiazepine
use constituted a significant problem. Out of 640
randomly selected inpatients in 3 hospitals, 88
were described as 'hazardous or harmful users of
benzodiazepines' )16] In contrast, long term day-
time users of prescribed benzodiazepines in a com-
munity study in Lincoln, England, constituted only
0.5% of the practice population; the majority found
the treatment currently beneficial, one-half wanted
to continue their treatment and only one-third had
experienced withdrawal symptoms at any point. I 171
Indeed, studies of withdrawal have shown that it
can be accomplished wholly or partially in many
of these patients. I lSI
The fourth and last group are the multi drug
users. These individuals escalate their doses, use
novel modes of administration and combine benzo-
diazepines with each other and with other drugs.
They have multiple physical and psychosocial
eNS Drugs 1996 Feb; 5 (2)
140
problems, I151 and probably currently represent the
most significant problem.
Recreational use of benzodiazepines seems to
have had a recent onset and is patchy in distri-
bution. As late as 1994, young individuals in
Wolverhampton, England, who were knowledge-
able about the abuse of a wide range of drugs (Le.
they knew someone taking drugs or had been
offered drugs) did not include benzodiazepines
when asked to list drugs taken by abusers. 1181
In contrast, among a cohort of drug abusers in
Edinburgh, Scotland, benzodiazepine abuse, es-
pecially oral administration, has taken over from
heroin abuse as the most common form of drug
abuse.l l91 In a hospital study in Toronto, Canada, of
alcohol (ethanol)-dependent patients under treat-
ment, overt or covert benzodiazepine abuse was
commonPOI In a quite different setting, McDer-
mott,1 21 1 of the long-established Lifeline organis-
ation in Manchester, England, has recently graphi-
cally described the new place of 'downers' in
the era of dance drugs and rave scenes. Overall,
across Europe, the US and Australia, this form
of benzodiazepine abuse is now extremely com-
mon. 1221
This recent trend in drug abuse has several char-
acteristics. Among amphetamine abusers in Syd-
ney, Australia, benzodiazepine use was associated
with several features (see table I), although not
with promiscuity.l23] Another study of intravenous
drug users in New South Wales, Australia, found
that benzodiazepines were often used in combi-
nation with other drugs. In addition, their use was
associated with the administration of multiple
drugs and more needle sharing, hepatitis C sero-
positivity and frequent injection, and the individu-
als involved had higher rates of unemployment,
crime, imprisonment and psychopathology, and
poorer health, social functioning, fewer friends and
lower levels of education than abusers of other
drugs)22,241Benzodiazepine use is also a risk factor
for heroin overdoseP51
One of the most remarkable features of this new
form of drug abuse is the use of massive doses.l 261
The use of sedative drugs has always been charac-
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Robertson & Treasure
Table I. Characteristics of individuals abusing benzodiazepines as
determined by Darke et al. 1231
Older age
Less formal education
Criminality and imprisonment
Higher levels of psychological distress or prostitution
Current enrolment in a drug withdrawal programme
Multiple drug use
Injection of drugs and needle sharing
terised by the excessive doses taken by some users,
but recently observed recreational drug users often
have a variety of drugs at their disposal, some of
which are used to counteract the effects of others.
For example, benzodiazepines may be used to re-
duce or reverse the effects of stimulants such as
cocaine, amphetamine or ecstasy. These users are
therefore vulnerable to, and at considerable risk
from, the direct toxic effects of the drugs and a
wide range of associated medical, psychological
and social problems, including HIV infection.
2.3 Why Are Benzodiazepines Abused?
Benzodiazepines, in behaviourist terms, are
powerful primary reinforcers in that they produce
pleasant effects and remove aversive states, lead-
ing to secondary reinforcement. So people abuse
these drugs, enjoy the effects and want to adminis-
ter them again. According to cognitive theory, ex-
pectations play a significant part in drug taking.
People who expect to feel better and interpret the
sensation as a better feeling want to repeat the ex-
perience.l271 The longer-acting benzodiazepines
may resemble barbiturates in these euphoric ef-
fects.l 281 There may be a preference for drugs and
routes of administration that lead to a rapid onset
of action.f221
The incentives to drug abusers are clearly pow-
erful, being enough not only to offset what may be
perceived as the remote infective risks associated
with injection, but also the immediate discomfort
of, for instance, the wide-bore needles required to
inject the contents of temazepam gel-filled cap-
sules. 1291
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Benzodiazepine Abuse
In a study of opiate users in Malaysia,[ 30 I it was
found that they used benzodiazepines orally or in-
travenously to relieve sleep disturbance or to treat
depression or agitation. Other studies report how
benzodiazepines are rarely used alone, and indeed,
in the Malaysian study, they were often used in
combination with other drugs, for instance to en-
hance the 'high' of opiates pOI
Among the many unanswered questions about
illegal benzodiazepine use are those concerning
the nature of:
dependence upon, and withdrawal from, high-
dose use
the damage done by long term administration of
massive doses
the characteristics of dependence
the variability between individuals, especially
in terms of tolerance
the practice of interchanging and combining
drugs with different pharmacological proper-
ties.
The pharmacological and pathological effects
of contemporary benzodiazepine abuse are poorly
understood.
2.4 Adverse Effects
The adverse effects of benzodiazepines in con-
ventional doses have been well described. They
include tiredness, drowsiness, torpor, depression
of respiration and, less commonly, dizziness,
ataxia and vivid dreams. The prolonged half-life of
benzodiazepines and their active metabolites re-
sults in accumulation, especially in the elderly, and
this may result in unsteadiness and confusionPIl
Benzodiazepine overdose is common and can lead
to coma and respiratory depression, but it is rarely
fatal unless there is additional sedation caused by
other drugs.
In usual pharmacological doses, there is fre-
quently impairment of cognitive function, behav-
iour and skilled tasks such as driving, all of which
can lead to litigationP2) Long term use seems to
impair visuospatial functioning along with the
ability to sustain attention on a repetitive task un-
der time pressure. This appears to be related to im-
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141
paired posterior rather than anterior cortical func-
tion. The effect seems to be cumulative and it is not
clear whether it is reversible on stopping the
drug.l 271 Judgement and memory may be affected
and some people show a 'paradoxical' response
such as increased aggression and hostility, crimi-
nality, sexual impropriety or emotionallabilityPl)
These effects may relate to behaviour that in-
creases the risk of HIV infection that may charac-
terise some benzodiazepine abusers.
However, much of the work on the toxicity of
benzodiazepines has been conducted with oral us-
ers taking conventional doses. The effect of mas-
sive doses over long time periods has yet to be
assessed. Intravenous use has additional hazards,
including:
superficial infection and embolisation
inadvertent or indiscriminate intra-arterial in-
jection leading to ischaemia
(isolated reports of) rhabdomyolysis[33) and uri-
nary retention.[34]
The possibility of teratogenicity is a cause for
great concern, but this has not been demon-
stratedP5] Sharing injection equipment also car-
ries the risk of infection with blood-borne vi-
ruses,[36] which can subsequently be sexually and
vertically transmitted. [37]
2.5 Dependence and Withdrawal
It is clear that benzodiazepine use can lead to
dependence, but the minimum dose or duration of
treatment that is required before withdrawal effects
occur, and what percentage of people are vulnera-
ble, are not so clear. It may be that withdrawal
phenomena are more severe following high-dose
treatment, the use of short-acting benzodiazepines,
concurrent use of other sedatives or in certain per-
sonality typesPS] Generally, the psychological
characteristics of benzodiazepine-dependent indi-
viduals appear not to fit into anyone category.
However, some studies in recent years have sug-
gested that personality factors may be important
predictors of withdrawal phenomena and later re-
sponseP9]
eNS Drugs 1996 Feb; 5 (2)
142
Physiological dependence on benzodiazepines
is associated with a withdrawal syndrome that can
follow different patterns, the commonest taking the
form of short-lived rebound anxiety and insomnia
starting I to 4 days after the cessation of intake,
depending on the half-life of the drug. Finally,
there may be a full-blown withdrawal syndrome
lasting 10 to 14 days,[38[ with the symptoms shown
in table lIP II
The withdrawal syndrome is often hard to delin-
eate clearly for a variety of reasons. Not all people
experience symptoms, and in others, the preva-
lence, severity and duration of withdrawal depend
on a multiplicity of variables, including: [31]
the duration of use
the dose taken
the half-life of the drug
the personality of the individual
a reverse placebo effect
the expectations of the doctor and the patient.
Most of these features of dependence and with-
drawal have been described in patients under close
clinical control on comparatively small doses of
the benzodiazepine prescribed. It is generally ac-
knowledged that, where abuse is concerned, unre-
liable and inconsistent histories make the assess-
ment of individual patients difficult, and it is hard
to separate out the compounding physiological,
psychological and social variables. There are few
descriptions and evaluations of withdrawal in peo-
ple abusing large quantities of benzodiazepines,
Table II. Symptoms of the benzodiazepine withdrawal syndrome
Rebound insomnia
Anxiety
Tension
Trembling
Palpitations
Sweating
Postural hypotension
Seizures
Confusion
Paranoia
Hyperthermia
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and understanding of this phenomenon is rudimen-
tary.
3. Management of
Benzodiazepine Abuse
Benzodiazepine abuse represents a significant
health problem. A large number of socially, psycho-
logically and intellectually disadvantaged people
are caught up in a web of harmful, often criminal
and high HIV-risk behaviour, in which benzo-
diazepine abuse plays a part, causally or not.
Intervention may take various forms, depending
on whether prevention, cure or harm reduction is
the main purpose. Prevention may be partly the
responsibility of individual doctors (in the sense
that their prescribing habits may influence public
perception about, and availability of, benzo-
diazepines), but it is largely a matter for govern-
ments, public health agencies and the police.
Control of the supply of drugs is difficult. In
New York, US, 'triplicate prescription' has been
required for opioids, barbiturates and amphet-
amines since 1979, and for benzodiazepines since
1989. One copy is sent to the Department of Health
and the other 2 retained by the prescriber and phar-
macist. This regulation has been accompanied by
dramatic reductions in benzodiazepine prescribing
and emergency admission for benzodiazepine
overdose, without any apparent increase in the pre-
scribing of harmful alternative drugs.l40J
Another strategy that has been adopted has been
the banning of specific drugs. In 1989, the manu-
facturers replaced injectable liquid-filled temaze-
pam capsules with semi-solid, gel-filled capsules,
but the drug in these was still injected, resulting in
even greater toxicity. A survey in London, England,
of the use of injected benzodiazepines revealed that
various preparations of a wide range of benzo-
diazepines had been injected and that, for instance,
if temazepam capsules were removed, about one-
half of the drug users injecting benzodiazepines
would continue to inject benzodiazepines.l 411
Many consider that, rather than providing a solu-
tion to the problem, this sort of control might shift
eNS Drugs 1996 Feb; 5 (2)
Benzodiazepine Abuse
drug users onto another preparation with equally
toxic or even new adverse effects.
For established abusers of benzodiazepines,
whether or not they are dependent on these drugs,
the chance of cure and the rate of relapse are un-
known. By analogy with other aspects of lifestyle,
it may be unreasonable to anticipate total absti-
nence or to expect the relatively minor influence
of heaIthcare professionals to achieve a significant
or measurable change in behaviour. Moreover, as
with other problems of dependence, relapse is
likely to be frequent. The natural history of opiate
abuse is that of a relapsing and remitting disorder,
with a spontaneous 'cure' rate increasing over
time. However, no corresponding information is
available as far as benzodiazepines are concerned.
Benzodiazepine abuse has generally been seen as
analogous to opiate abuse, but this is open to ques-
tion, and it may be that management strategies
should be different.
Since the development of awareness of HIV
transmission among injecting drug users in the
1980s, the concept of harm reduction as damage
limitation has permeated the management of such
individuals. The rationale for this approach is that
nonmedical use of certain drugs' is inevitable and
inevitably harmful in a variety of ways, both to the
individual and to society. It follows that drug abus-
ers should be integrated into society rather than
isolated, and that measures to deal with the problem
should be multifaceted, pragmatic and research-
based rather than ideological.[42]
General healthcare is important. Healthcare
professionals should provide advice and infor-
mation about contraception, including condoms,[43]
alcohol and smoking, and warn patients about the
dangers of driving while under the influence of
drugs, the risk of overdose, and the hazards of in-
advertent, careless or ignorant administration to or
by children. Some patients may be unfit for work
and will need appropriate certification. Many will
qualify for benefits and will need information
about these. Addicts should be notified to the ap-
propriate authorities in accordance with local regu-
lations. Attention to the wider aspects of the pa-
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143
tient's situation may be important, and HIV testing,
counselling about blood-borne disease and the im-
plications of diagnosing HIV infection and hepa-
titis B immunisation may be needed.l 44 ] There is
also a role for needle exchange facilities and infor-
mation about how to clean injecting equipment.
Recent events, including the rapid escalation in
the numbers of young people abusing drugs ofvar-
ious classes, have given rise to an international de-
bate on the best setting in which to manage patients
with drug problems. In many countries, drug de-
pendency problems are the preserve of specialist
clinics alone, but a study in London revealed that
drug users had an overwhelming preference for de-
toxification or maintenance prescribing to be un-
dertaken in general practice rather than in hospital
clinics.l45 ] There are resource implications regard-
ing this, however.l461 Resources need to be made
available to general medical practitioners to cope
with the increased demand on their facilities, staff,
time and skills. There is evidence from North West
England that general practitioners and psychiatrists
are becoming less rather than more involved in the
management of drug abusers.l471 This needs to be
addressed if the problems of drug abuse and HIV
infection are to be tackled.
The problems within prisons are a particular
cause for concern. It is not certain that imprison-
ment is associated with greater drug injection or
blood-borne virus transmission, but it provides an
opportunity to capitalise on access to those at
risk.l48 ] A recent worldwide review revealed wide
differences in prison policy and this may represent
an important, overlooked opportunity to protect
vulnerable inmates, and ultimately society at large,
from serious health risks.[49]
In the discussion about the general care of
benzodiazepine abusers, prescribing either for
long term maintenance or tapered withdrawal (see
section 3.1) is an important issue. This is some-
times done and it is interesting to speculate why.
The obvious explanation is that the practice has
arisen by analogy with opiate maintenance pre-
scribing, in which the practice is argued to be ben-
eficial. However, there is no evidence of benefit
eNS Drugs 1996 Feb: 5 (2)
144
where benzodiazepines are concerned. Doctors
may prescribe in order to prevent withdrawal symp-
toms, to relieve minor psychiatric morbidity as
with non-drug users, or in the process of maintain-
ing (hopefully) therapeutic contact with the patient
to mimic the effects of street drugs within the limits
of good professional practice)50) This is an im-
portant debate since, in view of the association
between benzodiazepine use and high HIV-risk
behaviour, it may be that prescribing benzo-
diazepines to drug abusers is detrimental. Although
the situation is unclear, such prescribing should be
done with extreme caution. If a decision is made to
prescribe, it is important to consider carefully the
choice of drug, and perhaps to preferentially use
the less popular slow-onset drugs rather than the
easily injectable temazepamP2)
Among drug abusers, different benzodiazepines
seem to have different abuse liability, and abuse
preference is partly independent of drug availabil-
ity. Flunitrazepam and diazepam have particular
positive reinforcing properties[5l) and both have
high 'liking' scores)52) Some data suggest that lor-
azepam and alprazolam also have greater abuse po-
tential than other benzodiazepines, and oxazepam,
halazepam and chlordiazepoxide in particular have
low abuse liability)53)
If the decision to prescribe rests on the diagnosis
of dependence, it is important to first confirm or
refute this diagnosis. The patient may be seen on
more that one occasion over a period oftime. Urine
samples may be taken, preferably under super-
vision, to ensure that benzodiazepines are present
in the body. The patient may be observed 24 hours
after their last dose to establish that they exhibit
signs of withdrawal. And they may be observed
swallowing what they claim is their daily dose and
reviewed an hour or 2 later to assess the effect.
Doses can then be issued on a daily basis by the
pharmacist, with administration possibly being ob-
served by a healthcare professional.
3.1 Therapeutic Withdrawal
Withdrawal strategies can be classified accord-
ing to their mode of intervention (authoritative or
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Robertson & Treasure
negotiated) and their focus of intervention (indi-
vidual or collective). Using this model one can
identify 4 different strategies:
the professional can try to persuade the individ-
ual to give up on health grounds
the counsellor may help clients to arrive at the
best decision they can for themselves
the state can impose changes by rule of law
community-based self-help groups can provide
information and support.
While the latter two approaches are important,
the first two are the most common,[54) and the de-
cision to withdraw benzodiazepines or not should
rest with the user)55)
More intensive approaches may require that the
benzodiazepine dosage be tapered at an individu-
ally titrated rate, usually under the patient's con-
trol, over weeks or months. If the patient is taking
a short-acting benzodiazepine, it may be useful to
transfer the patient to diazepam, which is long-
acting and is available in a wide range of doses.
Adjuvant drug therapy is not of proven efficacy,
but psychological support is important, including
information about what to expect while withdraw-
ing, encouragement, and measures to reduce
anxiety and stress}3S.55) It is important for the pa-
tient to learn alternative coping strategies[27) (such
as individually tailored withdrawal schedule, cog-
nitive restructuring, relaxation techniques, prob-
lem solving techniques and patternlhabit disrup-
tion) and to understand that benzodiazepine
withdrawal is different from opiate withdrawal,
with additional features and probably a more pro-
longed course.
4. Directions for Research
There are many ripe areas for research into the
problems of benzodiazepine abuse across the areas
of pharmacology, epidemiology and clinical prac-
tice. Cross-fertilisation of ideas is valuable. For in-
stance, it may be useful to study withdrawal in
medical benzodiazepine users, such as those given
long term benzodiazepines for epilepsy, to better
unravel the many factors in nonmedical usersgov-
eming abuse, tolerance and dependence.[15)
eNS Drugs 1996 Feb; 5 (2)
Benzodiazepine Abuse
As far as nonmedical users are concerned it
would be helpful to know more about:[22!
the sources of street drugs
the way in which drug abusers present to health-
care workers
the effects of different drug combinations
the natural history of benzodiazepine depend-
ence and abuse
the nature of the apparent association between
benzodiazepine use and high HIV-risk behav-
iour.
Other unanswered questions are: What is the
typology of the benzodiazepine user?1 50 I Is benzo-
diazepine maintenance therapy efficacious?156! Is
it possible to distinguish between tolerance and
dependence, and is there a role for, perhaps, flu-
mazenil in the prevention or reversal of benzo-
diazepine tolerance?157! Does long term benzo-
diazepine use cause brain damage? These and
many other questions urgently await answers.
Some progress may be made as a result of new
developments on a local, national and international
basis to gather informationJ58.59! The paucity of
research, other than case finding and simple epide-
miology, reflects the novelty of this form of drug
abuse. The urgency of proper description and de-
tailed study of many aspects is palpable to those
clinicians observing epidemic benzodiazepine use
in young people.
5. Conclusion
There is no doubt that benzodiazepine abuse is
a problem. The dangers of prescribed use in con-
ventional oral doses are well recognised and it
seems unnecessary to institute any new strategies
to cope with this. The emerging problem of recre-
ational use by unconventional routes of adminis-
tration and in large doses is, on the other hand, a
major medical and social problem.
Nevertheless, the difference may sometimes be
perceived rather than real. Prescribed drugs may
reach recreational users by a variety of means,
which may not be apparent to prescribing doctors.
It is our clinical impression that the pool of black-
market drugs is fed not only by clearly criminal
Adis International Limited. All rights reserved.
145
sources and by the selling of drugs prescribed to
nonmedical drug users - issues enough for concern
- but also by seemingly law-abiding patients re-
ceiving anxiolytics and hypnotics for clinical indi-
cations. Furthermore, it can be argued that social
norms and perceptions influence the behaviour of
individuals at the margins, so that in a more insid-
ious, subliminal manner, the prevalence of drug
use, even in medical and legitimate contexts, par-
tially governs the level of nonmedical drug use and
abuse.
In complete distinction from the long recog-
nised problem of dependence on small quantities
of prescribed benzodiazepines, there is an inde-
pendent emerging phenomenon of widespread ille-
gal drug use of this class of substances. Perhaps
unrelated to, or at least only loosely associated
with, excessive prescribing is the problem of injec-
tion of, as well as oral abuse of, excessive quanti-
ties of various proprietary preparations. The toxic-
ity associated with the medium to long term use of
large doses of benzodiazepines is at present un-
quantified. Serious brain damage or other cata-
strophic consequences should not be ruled out. Im-
plications for mv transmission, hepatitis Band C
dissemination, death from overdose and long term
management problems are many, and little atten-
tion has so far been given to serious strategies for
dealing with any of these problems.
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