We have a saying here , ‘ Don ‘ t poke the bear ’ – aside from its obvious meaning as a wilderness warning it also means avoiding a discussion of something that is controversial and likely to end in arguments . I heard this expression for the first time last year on a Zoom call with the BC Provincial Opioid Task Force . Benzodiazepine ( BZ ) policy for people on opioid agonist treatment ( OAT ) was on the agenda but time was running short . As we moved to the last item one of my colleagues drily observed , ‘ I ’ m not poking the bear when there ’ s only 20 minutes left ’.

The bear here is , of course , prescribing benzodiazepines to people who are on opiate agonists for their opioid use . So I ’ ll start with three clear statements : benzodiazepine use increases drug-related poisonings and mortality when taken in quantity

with alcohol or opioids ; these risks start to increase as you get older , so avoid excessive use ; and , it is reasonable for doctors to decrease your dose .

And sincere congrats if you have done the stopping or helped someone else to do this .

But things can go too far . Four years ago we adopted a strict no benzo policy – actually prohibition – for people on OAT in this province . Doctors face serious misconduct proceedings for stable dose prescribing except in end-of-life care , and prescriptions are reviewed through a real-time network called Pharmanet so concurrent prescribing is flagged . Only tapering is permitted , as long as it is reasonably fast . This policy came in rather suddenly , and some doctors have tried hard to contain the deep distress that this caused to many patients .

But the key word here is excessive . For more than 50 years , BZ drugs have been a much safer alternative to barbiturates and other stronger sedatives . Taken on their own , they are remarkably safe . And they were often thrown at users – and I do mean scripts thrown across the doctor ’ s desk – as ‘ shut-up ’ pills by doctors who

wouldn ’ t provide OAT .

It ’ s also been forgotten that BZ drugs are specific anti-anxiety and hypnotic medicines . They are not anti-depression drugs like SSRIs , although these have now become the ‘ go to ’ drugs for anxiety , which is not quite the same as depression . More problematic is the use of atypical anti-psychotics such as quetiapine ‘ off-label ’ as hypnotics , despite the manufacturers ’ warning that they should not be used as sleeping medications . Some of you will already have read about a programme in Scotland to provide access to genuine benzodiazepines as ‘ safe supply ’, led by no less a figure than Professor Roy Robertson – widely known as the Scottish doctor who , in a seminal study in the Lancet in 1985 , alerted the UK to the high levels of HIV among injecting drug users in his Edinburgh practice . I think this is a reasonable response to current circumstances , but we can ’ t do it here – yet .

I can live with a policy of reducing their use in general , but people prescribed these drugs for years who cannot live without a small amount should not be cut off . By all means don ’ t start people on them , but have a care for those

‘ We have a saying here , “ Don ‘ t poke the bear ” – aside from its obvious meaning as a wilderness warning it also means avoiding a discussion of something that is controversial and likely to end in arguments .’

who cannot stop them and who are now purchasing toxic fakes instead . Absolute bans are rarely appropriate , tempting though they may be . Leave some wiggle-room for those who are suffering and avoid our approach .

Bill Nelles is an advocate and activist , now in Canada . He founded The ( Methadone ) Alliance in the UK

Illustration : JellyPics