Drink and Drugs News DDN June 2020 - Page 7

BENZO TRAP far higher doses than they would have obtained on the NHS. These same patients, when presenting to GPs for treatment, may encounter the same reluctance to prescribe benzos that pushed them to the street market in the first place. PRESCRIBING TRAP The NICE BNF guidance on benzos for the treatment of anxiety allows for doses up to 30mg a day. For someone who has a significant street-acquired strong benzo habit, the BNF upper limit may be well below that person’s current dose. The dose equivalence for someone using four 2mg alprazolam a day (8mg x 20) would be 160mg diazepam – more than five times the BNF upper limit for treating anxiety. Where services do have a benzo-prescribing pathway it typically requires a person to reduce themselves off their own illicit benzos to a level where drug services or GPs could take over prescribing. This approach effectively directs a person to continue purchasing off the illicit market, with all the risks that this entails. It is the equivalent of having an arbitrary maximum dose of 30ml methadone and saying to heroin users they should reduce themselves off street heroin until they get to this level. This situation also assumes that the person has continued access to illicit benzos that they can taper off. If a person has been purchasing off a dark web site which is then shut down, they could be left without any access to drugs, withdrawing off a high dose with no access to legal substitutes. This brings with it huge risks, including psychosis and life-threatening convulsions. ASHTON MANUAL Many professionals and people seeking help online will find the Ashton Manual, a guide to benzo reduction and withdrawal by Professor C Heather Ashton. A helpful resource for many, the manual and related resources create two key challenges. First, for some people, reading the manual could reinforce fear and anxiety of withdrawal symptoms. There is a risk that people will anticipate and expect symptoms and could therefore experience a wider range of symptoms and with greater severity. Second, the withdrawal schedules suggested by Ashton typically reflect people reducing off NHS-prescribed dose ranges. Where people have built up dependency on stronger novel benzos, and built up high tolerance on street drugs, following the sort of slow tapers proposed by Ashton could take one to two years or longer to complete. While on the one hand very slow tapers as described by Ashton minimise risks of unpleasant or dangerous symptoms, they can prove prohibitively and unnecessarily slow for people who have been using at high doses. Minute dose reductions can lead to people fixating on each reduction, and losing motivation over a protracted reduction programme. UNKNOWN TABLETS Efforts to accurately substitute prescribe for illicitly acquired benzo habits are further confounded by our uncertainty as to the specific drug and specific dose that the person is actually taking. A significant amount of the tablets sold as Xanax could contain one or more other compounds. Alprazolam may or may not be present – weaker or stronger benzos could be present, and these could be shorter or longer acting than alprazolam. Dose may be higher or lower than the claimed strength, and there may be other psychoactive compounds present such as quetiapine. While drug testing websites such as WEDINOS are invaluable in highlighting trends in pill composition they are less helpful when considering tapers and withdrawal protocols – even if pills held by the client are submitted for analysis. The analysis doesn’t show the amount of each psychoactive compound in a pill, and without testing several pills from a batch, Escaping the trap no certainty can be derived from testing a single pill. This uncertainty about drug, dose and strength makes it impossible to accurately assess: • what level of substitute prescribing is required • how fast or slow a taper should be applied – some novel benzos have a very long duration of effect (100-200 hours) and so slower tapers may be required. In lieu of accurate and rapid pill testing, the only practical way of substitute prescribing and tapering is to prescribe symptomatically, increasing dose and slowing withdrawal where there are clinical indicators of unmanageable withdrawal symptoms combined with careful assessment of the patient’s self-reported symptoms. Kevin Flemen runs the drugs education and training initiative KFx – www.kfx.org.uk Workshops have moved online during the current lockdown. Email [email protected] for joining instructions. Services need to urgently develop new pathways and treatment protocols for people using benzodiazepines outside of clinical and prescribed settings. These need to include: • screening tools to assess for patterns and nature of benzo use • research into the extent of non-prescribed benzo use in the UK • protocols to test clients’ pills for content and potency • appropriate levels of substitute prescribing with tapers • rapid access for children experiencing anxiety to CAMHS to reduce self-medicating with benzos • staff training and training for GPs about addressing the use of prescribed benzos without driving people towards illicit markets. Photo: ajt/iStock WWW.DRINKANDDRUGSNEWS.COM JUNE 2020 • DRINK AND DRUGS NEWS • 7