Benzodiazepine
Image via components from Wikimedia Commons photoshopped by Dimas Adiprasetyo
Drugs

The Rise, Fall, and Explosive Return of Benzos to Australia

Like many places, Australia tried to reduce prescriptions of Xanax and Valium. Unlike many places, it's ended up with a thriving black market.
28 July 2020, 9:30am

Nicola* was 16 when she was first prescribed valium; a moment in time that she struggles to recollect. “One of the downsides of benzo addiction is that my memory is pretty bad,” she explains.

What Nicola can remember is struggling with chronic anxiety and how her psychiatrist wrote out a prescription. According to Nicola, there was no discussion on whether the medication was addictive—just a brief instruction that if she felt anxious, she should take a single 5mg pill.

Many people have received this instruction. Millions around the globe have been issued a prescription for Valium, or diazepam as it’s known to chemists, or some other drug in the benzodiazepine family, to which Valium belongs. Other benzodiazepines (or benzos for short) include temazepam, nitrazepam, diazepam, oxazepam and alprazolam. And although there are slight differences between all, they each enhance the effects of the neurotransmitter GABA, which dials back the kinds of brain activity associated with rational thought and memory, resulting in a feeling of calm sedation. People on benzodiazepines generally feel more relaxed, which is why they’re prescribed for stress and insomnia.

This family of chemicals was first brought to market in 1960 by Swiss pharmaceutical giant Roche, but it wasn’t until the release of Valium in 1963 that benzodiazepine use became widespread. By 1968, Valium was the most prescribed medication in the United States. In 1973 it was reported that Australian practitioners had scribbled out 7 million Valium prescriptions in that year alone. And by 1977, benzodiazepines were estimated to be the most prescribed medication globally.

Back then Valium was widely considered to be as effective as it was safe. Given the harms associated with barbiturates—which were the earlier overdose-prone sedative of choice—and the addictiveness of Miltown, Valium was painted as a wonder drug.

It was not without problems—as made clear as early as 1967 in a letter to the British Medical Journal from a doctor who’d witnessed a patient going debilitating withdrawal symptoms—but it seems most medical professionals largely ignored their own observations, as well as an increasing amount of literature on dependence. Whether it was a consequence of Roche’s heavy marketing for Valium, or whether it was the attractiveness of the notion that a simple pill could solve stress, prescriptions of benzodiazepines went unchecked for decades.

Nowadays, the harms of Valium specifically and benzodiazepines in general are well-accepted. Doctors recognise that if they’re mixed with other drugs, such as alcohol or opiates, there’s a real chance of fatal overdose. They also know withdrawal symptoms develop after as little as three weeks, and that getting off the drugs is hellish. Your muscles cramp. Your stomach twists. Your brain contorts and collapses in on itself. You can’t eat. You can’t sleep. And, if you don’t follow a Valium reduction for an average of 10 weeks, you can experience seizures and, in rare cases, die.

But 11 years ago, neither Nicola nor her parents were informed about any of this. All they knew was that Nicola was struggling with anxiety and that Valium would fix it. So whenever she felt nervous or unable to sleep, Nicola followed her psychiatrist’s advice and swallowed a pill, which made her feel almost instantly better.

“You have no anxiety,” Nicola explains. “And you just feel like you can do everything.”

It didn’t take long for Nicola to realise that the more she took, the better she felt, and in less than a year she’d developed a dependency. By 20, her tolerance had grown and she was prescribed 6mg of Xanax—equivalent to 120mg of Valium—which she took almost every day. When she wanted to detach, she’d spend the day eating Xanax and sometimes adding lorazepam to the mix. When she wanted to lose her inhibitions, she’d drink or add stimulants. To just function on a daily level Nicola relied on benzodiazepines.

Nicola’s experience is one of countless stories about benzodiazepine abuse that have been circulating for almost 60 years—which is interesting, because their overprescription was acknowledged in Australia at least 30 years ago. But every harm reduction strategy has so far produced only mixed results.

In the early 1980s Gwenda Cannard was the director of nursing for a small Adelaide hospital devoted to alcohol dependence when she first began witnessing benzodiazepine withdrawal firsthand. As she recollects, she had swathes of people coming through her doors with symptoms they didn’t understand. And all of them had been prescribed benzos.

Cannard treated them the way she treated alcohol dependence: with a 10-day Valium reduction. But to her surprise, it made her patients sicker.

“It was really an observation of the fact that these people were having severe withdrawals and we couldn’t understand why,” Cannard explains. “And then learning that withdrawal from benzodiazepines is, in fact, probably worse than anybody had anticipated.”

Cannard’s exposure to these symptoms steered her towards the co-founding of Tranx in 1986 (now Reconnexion): Australia’s first support service for benzodiazepine dependence. The birth of Tranx coincided with an amplification of public awareness, and in 1988 the federal government launched a campaign to stem the national consumption of tranquilisers, which helped to lower the number of daily dosages per 1,000 people by 14 percent between 1990 and 1991.

By 2011, only about 20 people per 1,000 were being prescribed benzodiazepines, which was a 24.9 percent decrease from 1992. That reduction was seen as a victory, leading to a mentality within Australia’s medical community that Cannard describes as “oh, that’s not a problem anymore, we don’t have to think about it.”

This goes some way to explain why calls for further work in the area fell on deaf ears throughout the 2000s. In 2006, when parliamentary recommendations and letters from medical officials pleaded for stricter access to benzodiazepines, government bodies dismissed them, claiming the problem to be “the professional responsibility of medical practitioners and pharmacists.”

It wasn't until the 2010s when benzodiazepines regained mainstream attention as part of a larger pharmaceutical drug crisis. As the opiate crisis became front page news in the US, Australian authorities clamped down on local prescriptions of both opioid painkillers and benzodiazepines.

Doctors were told to say no to demanding patients and many clinics installed signs explaining that they didn’t prescribe benzodiazepines. In recent years there’s also been growing support for a national Real Time Prescription Monitoring program, providing practitioners with information about what drugs their patients have been previously prescribed.

On the surface, this reduction of supply makes sense, but it ignores the other half of the equation: demand.

In 2015, Xanax became a controlled drug in Australia. Xanax is a benzodiazepine that’s been around since the 80s, but it became widely used during the 2000s, with a prevalence doubling between 2000 and 2010 to over 400,000 prescriptions. It subsequently became implicated in rising numbers of overdoses, accidental deaths, ambulance callouts, violence and misuse. This 2013 article from The Conversation further claims that 65 percent of Victoria’s forged prescriptions in 2012 were for Xanax.

Naturally there was an outcry, and in the summer of 2015 Xanax went from a prescription medicine to a controlled drug, making it almost impossible to obtain. Xanax prescription rates dropped immediately, but while many assume this solved the problem, it actually just created a new opportunity for the black market.

“Early on everything was mainly prescribed. And then I guess once you start exploring other drugs, you realise you can get benzos off the street easy,” Nicola explains on the appeal of buying illicit Xanax. “It’s kind of easier than going to a doctor.”

It’s often assumed that Australia’s illicit market for pharmaceuticals is floated through onselling and “doctor shopping”, which justifies further restrictions on legal practitioners. But in reality, a new wave of illegitimately “pressed” benzodiazepines is currently flooding the black market.

“The rule for Xanax is: always assume it's pressed,” a 17-year-old from Sydney, who’s been taking benzos since he was 12, explains via DM on drug research forum Bluelight. “There hasn't been Australian pharmacy bars in quantity around for years.” [Meaning bars of Xanax purchased from a pharmacy].

The street term “pressed” describes liquid or powdered benzodiazepines that have been smuggled into Australia, cut, pressed in a pill machine, and sold as knockoffs. The look and quality, as well as what they’re cut with, varies depending on who you ask, but their availability has become widespread and further fuelled by restrictions on pharmacies.

Moreover, the rise of pressed Xanax has helped drive an influx of benzodiazepine analogues: grey market compounds with near-identical effects, but slightly different molecular makeups.

“So [flubromazolam] is just an analogue of diazepam,” explained a user from Western Australia via Telegram. “Why did someone create this? Simply to get around importation laws. That’s why people are dropping from fake benzos.”

Some analogues are actually controlled and regulated—but considering that 2011 saw at least 41 new synthetic drugs created within 12 months, regulations can’t keep up with production.

“Valium is even getting very restricted and I was forced to go cold turkey from benzos which gave me seizures. Very intense shit,” a former benzodiazepine dealer and user, based in Victoria, explains via Wickr. “[With pressed Xanax] you have a more common mix of etizolam and alprazolam—[there’s] also the possibility of having diclazepam in some products.”

“[I’ve also] heard about [Rohypnol] being used in low doses to increase the effects,” they add. “But I'd assume they would just cut the alprazolam with etizolam [a common benzodiazepine analogue], to cut costs, as etizolam is half the price [of alprazolam].”

The more affordable price point of analogues makes sense on the supply end, but for users, there’s concern. Analogues are generally untested, meaning their potency and side effects are often a mystery.

“[It] can last up to a full week in my experience,” says Jason*, a self-described long-term user, of his first time with the analogue flubromazepam—adding that flubromazolam can “knock a person out at .25 mg.”

“It's not ideal to mess with when the doses are so massive and so easy to overdose with,” says Jason, after explaining how another analogue, flualprazolam, is 10 times stronger than Xanax.

Here we encounter the much-covered side effect of restricting supply without reducing demand—the way it invariably provides opportunity for the black market. And while these observations are anecdotal, the underlying issue here is that restrictions on medical professionals have pushed benzodiazepines and users underground, creating the very problems they’re intended to prevent.

“When you’re trying to address inappropriate use of anything, particularly medicine, there’s low-hanging fruit and there’s high-hanging fruit,” says Dr Jonathan Brett, the staff specialist in clinical pharmacology, toxicology and addiction medicine at Sydney’s St Vincent’s Hospital. “The low-hanging fruit is stopping use in people who are probably low-risk. The high-hanging fruit are the people who are more driven to go seek it, and the people who are probably in more psychological distress.”

Dr Brett has spent the last decade researching prescription drugs in Australia. His unpublished and published research has found some unexpected patterns, such as how teenage girls are more likely to overdose from benzodiazepine, or how most users are elderly, while doctors are generally prescribing larger amounts.

According to Dr Brett, one part of the solution to reduce rates of overdose is to address prescription sizes. He points out that it’s equally important, however, to understand the people using these pharmaceuticals.

“Unless we address demand along with supply, supply will shift to places like the Internet,” Dr. Brett explains. “When we’re implementing policies to address supply, it’s quite important to measure unintended consequences.”

Meanwhile, Nicola no longer uses benzodiazepines, having stopped cold turkey about a year ago. But she still knows plenty of people who do. Some have overdosed, while others are caught in the cycle of using-detox-using. She tells one story of a friend being red-flagged by a pharmacy, then talked into a two-week inpatient detox—an approach Nicola disparages as missing the point.

“I just don’t feel like it’s really addressing the issue, or helping people come off benzos or other drugs of addiction,” she tells me. “Obviously it’s helpful to take people off, but you have to do it in a way where they want to get off, and they stay off. That’s what you want in the end, don't you?”

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