Benzodiazepine use - current trends: evidence review

Footnotes

1. Z-drugs have different chemical structures to benzodiazepines but exhibit broadly similar effects.

2. National Records of Scotland (2021). Available at: Drug-related deaths in Scotland in 2020, Report (nrscotland.gov.uk).

3. Information Services Division (ISD) (2021). Available at: Drug-Related Hospital Statistics (ISDscotland.org).

4. McAuley et al. (2021). Available at: From the clinic to the street: the changing role of benzodiazepines in the Scottish overdose epidemic (sciencedirect.com).

5. Neilson and McAuley (2020). Available at: Etizolam: A rapid review on pharmacology, non-medical use and harms - PubMed (nih.gov).

6. Roe (2020). Available at: Echoes of endlessness : time, memory, and experience for heroin users in Scotland (ethos.bl.uk).

7. Ibid.

8. The author notes that Valium (diazepam) tablets, or tablets thought by participants to be diazepam, were the tablets most commonly available during the research.

9. Roe (2021). Available at: Isolation, Solitude and Social Distancing for People Who Use Drugs: An Ethnographic Perspective - PubMed (nih.gov).

10. Roe (2020). Available at: Echoes of endlessness: time, memory, and experience for heroin users in Scotland (ethos.bl.uk).

11. McAuley et al. (2021). Available at: From the clinic to the street: the changing role of benzodiazepines in the Scottish overdose epidemic (sciencedirect.com).

12. 'New benzodiazepines' are defined by the EMCDDA as NPS that contain a benzodiazepine core and that are not controlled under the international drug control system, although some 'new' benzodiazepines, such as phenazepam, etizolam and flualprazolam, have since been controlled.

13. Ibid.

14. Ibid.

15. National Records of Scotland (2021). Available at: Drug-related deaths in Scotland in 2020, Report (nrscotland.gov.uk).

16. The Information Services Division (ISD) of NHS National Services Scotland, which is now part of Public Health Scotland (PHS) defines 'prescribable' benzodiazepines as those licensed for prescription in the UK and widely prescribed in Scotland (but which may not actually have been prescribed to the person who died after taking them), such as diazepam, and 'street' benzodiazepines as those not licensed for prescription in the UK or thought to have originated from an illicit source.

17. National Records of Scotland (2021). Available at: Drug-related deaths in Scotland 2020 (nrscotland.gov.uk).

18. EMCDDA (2021). Available at: New benzodiazepines in Europe – a review (europa.eu).

19. Neilson and McAuley (2020). Available at: Etizolam: A rapid review on pharmacology, non-medical use and harms - PubMed (nih.gov).

20. Medicines and Healthcare products Regulatory Agency (2020). Evidence of Harm from Illicit or Fake Benzodiazepines. Medicines and Healthcare products Regulatory Agency.

21. Neilson and McAuley (2020). Available at: Etizolam: A rapid review on pharmacology, non-medical use and harms - PubMed (nih.gov).

22. Street benzodiazepines here include alprazolam, diclazepam, etizolam, flualprazolam, flubromazolam and phenazepam.

23. This specific data was sourced from the National Records of Scotland at the request of the Scottish Government and is currently unpublished.

24. NRS (2021). Available at: Drug-related deaths in Scotland in 2020, Report (nrscotland.gov.uk).

25. Based on the quintiles outlined by the Scottish Index of Multiple Deprivation (SIMD).

26. This comparison may be affected by differences in reporting practices between areas.

27. It should be noted that deaths presented in Table 1 may be implicated by or involve both prescribable and street benzodiazepines, hence the individual numbers for each may equate to more than the total number of benzodiazepine-related deaths when combined.

28. Some difference may be accounted for by different toxicology practices among Scotland and England & Wales.

29. EMCDDA (2021). Available at: Drug-related deaths and mortality in Europe: update from the EMCDDA expert network (europa.eu)

30. Many countries do not register deaths involving only benzodiazepines as an overdose death, which may affect data reporting.

31. EMCDDA (2021). Available at: European drug report 2021: trends and developments (europa.eu)

32. ISD (2021). Available at: Drug-Related Hospital Statistics (ISDscotland.org)

33. Scottish Government (2021). Available at: drug seizures and offender characteristics, 2018-19 and 2019-20 (pdf).

34. UK Government (2022). Available at: Seizures of drugs in England and Wales, financial year ending 2021 - GOV.UK (www.gov.uk)

35. It should be noted that some difference in figures between Scotland and England & Wales may be accounted for by different measurements used to quantify drugs seized, as well as data quality issues in some areas, for which seizure figures were estimated.

36. Police Scotland (2020). Available at: National serious and organised crime disruption operation - Police Scotland.

37. EMCDDA (2021) New benzodiazepines in Europe – a review (europa.eu).

38. The main Class A drugs were heroin, cocaine and ecstasy tablets, while Class B drugs were largely herbal cannabis, cannabis resin and amphetamines.

39. Scottish Government (2021): Short Life Working Group On Prescription Medicine Dependence And Withdrawal: consultation - gov.scot (www.gov.scot).

40. Ibid.

41. Ibid.

42. Ibid.

43. ScotPho (2021). Available at: Treatment for drug misuse - ScotPHO

44. It should be noted that SDMD data may be affected by data quality issues.

45. Information Services Division (2018). Available at: The National Drug-Related Deaths Database (Scotland) Report (isdscotland.org)

46. Public Health Scotland (2021). Available at: Scottish Drug Misuse Database (publichealthscotland.scot)

47. Public Health Scotland (2021). Available at: Scottish Drug Misuse Database (publichealthscotland.scot).

48. Drug Deaths Taskforce (2021). Available at: MAT Standards Informed Response for Benzodiazepine Harm Reduction, interim guidance, august-2021 (drugdeathstaskforce.scot).

49. Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group (2017). Available at: Drug misuse and dependence (publishing.service.gov.uk)

50. MacLeod et al. (2019). Available at: Prescription of benzodiazepines, z-drugs, and gabapentinoids and mortality risk in people receiving opioid agonist treatment: Observational study based on the UK Clinical Practice Research Datalink and Office for National Statistics death records (plos.org)

51. Drug Deaths Taskforce (2021). Available at: MAT Standards Informed Response for Benzodiazepine Harm Reduction, interim guidance, august-2021 (drugdeathstaskforce.scot)

52. Ibid.

53. EMCDDA (2021). Available at: New benzodiazepines in Europe – a review (europa.eu)

54. Drug Deaths Taskforce (2020). Available at: Drug Deaths Task Force: Research Fund | Drug Deaths Taskforce.

55. The annotated bibliography is intended to give a general overview of the evidence and guidance relating to benzodiazepines in Scotland and is not intended to be exhaustive.

56. Report by PHS estimates prevalence at 1.91% when cocaine and amphetamines are included: Prevalence of problem drug use in Scotland: 2015/16 Estimates (PublicHealthScotland.scot)