Research paper
High enhancer, downer, withdrawal helper: Multifunctional nonmedical benzodiazepine use among young adult opioid users in New York City

https://doi.org/10.1016/j.drugpo.2017.05.016Get rights and content

Abstract

Background

Benzodiazepines are a widely prescribed psychoactive drug; in the U.S., both medical and nonmedical use of benzodiazepines has increased markedly in the past 15 years. Long-term use can lead to tolerance and dependence, and abrupt withdrawal can cause seizures or other life-threatening symptoms. Benzodiazepines are often used nonmedically in conjunction with other drugs, and with opioids in particular—a combination that can increase the risk for fatal and non-fatal overdose. This mixed-methods study examines nonmedical use of benzodiazepines among young adults in New York City and its relationship with opioid use.

Methods

For qualitative analysis, 46 90-minute semi-structured interviews were conducted with young adult opioid users (ages 18–32). Interviews were transcribed and coded for key themes. For quantitative analysis, 464 young adult opioid users (ages 18–29) were recruited using Respondent-Driven Sampling and completed structured interviews. Benzodiazepine use was assessed via a self-report questionnaire that included measures related to nonmedical benzodiazepine and opioid use.

Results

Participants reported using benzodiazepines nonmedically for a wide variety of reasons, including: to increase the high of other drugs; to lessen withdrawal symptoms; and to come down from other drugs. Benzodiazepines were described as readily available and cheap. There was a high prevalence (93%) of nonmedical benzodiazepine use among nonmedical opioid users, with 57% reporting regular nonmedical use. In bivariate analyses, drug-related risk behaviours such as polysubstance use, drug binging, heroin injection and overdose were strongly associated with regular nonmedical benzodiazepine use. In multivariate analysis, growing up in a middle-income household (earning between $51,000 and $100,000 annually), lifetime overdose experience, having ever used cocaine regularly, having ever been prescribed benzodiazepines, recent drug binging, and encouraging fellow drug users to use benzodiazepines to cope with opioid withdrawal were consistently strong predictors of regular nonmedical benzodiazepine use.

Conclusion

Nonmedical benzodiazepine use may be common among nonmedical opioid users due to its drug-related multi-functionality. Harm reduction messages should account for the multiple functions benzodiazepines serve in a drug-using context, and encourage drug users to tailor their endorsement of benzodiazepines to peers to include safer alternatives.

Introduction

Benzodiazepines, which include alprazolam (e.g. Xanax), clonazepam (e.g. Klonopin), diazepam (e.g. Valium), and lorazepam (e.g. Ativan), among others, are a class of psychoactive drug that are widely prescribed in the U.S., most commonly for anxiolytic and muscle-relaxant purposes (National Institute on Drug Abuse, 2014). Approved for treating various conditions including panic attacks, anxiety, seizures and alcohol withdrawal, they enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA), resulting in sedative, hypnotic, anxiolytic, anticonvulsant and muscle relaxant properties (Longo and Johnson, 2000, White and Irvine, 1999). While safe and effective for short-term use, long-term benzodiazepine use can be problematic due to the development of tolerance and dependence (Ashton, 2005). Physiologic dependence on benzodiazepines can cause seizures and other life-threatening symptoms if withdrawal is abrupt and managed improperly (Ashton, 2005; Puntillo, Casella, & Reid, 1997).

Between 1996 and 2013, the percentage of adults filling a benzodiazepine prescription increased from 4.1% to 5.6% (Bachhuber, Hennessy, Cunningham, & Starrels, 2016). Paralleling this increase, nonmedical benzodiazepine use has become a growing problem in the U.S. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Set (TEDS), drug treatment admissions for nonmedical benzodiazepine use tripled between 1998 and 2008, while overall treatment admissions increased by only 11% (TEDS Report, 2011). Benzodiazepines are often used nonmedically in conjunction with other drugs; while only 12.9% of persons admitted to treatment between 1998 and 2008 reported benzodiazepines as their primary drug, 82.1% reported them as secondary (SAMHSA, 2011a). Between 2005 and 2011, there were nearly one million emergency department visits involving benzodiazepines, used either alone or in combination with other drugs, most commonly opioids and/or alcohol (SAMHSA, 2014). Overdose-related deaths involving benzodiazepines also increased from 0.58 per 100,000 adults in 1999 to 3.07 in 2013 (Bachhuber et al., 2016).

Despite emergency room and treatment admission data signalling a significant and growing public health problem, research on nonmedical benzodiazepine use is limited. Recent work includes McCabe’s (2005) analysis of national survey data from a random sample of American college students, 7.8% of whom reported past-year nonmedical benzodiazepine use. Similarly, in a recent study of high school seniors, McCabe and West (2014) found that 7.5% of youth reported lifetime nonmedical benzodiazepine use. Among those (4.9%) who reported ever having a prescription for benzodiazepines, more than half (59.4%) reported lifetime nonmedical use. Nonmedical benzodiazepine use is especially common among individuals using other drugs (McCabe, 2005, SAMHSA, 2012). A 2011 study of young adult “club drug” users who also misuse prescription drugs found benzodiazepines were the most commonly misused prescription drug, with 86.8% of participants reporting nonmedical benzodiazepine use in the past 90 days and 25.0% meeting DSM-IV criteria for benzodiazepine abuse and/or dependence (Kurtz, Surratt, Levi-Minzi, & Mooss, 2011). Dwyer’s (2008) ethnographic study concluded that the main motivation for benzodiazepine injection among Vietnamese heroin users was the pursuit of intense pleasure.

Concurrent with rising rates of nonmedical benzodiazepine use, the U.S. is in the midst of an opioid use epidemic, with rates of heroin use more than doubling over the past decade (Centers for Disease Control and Prevention, 2015). These heroin users are often young people who embarked upon long-term opioid use and dependence via nonmedical prescription opioid use (Jones, Logan, Gladden, & Bohm, 2015; Mateu-Gelabert, Guarino, Jessell, & Teper, 2015). The relationship between nonmedical opioid and benzodiazepine use has been previously established (Chen et al., 2011; Gelkopf, Bleich, Hayward, Bodner, & Adelson, 1999; Khosla, Juon, Kirk, Astemborski, & Mehta, 2011; Ross, Darke, & Hall, 1996). Studies have found benzodiazepines are often procured from doctors and illicit sales to mitigate withdrawal symptoms from other drugs, including opioids, and, conversely, to intensify or prolong their effects (Jones, Mogali, & Comer, 2012; Lankenau et al., 2012, Liebrenz et al., 2015, O’Brien, 2005). Havens, Walker, and Leukefeld’s (2010) study of Appalachian prescription opioid users found that approximately half of participants (48%) had used benzodiazepines nonmedically in the past 30 days. Participants described lengthy histories of benzodiazepine use, reporting a mean of eight years of use, with a quarter reporting over 13 years of use. National treatment admissions data from the U.S. reveal that, as rates of opioid use have increased, so too have rates of the co-use of opioids and benzodiazepines; admissions for the nonmedical co-use of prescription opioids and benzodiazepines have increased by 569.7% from 2000 to 2010 (SAMHSA, 2012). Similarly, other researchers have documented frequent use of benzodiazepines among people who inject drugs (Bramness & Kornør, 2007; Darke, Ross, Teesson, & Lynskey, 2003; Darke et al., 2010, Dwyer, 2008; Evans, Halm, Lum, Stein, & Page, 2009; Forsyth, Farquhar, Gemmell, Shewan, & Davies, 1993; Fry & Bruno, 2002; Lavelle, Hammersley, Forsyth, & Bain, 1991; Smith, Tett, & Hall, 2010; Strang, Griffiths, Abbey, & Gossop, 1994).

The nonmedical use of benzodiazepines among opioid users is a serious concern as benzodiazepines can markedly increase the harmful effects of opioids, particularly risk for fatal and non-fatal overdose (Chan, Stajic, Marker, Hoffman, & Nelson, 2006; Dietze, Jolley, Fry, & Bammer, 2005; Dilokthornsakul et al., 2016; Jann, Kennedy, & Lopez, 2014; Jones and McAninch, 2015, Kerr et al., 2007; Perret, Deglon, Kreek, Ho, & La Harpe, 2000; Toblin, Paulozzi, Logan, Hall, & Kaplan, 2010; White & Irvine, 1999). While opioids are the most common drug class involved in overdose, most overdoses involve more than one substance (McGregor, Darke, & Christie, 1998; Oliver and Keen, 2003, Ward and Barry, 2001; Wunsch, Nakamoto, Behonick, & Massello, 2009). In New York City, the location where the present study takes place, the NYC Department of Health and Mental Hygiene recently found that 79% of overdose deaths involved an opioid. However, 97% of overdose deaths involved more than one substance; benzodiazepines were a frequent substance involved in overdose deaths, found in 55% of methadone, 53% of prescription opioid, and 41% of heroin-related overdose deaths (Paone, Tuazon, Nolan, & Mantha, 2015).

Given the broad and significant role benzodiazepines play as both primary and secondary drugs of misuse, and their association with overdose risk, more work is needed to explore patterns of nonmedical benzodiazepine use, especially among opioid users. The present analysis contributes to this research by reporting findings related to nonmedical benzodiazepine use among young adult nonmedical prescription opioid and/or heroin users in New York City.

Section snippets

Methods

This mixed-methods paper, part of a study designed to assess risks associated with opioid use, examines patterns, contexts, motivations for and correlates of benzodiazepine use among New York City young adults who use prescription opioids nonmedically and/or use heroin. Qualitative data explore the contexts, motivations for and consequences of participants’ nonmedical benzodiazepine use and are presented to assist in the interpretation of quantitative results. Quantitative data report key

Qualitative findings

Of the 46 qualitative interviewees, 27 were male, 18 female, and one was transgender-female. Participants were a mean of 25.3 years old (SD = 3.9 years; range = 18–32 years). Thirty-two identified as White/Caucasian, 3 as African American/Black, 9 as Hispanic/Latino, and 2 as Asian/Pacific Islander. Fourteen attended some high school, 9 had received a high school diploma or GED, and 23 had attended or graduated college.

In response to interview questions regarding participants’ use of opioids, the use

Discussion

The results of this mixed methods study reveal a high prevalence of nonmedical benzodiazepine use among young adult opioid users, supporting previous findings (Chen et al., 2011, Havens et al., 2010, Khosla et al., 2011; Lavie, Fatseas, Denis, & Auriacombe, 2009; Toblin et al., 2010) and highlighting the under-acknowledged role of benzodiazepines in the current heightened rates of opioid use in the US. Both qualitative and quantitative findings indicate that benzodiazepine use is very common,

Funding

This research was supported by the National Institutes of Health (NIH)/National Institute on Drug Abuse (NIDA), Grant No. R01DA035146. The content is the sole responsibility of the authors and does not necessarily reflect the official views of NIDA or NIH.

Conflict of interest

All authors have no conflicts of interests to declare.

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