Under the 1977 and 1984 Misuse of Drugs Acts, benzodiazepines and ‘Z’ drugs (zopiclone, zolpidem and zalepon) and are not yet controlled.¹ These drugs are prescribed for insomnia and anxiety.² However, they are regarded by doctors and criminal justice stakeholders as having the potential for abuse and carry a street value.³

Concern has grown among the medical profession that such hypnotic and anxiolytic agents have adverse effects when taken in quantities exceeding prescription guidelines.⁴ Therefore, the Draft Misuse of Drugs (Amendment) Regulations of 2013 aim to control importation, exportation and possession of benzodiazepines and Z drugs by making it an offence to import or export these drugs without a licence, making it an offence to possess these drugs without a prescription (unauthorised possession), increasing restrictions on prescribing benzodiazepines and Z drugs, and scheduling these drugs as controlled. 

Re-scheduling drugs as controlled will target the black market, including internet supplying,⁷ and aims to ‘remove’ drugs from the streets by limiting the way in which doctors are currently (perceived to be) over-prescribing.⁸

Doctors would be required to hand-write prescriptions using a template, and to seek ID from patients before prescribing. Pharmacists would need to maintain a register for every benzodiazepine and Z drug prescription, to collate trends. 

In addition, the 1977 and 1984 Misuse of Drugs Act schedules cannabinol and cannabinol derivatives as controlled drugs.⁵ This needs to be amended to allow for legal prescribing of new drugs containing cannabinol derivatives, manufactured by licence in Europe for treatment of multiple sclerosis (MS).⁶

Some of the current controls over drugs will be loosened. Nurses will be allowed to prescribe more controlled drugs in hospitals for pain relief and palliative care. Doctors will be allowed to computer-print prescriptions for methadone as opiate substitution therapy (OST) under the Methadone Protocol.⁹ However, the regulations will also target body-builders who are currently self-administering anabolic steroids,^10,11 by making this activity a crime, and will also make novel psychoactive substances (NPS) sales and possession a crime.¹

Hitting the right target? 

Much of the proposed changes for the amendment to the regulations of the Drugs Misuse Act are to target drugs misusers and to increase penalties, while other changes aim to improve prescribing amenability for OST, and to make legal new treatments for MS. 

Most doctors would be in favour of more amenable OST regulations, and the availability of legal cannabinol for multiple sclerosis. But while some doctors are concerned that benzodiazepine and Z misuse is a public health problem in Ireland⁷ and may be associated with morbidity and mortality,³ risks due to these drugs are minimal when taken alone.^4,12 Harm recorded from benzodiazepine use in Ireland has mainly been in persons who have simultaneously consumed other drugs, especially alcohol.³

Prescriptions for benzodiazepines and Z drugs are already falling, as doctors are increasingly aware of the risks of overprescribing these drugs: numbers of these drugs dispensed by pharmacies fell by 1,427 items in 2012 and is reported to be continuing to fall,¹³ saving the state e1.5 million in 2012 alone.

Benzodiazepines and Z drugs tend not to be regarded in the same risk category as controlled drugs such as opiates and cocaine.¹² They are calculably less harmful to individuals and to society than alcohol or cigarettes,¹² although there is an acknowledged problem with ‘therapeutic addiction’.²³

Benzodiazepine and Z drug misuse is a serious problem in people who use drugs, especially for polydrug users and there is little evidence to guide practitioners.²⁴ In one study, up to 90% of attendees at drug treatment services reported their use in a one-year period.²⁵ In another study, 54% of those entering treatment had used illicit benzodiazepines in the past three months, 34% were using them weekly or more frequently, and 4% were injecting them. Use of benzodiazepines was higher in those who also had an alcohol problem.²⁶ Hence, many people presenting to drug and alcohol dependency services have a problem with long-term dependence on benzodiazepines. 

People who use them, along with other illicit drugs and/or alcohol, generally are using them for a different reason, as they tend to increase rather than dampen activity in the brain reward centres. They are also used to alleviate withdrawal symptoms from other drugs, especially crack and/or heroin, and are more likely to be taken in binges.

However, people who use drugs may also use benzodiazepines and similar drugs as self-medication to improve their mood or their coping skills,²⁷ but these are not clinically appropriate reasons to use benzodiazepines, for which psychological therapy is the treatment of choice.⁴

The real costs of law enforcement

The current incarceration costs per prisoner in Ireland are estimated at over e75,000 per annum, and prisons are already dangerously overcrowded.¹⁵ Incarceration is the single greatest independent risk factor for hepatitis C virus (HCV) and is also a risk factor for HIV.¹⁶ Increasing penalties for drug possession does not deter drug use,¹⁶ but it does increase health inequality, stigma and marginalisation of drug users.¹⁴

The amendments aim to curb prescribing by increasing law enforcement. However, experience shows that attempting to manage drug misuse with increased law enforcement leads to health inequalities and stigmatisation.¹⁴ Doctors need to be in a position to prescribe appropriate medicines for the right patients,²² and therefore the solution to inappropriate prescribing practices is to increase training opportunities for physicians and increase investment in primary care, rather than increase criminalisation.

 The aim to criminalise steroid injectors in gyms may lead to an unnecessary burden of law enforcement which would be better placed as a public health and medical education campaign around healthcare in athletes and safe prescribing schedules for sports physicians.^10,11,12

Healthcare not handcuffs

Irish doctors are concerned regarding prescription drug misuse,¹⁷ but this is not a reason to increase law enforcement at the expense of providing medical care. The report of the Benzodiazepine Committee mentions that patients who receive prescriptions for benzodiazepines are ‘poorly supported’ by their doctors. Prescription monitoring is a valuable exercise but its findings must be met with a response that includes increasing availability of community-based treatment for affected individuals, rather than incarceration. 

The US has in many states implemented a prescription monitoring programme, but participation is poor due to lack of awareness and despite increasing restrictions on prescribing practices, substance misuse treatment options have not increased in line with restricted prescribing.¹⁸ The danger is that Ireland will now do the same and sacrifice treatment for the ‘war on drugs’.

Doctors who do prescribe benzodiazepines and Z drugs need to be protected by guidelines and should not prescribe outside recommendations unless for strong clinical reasons, to avoid becoming ‘trapped’ into drug-seeking behaviour⁴ or prescription fraud. Monitoring prescriptions may help to track misusing patients who doctor-shop, so that these patients can be encouraged into treatment.¹⁸ However, guidelines exist in the relevant postgraduate colleges,¹⁹ and doctors are obliged under the Medical Practitioners Act to follow these.²⁰

The ICGP has made a submission to the amendment suggesting that simply assigning a benzodiazepine prescription or Z drug to a specific, named pharmacy, and prescribing the tablets to be dispensed in weekly or even daily supervised doses. This is sufficient to eliminate prescription fraud and doctor/pharmacy shopping, and this precaution avoids penalising the patient or requiring unnecessary frequency of doctor consultations. This practice is the standard in specialist addiction treatment centres in Ireland, where it is highly acceptable to both patients and practitioners. 

Sports athletes are unlikely to engage in the debate due to an already existing stigma among athletes against ‘doping’ in sports.³ This needs to be addressed by the sports medicine community as advocates for athletes, not by the criminal justice system. 

Doctors should support harm reduction and treatment measures for persons most likely to use hypnotics problematically,⁴ by making funding available for more detoxification treatment and psychosocial support, rather than increasing law enforcement. 

International drug policy and Ireland: an economic and a social problem

Ireland is attempting to fulfil its obligations under the UN Economic and Social Council (ECOSOC) resolutions 1987/30 and 1991/44.¹ In March 2016, the UN General Assembly will hold a special session (‘UNGASS’) on drugs where the future of drug policy will be decided. 

Given the more recent body of research that now cautions against the war on drugs,¹⁶ it is widely understood by international drug policy makers and physicians that the ECOSOC resolutions are out-dated and in need of review. Therefore Ireland’s attempt to fulfil obligations under these resolutions is a problem. 

Doctors who work in impoverished areas are already under pressure and many already refuse to prescribe benzodiazepines or Z drugs due to an inability to cope with drug-seeking behaviour or lack of resources in their practice.⁴ Therefore, forcing doctors to see patients more often merely to comply with anti-drugs law enforcement can place a further barrier of cost between doctors and their patients, pushing low-income patients towards illicit supplies. 

By providing police with ‘low-hanging fruit’ in the criminalisation of essential medicines, these increased risks for consumers also increase the street value of such drugs and adds value to dealing.²¹

The role of the GP 

Family doctors are in an ideal position to address problematic benzodiazepine and Z-drug use and the inappropriate use of other proposed drugs such as injectable bodybuilding steroids. GPs are sited in communities where known trends of drug misuse can be observed and managed in a holistic setting. 

Primary care physicians can incorporate treatment and detoxification or prescription management of these drugs with due attention to other medical and social needs, identifying other sources of risk to the patient including child protection, psychiatric comorbidity, malnutrition, infectious disease and poly-drug misuse including alcohol disorders, cocaine and heroin, but they need to know how to ask, which takes training. 

GPs throughout the country are connected through the ICGP or RCGP substance misuse training scheme and the HSE specialist community-based addiction centres both in the voluntary and statutory sector, where referrals can be made and shared-care pathways developed, including integration with inpatient detoxification or stabilisation programmes, community-based rehabilitation and integration pathways, and referral to community-based specialist counselling and/or psychotherapy services. 

Prescribing

GPs can and do prescribe safely and with compassion. Sickness and drug misuse should never have to happen in a prison cell. 

No human should ever have to be incarcerated for the want of a medicine that their family doctor could prescribe. To quote aim two of the International Doctors for Healthy Drugs Policy (IDHDP): “Public health instead of criminal justice”. 

People with drug problems are patients first, therefore health must become the cornerstone of all drug policies. Criminalisation deters people from seeking medical help. It also has heavy repercussions on their futures, employment, education and travel. 

References

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2. Nowell PD, Mazumdar S, Buysse D, Dew MA, Reynolds CF, Kupfer DJ. Benzodiazepines and Zolpidem for Chronic Insomnia. A Meta-analysis of Treatment Efficacy. Journal of the American Medical Association, 1997; 278(24): 2170-2177
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