Co-use of benzodiazepines and opioids in the UK: a qualitative study on co-use motivations, consumption patterns, and overdose prevention behaviours.

Lay summary and abstract n= (n=479/500 max)
Lay summary. The number of people dying from drug overdoses has doubled in the last ten years. We know that most people who die from drug overdose have consumed sedatives (called benzodiazepines or z-drugs) along with opioids (e.g., methadone, heroin) before their death. We wanted to understand how we can reduce drug overdoses. We interviewed 48 people who use these drugs together in Glasgow, Bristol, and Teesside in the UK. We found that many people co-use drugs to get the energy and wellbeing to function during the day. To make it through the day, people co-use drugs in different ways, and this changes from day to day. Many people tried to look after themselves and keep themselves safe from overdosing. Some people felt there was no help for them, and they seemed indifferent to what might happen to them. This is important to know for everyone who works with people who use drugs. This information helps to make sure that treatments and psychological help match what people who co-use drugs need.
Introduction. Drug-related deaths (DRD) have doubled in the past decade in the UK, particularly in Scotland. Co-using prescribed and/or illicit opioids and benzodiazepines or z-drugs (BZ/z-drugs) contributes to overdose risk. It is, however, unclear why and how people co-use, and what strategies people use to minimise overdose risk.
Methods. Forty-eight semi-structured interviews were conducted with people who co-use opioids and BZ/z-drugs in community settings in Glasgow (n=28), Teesside (n=10) and Bristol (n=10). Most identified as male (77%), white British, Scottish or English (94%) with a mean age of 43 years. Eighteen (38%) interviews were (co-)facilitated by qualitatively trained local peer and/or academic researchers. Reflexive thematic and framework analysis were used.
Results. Participants’ motivations mapped onto self-medicating and making money to enable daily functions, and seeking experiences of (1) buzz, (2) glow, (3) feeling ‘gouchy’ and (4) oblivion. These were linked to six co-use patterns: (a) low-dose BZ/z-drugs (am and pm), (b) coming down with street BZ/z-drugs (am and pm, various doses), (c) co-use throughout the day (regular, high doses), (d) BZ/z-drugs/opioid binges (irregular, high doses), (e) curated co-use (structured, controlled) and (f) BZ/z-drugs use throughout the day (BZ unstructured, opioid use structured). Overdose risk perceptions ranged from self-efficacy driven ‘I can help myself’ to self-efficacy-lacking evaluations ‘there is nothing I can do’. Perceived lack of tailored support for co-use reinforced beliefs of help- and hopelessness. People expressing high self-efficacy employed their own risk reduction strategies, e.g., using a trusted seller, limiting alcohol co-use.
Conclusions. This study indicates opportunities for individualised interventions, tailored to people’s co-use motivations and patterns, building on existing harm reduction behaviours and overdose risk perceptions. These findings are informing neuropharmacological research to understand DRD mechanisms and the co-development of effective harm reduction strategies to prevent DRD. We suggest a ‘one size fits all’ intervention approach to co-use is unlikely to be appropriate for the majority.