In 2013, benzodiazepines contributed to 58%* of drug deaths in the State of Victoria and 71% in Scotland. Diazepam
is the benzodiazepine found in most of the deaths. A recommendation to increase control of all benzodiazepines,
including diazepam from Victoria's State Coroner has been refused. Now, the NSW Deputy State Coroner
has called for it again.
In June, the Deputy State Coroner of New South Wales recommended [1]that all benzodiazepines, particularly diazepam, should be rescheduled as they contributed to the highest number of overdose deaths in the State of Victoria in 2013. This is the second call from an Australian coroner to reschedule all benzodiazepines – the first was rejected by the Australian Government’s Therapeutic Goods Administration (TGA) in 2012.
Last year, The State Coroner for Victoria, Judge Ian Gray, took the unusual step of submitting evidence to the Australian Department of Health Therapeutic Goods Administration (TGA) in support of rescheduling all benzodiazepines, after the original recommendation from Coroner Audrey Jamieson was refused.
“Victoria’s coroners do not ordinarily engage in public submissions processes, as our findings into individual deaths are the primary vehicle through which we highlight public health issues and make recommendations aimed at preventing further deaths. However given the potential for the rescheduling proposal to reduce significantly drug related harms and deaths in the State of Victoria, I have determined it is appropriate for me to respond to your invitation.” Judge Ian Gray, submission to TGA,16.01.13
After wider consultation in 2013 the TGA rejected the recommendation, but the benzodiazepine alprazolam (Xanax) was rescheduled. Alprazolam (a short-acting BZ) was the sixth most frequent individual contributing drug in drug deaths in Victoria in 2012, whereas diazepam (a long- acting BZ) was the first most frequent.
“…I fail to see why all benzodiazepines were not rescheduled. This inquest has clearly demonstrated that Alprazolam is not the only benzodiazepines of concern. The Victorian Drug Overdose Deaths Register demonstrates that Diazepam, rather than Alprazolam, is of greatest concern in Victoria.” NSW Deputy Coroner Carmel Forbes, June 2014[1]
The TGA decision not to reschedule all benzodiazepines was mainly on the grounds of the negative impact on business. In their 2012 response, the TGA also cited:
- the cost to Australian taxpayers
- the regulatory impact upon the pharmaceutical industry
- that benzodiazepines continue to be supplied as prescription-only medicines in countries such as the United Kingdom and the USA.
The Royal Australian College of Physicians (RACP) submitted evidence against rescheduling all benzodiazepines, citing the administrative cost and extra work for medical staff and suggested there was little evidence that rescheduling was effective. The Australian Medical Association (AMA) also supported this view:
“The AMA has successfully headed off moves to make all benzodiazepines controlled drugs, which would have added significantly to the administrative burden on GPs and hospital staff.” AMA,12.07.13
IN THE UK
In 1999, the UK Advisory Council on Misuse of Drugs (ACMD) also recommended rescheduling all benzodiazepines (diazepam was present in 45.3% of Scots drug deaths in 1998). This was refused, when in 2004, after inviting submissions regarding rescheduling, the ACMD overruled their own advice on the grounds that all benzodiazepines were not the same and there was little evidence that rescheduling was effective. This, despite evidence given to them at the time by expert Professor Laurence Gruer:
Temazepam was rescheduled in 1996
“The rescheduling itself did appear to lead to the drop in the number of overdose deaths that were attributable usually to a combination of heroin and temazepam; but was replaced by an increase in deaths where diazepam was the main benzodiazepine in combination with heroin. There was certainly an impact of the rescheduling of temazepam.” Professor Laurence Gruer, ACMD Minutes 01.04.04
Diazepam was present in 56% of Scottish drug deaths in 2002 (figures available at the time) and is the only commonly misused benzodiazepine in the UK still in schedule 4 – most of the others are schedule 3.
DIAZEPAM
The British National Formulary (BNF) and the ACMD (in their report Reducing Drug Related Deaths) warn of an increased risk of fatal respiratory depression when any benzodiazepine is taken in combination with other depressant drugs.
Diazepam is the benzodiazepine most often found in drug deaths in the State of Victoria and the UK. It is a long-acting benzodiazepine with a half-life up to 100 hours (including active metabolites).
In the UK, diazepam is used for long-term maintenance prescribing and withdrawal treatment because of its long half-life, but this makes it more dangerous if it is used with other depressants as it can remain active for long periods. A user may not be aware that diazepam taken hours before can have an additive effect when other depressants are taken later.
There is also a 30-fold variation in diazepam metabolism between individuals [1] so its effects can be unpredictable, particularly if the person does not take it regularly. The unpredictable nature of diazepam when combined with another depressant is demonstrated in this case report of unexpected and prolonged respiratory depression after benzodiazepines were combined with alcohol.
CONCLUSION
For over 10 years, benzodiazepines have been a major contributor to drug-related deaths in the UK and Australia. The United Nations Office on Drugs and Crime (UNODC) state in their World Drug Report (2012), that benzodiazepines are highly represented in drug deaths worldwide, second only to opium. Several attempts to reschedule diazepam have failed, suggesting that it is protected from tighter controls.
In the UK, there are an estimated 0.5 to 1.5million patients maintained on long-term benzodiazepine prescriptions, (mostly diazepam). This population are invisible, because problems related to prescribed benzodiazepines are so rarely recorded, they are not seen in relevant statistics. Would one effect of rescheduling diazepam make these patients visible?
* Drugs contributing to drug-related deaths in the State of Victoria from January to June 2013 January to June 2013 only.
- State Coroner’s Court of new South Wales, Inquest into the deaths of Christopher Salib, Nathan Attard and Shamsad Akhtar , 27 June 2014, State Coroners Court, Glebe, Deputy State Coroner C. Forbes: Findings
Alternative link to PDF - Factors Influencing the Metabolism of Diazepam, Leif Bertilsson, Thomas A. Baillie, and Jesus Reviriego, Department of Clinincal Pharmacology at the Karolinska Institute, Huddinge Hospital, S-141 86, Huddinge, Sweden. Pharmac. Ther Vol. 45. pp. 85-91. 1990.
- United Nations Office on Drugs and Crime (UNODC), World Drug Report 2012, ( p.82).
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