A qualitative study of healthcare professional views on appropriate prescribing interventions for people who are co-dependent on opioids and benzodiazepines / z-drugs

Introduction: Poor mental health and trauma are associated with benzodiazepine and/or z-drugs dependency. Benzodiazepine/z-drug and opioid (Bz-Op) co-use is recognised as a frequent poly-drug death combination. Yet, most national guidance and treatment pathways focus solely on opioid dependence. With highly potent synthetic opioids being detected in UK street drugs, and the ever-changing drug market, updated guidance is urgently needed.

Aims/Objectives: To explore healthcare professionals’ views on facilitators, barriers and areas of improvements in current prescribing for people who co-use Bz-Op substances.

Methods: Twenty five semi-structured interviews (online /in person) were undertaken with clinicians (4 GPs, 3 Addiction Psychiatrists, 2 Pharmacist Prescribers, 1 nurse, 3 Clinical psychologists) and drugs workers/harm reduction experts (n= 10), across England (n= 12) and Scotland (n=13). Anonymised interviews were inductively coded for barriers and facilitators to appropriate prescribing interventions for Bz-Op co-use and mapped to the Capability Opportunity Motivation – Behaviour model.

Results: Current Bz-Op co-use treatment was highly variable, but the main treatment all services offered was opioid substitution treatment (OST) and guidance for benzodiazepine self-detox. Participants reported a lack of benzodiazepine prescribing policy in most services (opportunity barriers). The lack of evidence, guidance and clinical consensus to underpin Bz-Op prescribing decisions presented motivation and capability barriers. Motivation barriers to benzodiazepine prescribing were risk of diversion, overdose and iatrogenic harms with uncertain benefits were cited by prescribers. Non-prescribers agreed, but contextualised risk of overdose as greater from illicit rather than prescribed benzodiazepine use. Lack of integrated mental health care, especially in reducing benzodiazepine use, for people who co-use was a universally agreed barrier (opportunity barrier).

Discussion/Conclusion: Tailored prescribing and harm reduction advice specific to the co-dependent individual is needed to reduce variability in practice. Future research e.g. trials of co-prescribing benzodiazepines and OST alongside mental health support are crucial.