Under pressure

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The celebrity craze for stress pills is even reaching schoolchildren – should we be concerned? Kevin Flemen looks at the risks and availability of alprazolam, branded as Xanax.

A friend of mine in Hackney was recounting a recent case involving the death of a child at her daughter’s school. While the inquest results were still awaited, it appeared the death may have involved alprazolam. When I voiced some surprise at this drug being a factor, my friend said: ‘All of my daughter’s friends are going on about Xanax. It’s really the thing at the moment.’

Xanax is the brand name of the benzodiazepine alprazolam. It is highly potent – some 20 times the strength of diazepam (Valium) – with a medium duration of effect and a half-life of around 12 hours. It is widely prescribed in America with claims that it is now the number one prescribed psychiatric medication. Most legal use in the UK is from private prescriptions as it is not prescribed on the NHS, but it is also available via the dark web.

Over the past few years, most UK reports of alprazolam have referred to it as a cut in heroin rather than a significant drug in its own right. Norwich police warned of alprazolam in heroin back in 2004, and in the more recent heroin ‘drought’ around 2010, reports circulated of orange-tinted heroin linked to overdoses.

Historically, the most popular benzodiazepine in the UK has been diazepam, which was frequently diverted from legitimate prescriptions. As prescribers were repeatedly reminded about the need to address widespread over-prescribing, people seeking sedation have had to resort to looking elsewhere.

Some injectors turned to temazepam, albeit with disastrous health consequences following the intro­duction of Gelthix capsules intended to deter injecting.

Pregabalin and gabapentin increasingly became the prescribed drugs of choice, and workers and peer educators reported an increase in ‘pregabs’ as a core drug of polydrug use – initially in custodial settings and then in community settings too. ‘It’s like sciatica is a catching condition,’ commented a prison drugs worker on a training course, noting ruefully how many prisoners presented to the medical team complaining of neuropathic pain in the hope that it would result in a pregabalin prescription.

Further afield, online pharmacies represented a ready source of tablets sold as diazepam. Overseas suppliers sold it in the form of blue pills – some genuine, but others containing a range of compounds or none of the drug at all. Canny consumers became increasingly wary of purchasing diazepam from such sources.

The explosion of novel psychoactives brought with it the advent of numerous novel benzodiazepines, includ­ing phenazepam, etizolam and flubromazepam. These worked, and were cheap and widely available. Rather than seeking dwindling NHS prescriptions or chancing random blue pills from Asia, more of the depressant market turned to these NPS benzodiazepines.

So back to Xanax. Is it becoming a ‘thing’ in the UK? If so, why – and to what extent is this likely to become a trend?

The drug has gained profile significantly. It has been linked to a number of high-profile celebrity deaths and continues to be associated with the media, earning mentions in music and film as well as appearing in many internet memes.

If diazepam is possibly a bit old and fusty, Xanax has become the sedating pill for those stressed by celebrity rather than mundanity. The school-age peers of the friend I mentioned at the start had come to Xanax via its associations with American celebrities. It was fashionable.

In recent sessions with young people in a number of settings, I’ve been exploring awareness of Xanax. In one (albeit small) group of young people in Norwich, all had heard of it and they mentioned memes that they had seen.

Although alprazolam isn’t significantly prescribed in the UK, there’s good availability via the dark web. A search filtered for European suppliers returned 297 entries on Dream Market. By comparison, diazepam returned 391 entries. Costs varied significantly, but 200 x 2mg tablets (the equivalent of 4 x 10mg diazepam) worked out at around £1 a tablet. There is clearly no shortage of people offering alprazolam, with the product range including raw powder and pills in various strengths.

Increased restriction on other sedating substances could further encourage its use. The existing non-regulated benzodiazepines were all automatically covered by the Psychoactive Substances Act 2016 (PSA), reducing legitimate access to these compounds via head shops and online suppliers.

The ACMD has pushed for further regulation, suggesting they be made temporary class drug order (TCDO) drugs, with a view to later making them fully controlled drugs. However, the government has declined, arguing that this would reduce the capacity to control these drugs in custodial settings. Nonetheless, it is likely that all the novel benzodiazepines will be scheduled at some point in the future.

The ACMD and government are also concerned about the diversion of prescribed medicines, and the misuse of pregabalin is a key issue. Therefore it seems increasingly likely that this, alongside gabapentin, will be made a controlled drug in the coming months. So for anyone seeking non-prescribed sedation, the dark web and illicit markets will be the main source of drugs, and alprazolam is increasingly a feature. This will be especially true for people who have built up significant tolerance to benzo-type drugs pre-PSA, and who will need to cross-substitute with similarly strong benzos to stave off withdrawal. Someone with a 2g a day flubromazolam habit would probably need 80mg of diazepam for a similar effect.

A discussion on an NPS forum made a similar point, highlighting a red 5mg alprazolam bar on the market, saying: ‘There are now vendors based in the UK producing their own Xanax bars for our market… there’s one in particular that has just this week come out with red bars containing 5mg alprazolam. These are pressed and sold in the UK. I do not think it is a coincidence that this is happening right after the Psychoactive Substances Act has come into force. No one with a clonazolam habit is going to get much out of diazepam after all…

‘This could be the start of an interesting new trend in the UK. Alprazolam has never previously been a big thing here, but some of these UK Xanax vendors are geared up specifically to sell in bulk to dealers. I don’t doubt this is a direct result of UK benzo users getting a taste of more potent benzos from the RC [research chemicals] scene. I also fully expect etizolam bars to come onto the UK market shortly, but I suspect these will be more popular given the street cred of Xanax.’

It is too soon to know if alprazolam will become a significant drug on the UK scene, but some of the key risks and issues are:

• Alprazolam may crop up unexpectedly in compounds where it was not the sought-after drug. It may also crop up in a variety of strengths, with pills containing alprazolam ranging from 0.5mg to 5mg (equivalent of 20mg – 100mg of diazepam.) On its own this is a significant risk of overdose. This risk goes up significantly when used in combination with alcohol or opiates.

• If alprazolam is appealing to a younger demographic, there is likely to be a high level of ignorance in relation to risks around benzodiazepine use.

• As with other benzodiazepines, alprazolam can cause significant physical dependency and dangerous withdrawal symptoms. Tapered reduction may be required, including high-dose prescribing as part of a transfer from illegally sourced drugs.

Alprazolam is certainly a significant drug – and a big problem – in America, and increasingly crops up in polydrug overdoses. From looking at its growing influence in this country, it would seem that the risks are very real.

Kevin Flemen runs the drugs education and training initiative, KFx. Visit www.kfx.org.uk for free resources.