Benzodiazepines in Polydrug-using Repertoires: the impact of the decreased availability of temazepam gel-filled capsules

JANE FOUNTAIN,* PAUL GRIFFITHS, MICHAEL FARRELL, MICHAEL GOSSOP & JOHN STRANG
National Addiction Centre, 4 Windsor Walk, London SE5 8AF, UK

ABSTRACT Reporting on a research project which used a qualitative methodology, this paper examines the role benzodiazepines played in the polydrug-using repertoires of a sample of long-term, polydrug-using, opiate addicts. The impact of a decrease in the availability of temazepam gel filled capsules is monitored, showing the effect on both the illicit market for diverted prescription drugs and on the drug-using patterns of those who bought benzodiazepines there. The paper illustrates the complex factors which affect the substances polydrug users include in, or exclude from, their drug-using repertoires, and is an example of how measures aimed at harm reduction can have both positive and negative implications. It is argued that such measures must be evaluated in the context of their impact on a series of dynamic, interrelated changes.

Introduction
Statistics tend to define drug users according to their main problem drug, but opiate users in London typically engage in complex drug-using repertoires. Treatment modalities for such clients often include a prescribing component, and some of these prescribed drugs will be traded on the illicit market. It has been documented that many polydrug users use illicitly obtained prescription drugs (Dale & Jones, 1992; Haw, 1993), and the drugs bought will be dependent on a variety of factors including not only preference, but also availability and cost. However, the trade in, and use of, these drugs remains largely unexplored. The health and other costs or benefits to the drug user require consideration, as does the impact of prescribed drug availability on patterns of consumption of other illicitly acquired substances. If the illicit drug market can be compared to other consumer markets, changes in the supply of, or demand for, one product is likely to influence consumption patterns of similar products.

During the fieldwork period of a study which investigated the illicit market in prescription drugs, it was announced by the Department of Health that 2 months hence, GPs would no longer be able to prescribe temazepam gel-filled capsules (e.g. Gelthix); that hospital-based services for drug users were expected to follow suit; that private practitioners were expected to examine critically the prescribing of the capsules; and that temazepam was to be moved from Schedule 4 to Schedule 3 in The Misuse of Drugs Regulations, 1985 (which governs import, export, production, supply, possession, prescribing and record keeping). The research team were fortunate to have the unique opportunity of studying the impact of these changes on the study group over the following weeks.
The measures to restrict the supply of temazepam gel-filled capsules were a response to evidence that this preparation was causing harm to drug injectors. Among the health risks associated with injecting are deep and peripheral vein thrombosis, abscesses, scarring and gangrene. These particularly affect those who inject the gel from temazepam capsules, as it resolidifies in the body when it cools (e.g. Ruben & Morrison, 1992; Strang et al., 1993). Ironically, the gel preparation was originally promoted as a harm-reduction measure. Widespread concern about the misuse of benzodiazepines generally, and the injecting of the fluid from temazepam capsules in particular, resulted in the introduction of a gel-filled temazepam capsule in 1989. This preparation was an attempt to make the drug less readily injectable as the gel could not be drawn up into a syringe. Despite this, some drug users continued to inject the drug by heating the gel to liquefy it. Many of the informants of the study had ceased to inject the gel after experiencing these problems themselves or knowing others who had, although some continued the practice (the misuse of temazepam and changes in formulation is chronicled by Strang et al., 1993).

Methods
Data are presented here from an episode which occurred during a qualitative study of 100 polydrug users in London during 1995 and 1996 (Fountain et al., 1996). Interviews and observations centred around five marketplaces where illicit and prescription drugs were bought and sold. Informants were specially chosen because they were long-term, polydrug-using, chronic drug users who traded in prescription drugs. It is therefore not suggested that their behaviour, experiences and opinions are characteristic of all drug users. Data were collected using a combination of observations, conversations and in-depth interviews. Around a third of informants were repeatedly interviewed over the study period.

The aim of the study was to explore patterns of the acquisition and use of illicitly obtained prescription drugs amongst chronic drug consumers. All subjects were recruited in the community, although many had long histories of contact with services for substance misusers. Community-based recruitment was essential because it was felt that subjects might not have been comfortable discussing the buying and selling of prescribed drugs if recruited via a treatment agency which may have sanctions to inhibit this behaviour. The study was concerned with illicit drug markets where both treatment attenders and non-attenders interacted, and the research design called for observation over a 12-month period, and for the research worker to observe illicit drug trading and interview those participating in it. Access was facilitated by the research centre's good links with drug users and ex-users who had assisted with other research activities in the past. These individuals acted as 'gatekeepers' to introduce the research worker to participants in the markets under study.
A synthesis of analytic induction and grounded theory (Glaser & Strauss, 1967) was the most appropriate procedure for the analysis of the data collected for the study. Data analysis was not conducted as a separate stage, but rather interacted with the planning and execution of the fieldwork. Flow-charts were constructed in order that the issues pertaining to the study could be categorized for further interviewing and analytical purposes. Data collection with a view to a quantitative analysis was judged to be inappropriate, as the study was devised to highlight areas of interest and concern in relation to the distribution and use of prescription drugs outside treatment settings, with a view to informing the design of other studies.

Benzodiazepines in Polydrug-using Repertoires
Benzodiazepine is a generic term covering a wide range of substances, and they were not equally preferred by the informants of the study (see also Darke, 1994, p. 66; Orzack et al., 1988, p. 465). Some benzodiazepines have a fast onset, others are slower to take effect, and the effects of some are much longer-lasting than others. These properties—and, to some extent, what was fashionable as a 'street drug'—affected users' preferences.

Research has shown that polydrug use is a well-established pattern of drug misuse, particularly of those who also use methadone (e.g. Darke, 1994; Seivewright et al., 1993, pp. 42-43). Data from the study support these findings: benzodiazepines were a popular addition to the drug-using repertoires of many informants, most of whom also used methadone. Although many were prescribed methadone and benzodiazepines by drug treatment services, GPs or private practitioners, most supplemented these dosages by buying more on the illicit market and/or by prescription fraud ('multiple scripting' and 'overscripting'). Those who managed to acquire—by one means or another—more benzodiazepines than they needed would sell the surplus, usually in order to raise money to purchase drugs they preferred and/or to pay a doctor and a pharmacist for a private prescription.

Although heroin was the preferred drug of most informants, it was not necessarily the one they used most often. Many tried to mimic the effects of heroin by combining other drugs, typically methadone with benzodiazepines and/or alcohol, or methadone, benzodiazepines, and a stimulant—usually crack cocaine or dexamphetamine sulphate (Dexedrine). Some informants had obtained private prescriptions for dexamphetamine sulphate and sold on the illicit market any which was surplus to their own requirements.

Rationales for benzodiazepine consumption offered by subjects were complex and often drug-specific. Patterns of benzodiazepine use also varied greatly among subjects. Sakol et al. (1989, p. 440) link the popularity of benzodiazepines (and buprenorphine in some locations) amongst polydrug users to a decline in the quantity and quality of heroin, and some informants of the study agreed that they found it reassuring to use pharmaceutically prepared drugs. For example:

Herbie [1]: At least I know what's going in my arm ... I see it as a far less risky thing [than injecting illicit heroin].

Other informants, however, rationed their use of prescription drugs because they were afraid of adding to the catalogue of substances upon which they were dependent.

Around a third of the informants were dependent on benzodiazepines in addition to opiates, and some of them used a very high daily dosage (see also, e.g., Lavelle et al., 1991; Ruben & Morrison, 1992; Seivewright et al., 1993). Others restricted their benzodiazepine use to helping them 'come down' from stimulant use, particularly crack cocaine, or for the insomnia caused by stimulant use or opiate withdrawal. Klee et al. (1990, p. 1132) and Ruben & Morrison (1992) have suggested respondents may also use benzodiazepines instrumentally to give them the confidence to commit crimes. Some informants in this study also reported using the drug in this way: Derek, for instance, who used benzodiazepines before shoplifting expeditions, described benzodiazepines as 'the "invisible pills" ... you have got no fear—no fear at all'.

The study also found that a significant reason for the demand for benzodiazepines from the illicit market was their relatively low cost. As one informant commented, 'Downers is a poor man's drug—cocaine and heroin are a rich man's drug'. The informants of this study were chronic long-term opiate users who were almost universally unemployed. Most existed on low incomes and obtaining sufficient funds for their drug use and other needs was a constant preoccupation. Even compared to other groups of heroin users, many of the subjects can be considered particularly disadvantaged.

The announcement of the new regulations and aspects of the misuse of temazepam—such as its addiction potential and the consequences of injecting the gel from capsules—were widely reported and were the subject of several television programmes. Amongst the informants of the study there was considerable confusion as to the exact nature and timing of the new regulations, and rumours abounded. For example, the following comments were recorded a few days after the announcement:

Edward: If you are caught with them it's 10 years in prison now ...

Betty: ... [GPs] are getting really, really strict—and that's private doctors, too ... Don't matter how much you pay them—it's the Home Office ...

Sasha: I know people that are under The Hospital [2] and they are just cutting them straight off. No matter if they are on 60 [benzodiazepine tablets] a day, they are having fits and ending up going straight to hospital. They are getting no help ...

The Effect on the Price and Availability of Benzodiazepines on the Illicit Market
Data on the prices of prescription drugs on the illicit market were collected systematically over the study period by questioning key informants in each of the marketplaces. The proportion of those who injected at least some of the substances they used varied from approximately 40% to 80% between the different marketplaces studied, but temazepam capsules were particularly valued by those who injected benzodiazepines. This is to some extent reflected in the relative price difference benzodiazepines could achieve in the markets investigated. At the beginning of the study, the benzodiazepines most frequently used by the informants of the study were temazepam gel-filled capsules, which cost 50-75p (0.75-1.13 ecu) each on the illicit market; temazepam tablets (50p/ 0.75 ecu each), and diazepam tablets (e.g. Valium), which could be bought for 25p (0.38 ecu) each. These benzodiazepines were widely available in the locations studied. Flunitrazepam tablets (Rohypnol) were used by some informants, but they were less widely available. In the UK, these can be obtained only from private practitioners, and their cost on the illicit market—£1 (1.5 ecu) each—meant that many preferred cheaper benzodiazepines. Flunitrazepam is considered a major drug of abuse in many European countries, but until recently was rarely reported amongst samples of UK-based drug injectors. Chlordiazepoxide (e.g. Librium) had little value on the drugs marketplaces of the study, and lorazepam (Ativan) and nitrazepam (e.g. Mogadon) were used only as a last resort if no other benzodiazepines were available. These varieties were sometimes given away as favours, or as a 'free gift' when large quantities of other drugs were purchased.

On the markets studied, the economic effect of the intention to withdraw temazepam gel-filled capsules followed a classic supply-demand formula. Immediately after the announcement, those buyers who could afford it began to stockpile temazepam capsules, and some sellers doubled their prices:

Edward: Those documentaries [on TV] that have been out recently have really shook things up in The Field [drug market place] [3]. Oh yeah, definitely—they have blown it right up now ... Now they have been put up to M. each ... Some of them have just shot the prices up—to be greedy, to get the extra 50 pence. In a couple more months you won't be getting them any more you know, so they have stuck their prices up now.'

When the price of a product increases, the price elasticity of demand is a significant factor determining whether or not purchases continue to be made. It has been shown that, up to a point, the demand for drugs from the illicit market is not affected by price, particularly in the case of dependent users: the price elasticity of demand is therefore low (e.g. Wagstaff and Maynard, 1988, pp. 4956; Whynes et al., 1989, pp. 535-36). The reaction of some of the informants of the study to the rising price of temazepam capsules also illustrates a low price elasticity of demand, as they—albeit resentfully—paid it. Two of them explained why:

Sarah: I know one person ... and they are charging £1.25 for a temazi. I said to him like 'How do you get the money?' and he said 'Well, if people want them that much they will pay anything.'

Betty: And I said—and I've said it on many particular occasions to one particular person—I've said 'I'm a good customer of yours—don't you think that you're taking the piss asking me this price?' And he turned around—and it's always his answer—'Well if you don't want them then there is no problem, I'll soon get rid of them—only takes me 5 minutes and they will all be gone.' And the thing is you know it's true, they're not bullshitting, so you buy them ... 'Cos you're frightened.

Sarah: You could be waiting another 5 hours before the person with the next lot shows.

However, other informants stopped buying temazepam gel-filled capsules because of their higher price and uncertain availability, and began to use temazepam tablets instead:

Edward: ... there are still a lot of chalk ones [tablets] going about—all the people I know that were using them [capsules] before have just changed over to the chalk ones.

The reduction in the availability of gel-filled capsules affected the illicit market price of other formulations of temazepam. As the demand for temazepam tablets increased, their price increased from 50p to £1 (0.75 to 1.5 ecu) each. Informants also suggested that they had became less widely available. This may have been due to some GPs becoming increasingly reluctant to prescribe any temazepam preparation—or, in some cases, any benzodiazepine at all—to drug misusers.
The private practitioners who treated some informants did not appear to change their prescribing policies in the light of the announcement of the new regulations, and thus some temazepam capsules were still available on the drugs marketplaces of the study. However, benzodiazepines of all types were scarcer on the illicit market as sellers reacted to the situation by being less likely to sell their surplus supplies:

Sasha: It's just getting harder and harder [to find sellers]. People, when they get theirs now, they don't want to part with them.

Not surprisingly, however, those sellers who were prepared to part with their drugs expected a higher price. Again, the illicit market in street drugs appears to resemble other consumer markets where shortages of a product are accompanied by price increases:

Betty: ... because there is the demand for them.... Because the people that are selling them know we are so desperate. But we really, really begrudge paying the price, you know, we really do and we know that we are really gonna leave ourselves broke. But because we are so desperate and we know that we need them we overlook what we are being asked for. The price! And we still buy them! But the prices are getting really ridiculous ... and they're getting harder and harder to find.

JF: And the prices?

Betty: Going up—you can pay 65p for one Valium [4] and they used to be four a pound.

Like some other informants of the study, Betty's daily drug intake could include dozens of benzodiazepine tablets and/or capsules, in addition to heroin, methadone and alcohol. Seivewright & Dougal (1993, p. 20) have also shown that during shortages, some of their sample of polydrug users who used high doses of benzodiazepines displayed a desperation akin to that described by Betty, because of their fear of severe withdrawal symptoms, including seizures.

Substitutes
In their discussion of the price elasticity of demand for drugs, Wagstaff & Maynard (1988) point out that when the price of a drug increases beyond a certain level, demand becomes more price elastic and some users cease to buy it. This process is aided by the existence of substitutes. As a substitute for capsules, however, temazepam tablets were not universally popular. Andy explained one reason: 'they're [buyers] suspicious ... now it's just the pills, you can't identify them so well'. These suspicious were on occasions fuelled by rumours that counterfeit temazepam tablets were in circulation.

The reaction by some of the study's temazepam users to the increasing prices and decreasing availability of temazepam in both capsule and tablet form, and to the suspicion with which tablets were regarded was indeed to switch to another drug—diazepam tablets. This became the benzodiazepine of choice for many—both injectors and non-injectors.

As supplies of temazepam capsules became scarce, some temazepam users who had injected the capsules used temazepam or diazepam tablets orally. Even before the changes in regulations, some of those who injected heroin and methadone did not inject the benzodiazepines they used: the 'hit' was considered not to be worth the attendant damage to veins—especially by those long-term injectors with few usable injecting sites. Edward commented that 'when they went to the pills some people [injectors] couldn't be bothered any more'. Andy agreed:

temazepam pills are non-injectable, and even though people still inject pills, it seems to me that people can't really be bothered with them—to fix these pills. Either they can't be bothered or it's because they're almost impossible to fix anyway because of the sediment or chalk or whatever.... When they were gel, you'd know they were temazepam but all of a sudden you've got this white chalk pill and the significance and the myth around it kind of disappears ... from what I've seen, people seem to buy less.... Since the [temazepam] pills came in, the enthusiasm seems to have dropped off quite considerably ...

Other injectors, however, did inject temazepam tablets, and other benzodiazepines meant for oral use.

As temazepam and then its replacement, diazepam, became scarcer and more expensive on the illicit market, some ex-temazepam capsule users switched drugs again. Their benzodiazepine of choice became flunitrazepam tablets (Rohypnol). Those who injected benzodiazepines particularly preferred flunitrazepam, the effects of which are longer-lasting, to diazepam. Demand for flunitrazepam on the illicit market therefore rose, and the price correspondingly increased from £1 (1.5 ecu) per tablet to up to £1.50 (2.25 ecu). As the drug is available only on a private prescription, those who were registered with private doctors began to ask for it to be added to their prescriptions, both to use themselves and to sell.

Other injectors discovered diazepam ampoules which began to appear for sale in the marketplaces. There was no evidence that these were being prescribed by National Health Service (NHS) practitioners, but some informants with private prescriptions began to demand it from their doctors. The cost of the ampoules on the illicit market—£2.50 to £5 (3.75 to 7.5 ecu) each—was, however, beyond the means of many.
The informants of the study displayed an avid interest in legislation and media interest on issues which affected their drug-using repertoires. Some voiced their scepticism that the withdrawal of temazepam capsules was an effective way of preventing harm from drug misuse:

Kevin: ... all that the legislation has done has done has got rid of the

Gelthix. Nothing has been accomplished—there will still be temazepam pills. People will say that they don't get the same buzz off them, but they will still use the pills. If there is a quantity of the drug, be it in pills, gel, or what, people will still use them. It's irrelevant—people will still use them. The only thing is they are not going to satisfy is a needle fixation, because of the chalk [in the temazepam tablets]. One thing is that I'm sure there will be one or two heads around here that will try anyway.

Sasha: The temazepam thing now—the rugby ball thing [gel-filled capsules] now—it's stupid. They took the liquid stuff out and put the gel stuff in and that's why so many people died. If they had just left the liquid stuff in, then there wouldn't have been so many deaths.

Conclusion
After the initial furore and ensuing experimentation with substitutes for temazepam gel-filled capsules, the informants of the study adjusted their drug-using repertoires to take the changes into account—as they had done previously during their drug-using careers, when, for instance, in the 1970s methylamphetamine (Methedrine) was voluntarily withdrawn by the manufacturer, and barbiturates became the favoured substitute.

Whilst the policy to stop drug misusers injecting the gel from temazepam capsules was successful in reducing the numbers who did so, the 'knock-on' effect was an increase in fund-raising activities and experimentation with new substances, such as flunitrazepam (Rohypnol). The drugs marketplaces of the study were characterized by an underlying atmosphere of suspicion and aggression. The shortage and increasing prices of benzodiazepines added to this, as users became more desperate to secure supplies, unfamiliar tablets appeared for sale, and rumours of 'rip-offs' were rife.

The cost of the formulations of benzodiazepines still available on the drugs markets of the study remained at the new, higher levels, meaning that users had to increase activities which generated the funds to buy them (e.g. prescription fraud, shoplifting and selling drugs).

Although some ex-temazepam gel injectors did stop injecting benzodiazepines, there were no reports of informants ceasing to use this drug after the capsules became difficult to obtain on the illicit market, and many injected versions formulated for oral use.

This paper has provided an example of how measures aimed at harm reduction can have both positive and negative implications. This has also been discussed by e.g. Klee et al., (1990, p. 1126); Lavelle et al., (1991, p. 12); Strang et al., (1994). What appears to be a simple harm-reduction measure must be evaluated in the context of its impact on a series of interrelated changes to drug-using patterns and trade in the illicit marketplace. Understanding the dynamics of these changes, and balancing their costs and benefits, is of critical importance when designing intervention strategies, and research using qualitative methods has a crucial role to play in this process.

The paper has also illustrated the complex factors which affect which substance polydrug users include in, or exclude from, their drug-using repertoires. A better understanding of drug markets is needed in order to be able to assess the impact of harm-reduction measures in relation to the ingenuity and flexibility of drug users when, as illustrated here, they are faced with a shortage of a drug they want.

Notes
1 All informants' names are pseudonyms.
2 An out-patient Drug Dependency Unit.
3 A drugs marketplace selling mainly prescription drugs.
4 Most informants referred to diazepam as Valium, which is one of diazepam's brand names.

References
DALE, A. & JONES, S.S. (1992). The Methadone Experience. The Centre for Research on Drugs and Health Behaviour.
DARKE, S. (1994). The use of benzodiazepines among injecting drug users. Drug and Alcohol Review, 13, pp. 53-69.
FOUNTAIN, J., GRIFFITHS, P., FARRELL, M., GOSSOP, M. & STRANG, J. (1996). A Qualitative Study of Patterns of Prescription Drug Use Amongst Chronic Drug Users. Report prepared for The Department of Health, London.
GLASER, B.G. & STRAUSS, A.L. (1967). The Discovery of Grounded Theory: strategies for qualitative research. New York: Aldine.
HAW, S. (1993). Pharmaceutical Drugs and Illicit Drug Use in Lothian Region. Edinburgh: Centre for HIV/AIDS and Drug Studies (CHADS), City Hospital.
KLEE, H., FAUGIER, J., HAYES, C., BOULTON, T. & MORRIS, J. (1990). Aids-related risk behaviour, polydrug use and temazepam. British Journal of Addiction, 85, pp. 1125-32.
LAVELLE, T.L., HAMMERSLEY, R., FORSYTH, A. & BAIN, D. (1991). The use of buprenorphine and temazepam by drug injectors. Journal of Addictive Diseases, 10(3), pp. 5-14.
ORZACK, M.H., FRIEDMAN, L., DESSAIN, E., BIRD, M., BEAKE, B., MCEACHERN, J. & COLE, J.O. (1988). Comparative study of the abuse liability of alprazolam, lorazepam, diazepam, methaqualone, and placebo. International Journal of Addiction, 23, pp. 449-67.
RUBEN, S.M. & MORRISON, C.L. (1992). Temazepam misuse in a group of injecting drug misusers. British Journal of Addiction, 87, pp. 1387-92.
SAKOL, MS., STARK, C. & SYKES, R. (1989). Buprenorphine and temazepam abuse by drug takers in Glasgow—an increase. British Journal of Addiction, 84, pp. 439-41.
SEIVEWRIGHT, N., DONMALL, D. & DALY, C. (1993). Benzodiazepines in the illicit drugs scene: the UK picture and some treatment dilemmas. The International Journal of Drug Policy, 4(1).
SEIVEWRIGHT, N. & DOUGAL, W. (1993). Withdrawal symptoms from high dose benzodiazepines in ploy drug users. Drug and Alcohol Dependence, 32, pp. 13-23.
STRANG, J., GRIFFITHS, P., ABBEY, J. & GOSSOP, M. (1994). Survey of injected benzodiazepines among drug users in Britain. British Medical Journal, 308,23 April.
STRANG, J., SEIVEWRIGHT, N. & FARRELL, M. (1993). Oral and intravenous abuse of benzodiazepines. In.
C. HALLSTROM C (Ed.) Benzodiazepine Dependence. Oxford University Press: Oxford.
WAGSTAFF, A. & MAYNARD, A. (1988). Economic Aspects of the Illicit Drug Market and Drug Enforcement Policies in the United Kingdom. Home Office Research Study 95. London: HMSO.
WHYNF.S, D.K., BEAN, P.T., GIGGs, J.A. & WILKINSON, C. (1989). Managing drug use. British Journal of Addiction, 84, pp. 533-40.