Background Co-use of benzodiazepines and/or ‘z-drugs’ along with opioids is linked to the rise in drug related deaths (DRD) in the UK. Understanding patterns of co-use could inform harm reduction strategies for reducing DRDs. This study explored how people co-use, including dosages, timings, methods of administration, use of other substances and desired effects sought.

Methods Forty-eight semi-structured interviews across Glasgow in Scotland (n=28), Bristol (n=10) and Teesside (n=10) in England with individuals who co-use illicit and/or prescribed opioids and benzodiazepines/z-drugs were conducted. Eighteen interviews were co-facilitated with qualitatively trained local peer researchers. Interviews were analysed using the Framework method.

Results Six co-use patterns were generated: (1) co-use to aid sleep or come down, (2) curated co-use, opioid agonist therapy (OAT) only (3) morning and evening benzodiazepine doses with opioids throughout the day (4) co-use binges (5) co-use throughout the day, (6) benzodiazepine use throughout the day plus OAT. Patterns one to three reflected more controlled co-use with a focus on self-medicating to give confidence, manage anxiety, promote sleep and come-down from cocaine/ketamine. Patterns four to six involved greater poly-drug use, and less controlled co-use with a focus on seeking euphoria (“warm glow”, “gouching out”) or oblivion (to escape untreated mental health conditions and trauma). Patterns two, three, five and six involved daily co-use. People switched between patterns depending on available resources (e.g. finances) or changes to prescriptions (opioids or benzodiazepines). Near-fatal overdoses were reported by participants across all co-use patterns. Patterns four to six were conceptualised as presenting greater overdose risk due to less controlled co-use and more extensive polydrug use.

Conclusions The patterns identified provide opportunities for future harm reduction strategies, tailoring advice, updated prescribing guidance and policies, and the need for better access to mental health care, for people who co-use benzodiazepines and opioids to reduce DRDs.

Highlights

Six patterns of benzodiazepine/z-drug and opioid co-use were identified

People switched between patterns depending on access to resources (e.g. finances)

Near-fatal overdoses were experienced across all patterns

Patterns provide opportunities for harm reduction e.g. tailored interventions

The authors have declared no competing interest.

This work was supported by the Medical Research Council grant number MR/W029162/1. JK and HF are partly funded by National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) and NIHR HPRU in Behavioural Science and Evaluation. MH is funded by NIHR HPRU in Behavioural Science and Evaluation.

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Ethical approval for this study was obtained from the Faculty of Health Sciences Committee for Research Ethics, University of Bristol (ref 11906).

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Data are available on application at the University of Bristol data repository data.bris. Data access is restricted to bona fide researchers for ethically approved research and subject to approval by the University's Data Access Committee.

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