Benzos are like a box of chocolates: How tough drug laws lead to counterfeit drugs

What is actually in my Xanax?

by AJ Martin

The Psychoactive Substances Act 2016 is an Act of UK Parliament introduced under Theresa May’s government in an attempt to restrict the production, sale, and supply of novel psychoactive substances (NPS). NPS – also known as designer drugs, research chemicals or legal highs –, emerged in the mid-2000s. These new drugs, often compounds that were never marketed for medical use, were popularised for recreational use as they avoided criminalisation as outlined in the Misuse of Drugs Act 1971, which placed sanctions on individual substances such as MDMA. An amendment to this Act in 2017 placed several NPS, including 16 designer benzodiazepines, into Schedule I. 

While attempting to mimic the effects of these long-established ‘classical’ drugs, designer drugs pose potentially increased risks due to limited knowledge of their adverse health and social harms including seizures, acute psychosis, and the development of dependence. Though the introduction of the NPS blanket ban has led to the closure of above-ground “headshops”, the sale of NPS continues underground and drug-related deaths continue to rise.

What are people actually buying?

In 2021, there was an 88.3% increase in NPS-related deaths compared to the previous year. Benzodiazepines (benzos) contributed significantly to this figure, with analogues such as flubromazolam and etizolam involved in 176% more deaths in 2021 (176) than 2020 (62). Welsh Emerging Drugs and Identification Of Novel Substances (WEDINOS), a Welsh harm reduction project providing drug testing services, have identified a number of benzo analogues entering the supply. In 2022-23, WEDINOS found that only 45% (539) of samples thought to be diazepam (Valium, a prescription benzo) actually contained the drug – meaning 55% of samples contained a different psychoactive substance

The most commonly identified substitute in these counterfeit benzos was bromazolam – an unmarketed benzo analogue with limited safety data – which was found in 34% (411) of samples. Of those, 91% (372) also contained etizolam – another under-researched benzo analogue most often implicated in drug-related deaths in Scotland. Both bromazolam and etizolam are much more potent than diazepam, with 1 gram of etizolam equating to 500 doses. Therefore, more doses per kilogram can be imported, concealed, and cut with other substances and bulking agents to increase profit margins. However, their stronger effects can lead to an increased risk of accidental overdose for those unaware of what they are actually buying. Another worrying adulterant found in 8 samples thought to be benzos (alprazolam, 7; diazepam, 1) were nitazenes. Nitazenes are a group of synthetic opioids with a potency up to 1000x that of morphine that have been involved in at least 27 fatalities in the UK in 2021. 

Overall, NPS are still prevalent among illicit supply chains despite legislative changes, posing significant health and social risks to people who use benzos, who are often unaware of what they are actually consuming.

Based on this data, you can assume that if you buy benzos in the UK (i.e. not from a pharmacy), you are essentially flipping a coin to determine whether what you bought is what you asked for. This is of increasing concern following the Home Office’s effective withdrawal of permission to carry out back-of-house drug testing at UK festivals. Confiscated drugs, and drugs placed in amnesty bins, have been routinely tested on-site at festivals since 2014; the result of successful collaboration between event promoters, the police, and other agencies. This means that the lives of festival-goers – often young adults – will be put at risk, unaware of the dangerous adulterants circulating the drug supply.

How can people reduce the harms associated with designer benzos?

There are some steps that individuals can take to reduce the risks of counterfeit drugs. An overdose alert was sent out in July 2023 by the UK charity Humankind, urging people who use drugs in the UK to not use alone, and carry naloxone in the case of an accidental synthetic opioid overdose. Pfizer, the manufacturer of Xanax, released guidelines on how to identify counterfeit drugs. Drug checking services such as WEDINOS can remove some uncertainty by testing a sample of what they bought. To allow sufficient time for delivery and analysis, samples must be submitted a few days in advance, and unregulated drug manufacturing means purity can vary between pills in the same supply. Drug support services such as Crew advise to start with a low dose and wait to feel the effects before taking more of the tablet, and to avoid mixing with other drugs. 

However, it is clear that the UK government’s approach of “cracking down on drug use” is unfit for purpose. Continuing to ignore these unintended consequences of drug prohibition will lead to countless more preventable deaths. In order to fully eradicate counterfeit benzos and their greater associated harms from UK drug supply, a significant overhaul of our drug laws based on evidence is urgently needed.

AJ Martin is the Co-Head of Research at the Benzo Research Project and a BBSRC LIDo PhD student at Queen Mary University of London. The crossover between his academic and personal life has resulted in a passion for evidence-led drug education and support, centred around reducing harm to young people who use drugs. Tweets @AJL_Martin

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