‘Russian Roulette’: how do people who co-use benzodiazepines and opioids experience the absence of harm reduction?

Background

Polydrug use, particularly co-use of benzodiazepine (BZ) (or BZ-like z-drugs) and opioids (prescribed & street) contribute to drug related deaths in the UK. Nationally, there is a gap in treatment options and tailored harm reduction for people who co-use, creating a unique risk environment. This study examines harm reduction from the perspective of people who co-use, including views on opportunities for intervention. 

Methods

We conducted 48 semi-structured interviews in Bristol (n=10), Teesside (n=10) and Glasgow (n=28) with individuals who currently (or in the last 6 months) co-use illicit/prescribed opioids and BZs. Most participants self-identified as male (n=37, 77.1%), white British, Scottish or English (n=45, 93.7%), were 42.6 years of age (SD=8.7) on average ranging from 25-61 years. 18 (37.5%) interviews were co-facilitated by trained peer researchers, supporting in-depth exploration of local context. Interviews were analysed using reflexive thematic analysis. Researchers adopted a critical realist stance, interpreting themes through the lens of the Rhodes’ risk environment framework (REF). 

Results

Four themes capturing how people engaged with the co-use ‘risk environment’ and opportunities for harm reduction were developed: (1) Russian roulette: playing ‘Russian roulette’ was regarded as a necessary evil, where the need for the functional or experiential effects of co-use (e.g. avoidance of withdrawal), superseded the inherent risks of combining drugs from a harmful unregulated illicit market i.e. the fear of getting ‘the bullet’. Participants relied on self-generated evaluations of potency, adulteration and ‘safe’ polydrug use combinations; these judgements led to behaviours which could promote or reduce harm (e.g. megadosing). (2) Low perceived psychological, physical or social safety: the Russian roulette led to low percieved safety, again generating behaviours which could both prevent and promote harm. Disconnection from social networks against a backdrop of percieved vulnerability, scarce resources and poor housing situations was seen as protective encouraging solitary co-use, enhancing overdose (OD) risk. The lack of any treatment offer for co-use was apparent, leading to an internalisation of ‘no one cares.’ For some, this meant that they developed their own solutions (3) I can help myself, others, described their (4) learned helplessness and oblivion increasing co-use and reducing motivation to engage with harm reduction.

Conclusions

Themes are interpreted from the lens of the REF to consider risks at the physical, social, economic, policy levels, and across the micro/macro environment. The lack of an agreed treatment offer for co-use generates avoidable opportunities for risk associated with co-use behaviour, particularly for the most marginalised with histories of extensive polydrug use. Results suggest opportunities for systemic changes to manage OD risk, including the co-development of harm reduction protocols.