Rough Treatment

Release is the national centre of expertise in drugs and drug laws. We were founded in 1967 – potentially making us the world’s oldest drugs charity – and we provide free, non-judgmental, specialist advice and information to the public and professionals on issues related to drug use and drug laws. We also fight for drug policy reform, so that in the future people who use drugs are treated based on principles of human rights, dignity and equality. To achieve this, we advocate for evidence-based drug policies that are founded on principles of public health rather than a criminal justice approach.

We provide frontline services via our legal clinics around the country. We also provide direct advocacy support to people who use drugs, to ensure that those in drug treatment are receiving person-centred care. Over the years, we’ve advocated for the rights of many different groups of drug-using people. In some cases, matters are swiftly and positively resolved for all involved – with others, issues can sadly drag on for years at the expense of the service user, who is subjected to inadequate or ill-fitting treatment plans throughout this lengthy process. 

Orange book and ashton manual
The Orange Book details how clinicians should treat people with drug misuse and drug dependence problems. The Ashton Manual contains protocols for tapering safely.

Release actively works towards a world where our drugs advocacy service becomes obsolete, and where people who use drugs are heard when they need changes to their treatment plans – not because they’ve brought in ‘a national expert’ to sit in on their medical review, but because their needs are respected. To make this vision a reality, we’ve embarked upon a mission to create, publish and widely distribute our own advocacy toolkit, so that people can more readily advocate for themselves and their communities. 

Of course, our toolkit won’t account for everything, and we still find ourselves regularly stumped on advocacy cases. Much of what we’ve achieved would not be possible without help from others in the harm reduction world, who have generously shared examples of good practice, specialist resources, and strategy ideas for our advocacy cases. We want to return that kindness by sharing with our community what we have been through and learnt, in the hopes that future services can improve their practices and people can more easily access high quality treatment.

For this reason, every other month, Release will publish a case study in DDN from our advocacy work, including relevant guidelines and pieces of evidence we used. Our aim is to promote better practices for DDN readers who work in services, and to give people tools to challenge their own treatment decisions, if they find themselves in similar circumstances.

Nick’s Case

For our first case study, I’d like to introduce ‘Nick’ – not his real name, but a very much real and recent situation. Nick is a 42-year-old man who was dependent on street benzos, mainly diazepam, when he contacted Release. His benzo supply has not been regular, and when he has accessed drug testing via WEDINOS he has seen that at least on one occasion his supply was bromazolam as opposed to diazepam, which is what it supposedly was when purchased. 

Nick has used benzos for six to seven years, on and off for the first few years. He is not sure how long he has been ‘dependent’, although he believes this has been since around lockdown. During lockdown, Nick’s overall quality of life deteriorated, and his drug use increased. In 2021, he admitted himself into a private rehab clinic, staying there for two months. He was consulted by a virtual clinician for 20 minutes who was based abroad, then immediately put on only 30mg of diazepam when he was previously on a much higher dose of street benzos. The withdrawal was difficult to manage, impacting his sleep and his ability to take part in psychosocial interventions, causing him eventually to leave the rehab.  

Nick has been in drug treatment twice, not counting his time in private rehab. His first time was around 2019. During lockdown, he returned to drug treatment and has been there since. However, since the end of lockdown, Nick’s service has been recommissioned, causing significant staff turnover. Nick was assigned a new key worker every few weeks, negatively impacting his ability to build a therapeutic relationship and make progress in his treatment plan. At this point, Nick reached out to Release, with the goal of safely working towards becoming abstinent from benzos. However, his treatment service says they won’t prescribe benzos to him to use for this reduction as it is against the service’s policy. 

What do the guidelines say about Nick’s case? 

Regarding the care Nick received at his private rehab, the Drug misuse and dependence: UK guidelines on clinical management, otherwise known as the Orange Book, states that: ‘For those who are benzodiazepine dependent, sudden cessation in their use can lead to a recognised withdrawal state. Good assessment and care planning – and adherence to local protocols – are prerequisites for considering prescribing benzodiazepines. Prescribing benzodiazepines to drug misusers requires competencies in this form of treatment and appropriate supervision.’

As for the commissioned drug treatment provider, the same guidelines say that to ‘prevent symptoms of benzodiazepine withdrawal, the clinician should continue a current prescription but the dose should be gradually reduced to zero… The aim should normally be to prescribe a reducing regimen for a limited period of time.’ 

When Nick contacted us, he was already quite knowledgeable about the Orange Book and other resources such as the Ashton Manual, which contains protocols for tapering safely off different benzodiazepines. We obtained permission from Nick to contact his treatment provider and request their benzodiazepine treatment policy. They then produced a policy which allowed for prescribing, but only for a very short period of time – there was little room for flexibility in how a person can detox safely and comfortably. 

Once again, the Orange Book states that: ‘While full detoxification can proceed without difficulty within weeks or within 2-3 months for some patients, NICE expert review has noted that withdrawal may take three months to a year or longer in some cases. An optimal speed or duration of dose reduction is not known.’

Ultimately, Nick ended up doing the taper himself with his illicit supply rather than continuing to battle his service to access care. His goal now is to share his story and influence treatment systems to better support people who use benzodiazepines. Nick worked with Release to turn his story into a case study to share with attendees of the Managing Drug And Alcohol Problems In Primary Care Conference, to promote more understanding amongst prescribers, and has given permission for its use here.

Shayla Schlossenberg is drugs service coordinator at Release.

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