Criminology Files : #3 - Drugs and Society
Launching the third part of the criminology series. This goes into drugs and their effect on society. My assignment focuses on Benzodiazepines. As I mentioned in my first post of the series, the Criminology Files will now go into hiatus until some time in summer, by which time I should have presented and received the result for four more assignment, the final additions to the series.
This edition is likely to appeal to those interested in : Medicine, Criminology, Pharmacy, Law (specifically drug legislation) and Lost (on a superficial level).
The entire series is posted as has been presented to the university, and no part has been altered or inserted after it's presentation.
Courtesy of Darryl, from Malta - Online.
This edition is likely to appeal to those interested in : Medicine, Criminology, Pharmacy, Law (specifically drug legislation) and Lost (on a superficial level).
The entire series is posted as has been presented to the university, and no part has been altered or inserted after it's presentation.
The aim of this assignment is to explain the use and potential abuse of a given drug as well as the legal aspect of the use of such a drug. Furthermore, an analysis of the socio-psychological explanation of its use and the possibilities for punishment, treatment and prevention where relevant, will also be provided. Throughout the course of this assignment I will present this information with regards to Benzodiazepines. Thus, my research will focus on the way benzodiazepines affect the user at different stages of use as well as after their use (withdrawal symptoms). When necessary, I shall also make references to the portrayal of the drug, or its derivatives, in the media.
Explanation of the Use and Abuse
Benzodiazepines are depressants and therefore induce a calming effect within those who administer it or have it administered to them. Thus, like most drugs, benzodiazepines can be used legally as well as abused illegally and in this section, I will attempt to cover the various ways in which these could happen. Acute mania is one such case when benzodiazepines are used clinically. The American Psychiatric Association lists some of the symptoms of mania as being euphoria and impulsiveness as well as less need for sleep (which could develop into insomnia). Being depressants, benzodiazepines are able to counteract these conditions. Incidentally, insomnia is another condition which is treated with benzodiazepines as some strands are hypnotics and thus, encourage sleep. However, with use, tolerance increases requiring greater dosages to be used and potentially leading to addictions.
This is, in fact, why treatment with benzodiazepines is reserved for short-term treatment. Conversely, insomnia is one of the withdrawal symptoms of benzodiazepines (Katz et al, 2000), which I will delve into further later in the assignment. The media has used benzodiazepines for the treatment of mania in the television series Lost. While I will not get into the specifics and accuracy of the situation portrayed, it is worth noting that Clonzepam, a type of benzodiazepine, was prescribed for someone displaying insomnia and other symptoms of mania as well as anxiety. This brings me to the next legal use of benzodiazepines which is that of an anxiolytic.
On this note, in 2003, the American Psychiatric Association questioned whether benzodiazepines were still the preferred drug for those suffering from panic disorder (anxiety). The results of the study showed that “treatment patterns for psychotropic drugs appear to have remained stable over the past decade, with benzodiazepines being the most commonly used medication for panic disorder” (Bruce, Goisman et al).
Benzodiazepines can also be used as anticonvulsants and have proven effective in the management of status epilepticus. The drug is used with patients in extreme pain and in intensive care; however, it is used cautiously due to instances when chemical problems may lead to benzodiazepine overdose. In spite of having their own withdrawal symptoms, benzodiazepines are effective in treating the symptoms of alcohol withdrawal. However, in 2006 the National Treatment Agency for Substance Misuse (UK) claimed that while benzodiazepines are the best documented drugs for alcohol withdrawal, the insufficient evidence together with the risk of benzodiazepine dependence deny that the drug’s use is possibly the best method of dealing with alcohol withdrawal.
Benzodiazepines are widely used in animals too, ranging from the sedation of wild animals to treating epilepsy in dogs and treating muscle spasms in cats (Polizopoulou et al, 2002). Muscle spasms are also treatable in humans with benzodiazepines. So far, I have dealt with the legal uses of benzodiazepines and I will now look at the illegal consumption of the drug. Benzodiazepines are primarily abused to benefit from the sedation which aids one to relieve oneself from emotional stress. Abusers become dependant on and tolerant to the drug resulting in increasing dosages to achieve the same effect. Benzodiazepines, such as Clonazepam, are only intended to be used in the short-term, and withdrawal after long-term bears the risk of inducing the same ailments that benzodiazepines generally treat (including seizures).
McLellan, Woody and O’Brien (1979) conducted a study of fifty-one Vietnam veterans who were abused drugs, fourteen of whom abused benzodiazepines. The aim of this study was to examine the causal relation between drug abuse and psychiatric disorders. The study took place over six years. At the end of the six years, eight of the fourteen had developed depression. This would seem to indicate that benzodiazepine abuse has a significant impact on one’s mental health. It is worth noting, that those who conducted the study do not ignore the possibility that personality disorders which existed before the study may have lead to different kinds of drug abuse.
Legal Aspect of the Use of the Drug
Like all drugs, benzodiazepines are subject to a degree of control. However, the level of control varies from one country to another. According to the website of the United States Drug Enforcement Administration, benzodiazepines are regulated under Schedule IV of the Controlled Substances Act. This ranking means that it has a relatively low potential for abuse and that the drug is used for medical treatment within the United States. Additionally, drugs ranked at level four have, in the opinion of the Drug Enforcement Administration, a lower potential for physical and psychological dependence. Hence, in the United States of America, prescriptions for any benzodiazepines are legally allowed to be refilled up to five times in a period of six months. According to the same website, in 1999 there were approximately 100 million prescriptions written for benzodiazepines. In spite of this, the Medicare Prescription Drug, Improvement, and Modernization Act (2003) does not allow health insurance companies to cover benzodiazepine prescriptions in their policies. In Canada, benzodiazepines are under similar controls. The same cannot be said for the rest of the world, where regulations are harsher due to the large potential for abuse.
The Standard for the Uniform Scheduling of Drugs and Poisons (SUSDP) used in Australia lists two types of benzodiazepines (flunitrazepam and temazepam) under Schedule 8 (Controlled Drugs). This makes them illegal to possess because of their potential to be abused and their dependence producing qualities. While other benzodiazepines can legally be owned for personal use (when prescribed), distribution and trafficking of the drug is illegal and subject to fines or imprisonment. On an international level, temazepam, flunitrazepam and nimetazepam are under Schedule III in the Convention on Psychotropic Substances of 1971. This ranking means that while they are therapeutically useful, they have the potential for serious abuse. All other benzodiazepines are listed under Schedule IV – mainly used in therapy but are still able to generate a significant degree of dependence. In New Zealand doctors are obliged to only allow one month’s supply of benzodiazepines per prescription.
Dr. A. E. Smith (1989) claimed that while under the effects of benzodiazepines, patients of all dosage levels may become vulnerable to committing crimes and in which case doctors may be required to confirm the prescription. Thus, while Smith’s research does not deal with the direct legal implications of the possession and use of benzodiazepines, she is looking at cases when benzodiazepines, because of the behavioural changes they cause together with other effects, may lead the user to commit crimes which not be dealt with by any drug laws.
“The use of benzodiazepines presents a unique set of clinical, ethical, and legal dilemmas” (Bursztajn and Brodsky, 1997). This is because while it is a very important medical drug, it also produces various forms of dependence. Thus, Bursztajn and Bordsky go on to explain how the prescription of benzodiazepines is laden with ethical considerations and that different circumstances may make it unethical to prescribe them, or unethical not to prescribe them. They cite Salzman who summed up the controversial situations that may arise with regards to benzodiazepine prescription into three. Firstly, the potential for abuse following the cessation of the use of the drug for medical reasons. Secondly, controversies relating to long-term use due to the development of dependence and withdrawal symptoms. The third group are those relating to side effect with a special emphasis placed on behavioural changes, as explored by Smith.
So, to bring this section to a close, while benzodiazepines are not considered to be as dangerous as drugs like cocaine and oxycodone (Schedule I and II respectively in the US) in terms of the capacity for addiction and physiological danger, they are still closely controlled in virtually all parts of the world. The need for benzodiazepines in the medical world prevents governments from imposing more serious controls on the drug. The paradoxical side effects that can arise from their prolonged use such as mania and schizophrenia make this drug dangerous when not used under the guidance of a qualified medical professional. In the next section, I will drift away from the legal perspective of benzodiazepine use and focus on the socio-psychological explanation for the use of this drug.
The Socio-Psychological Explanation
Unlike stimulants which increase alertness and activity, depressants decrease awareness and energy levels. This makes it slightly more difficult to understand why such drugs would be used/abused when there is no medical need for them. In a survey carried out by the Australian government between 1999 and 2005 of people in police custody, it was discovered that benzodiazepine users had certain traits which, while not enough evidence existed to generalise for the entire community, gave some insight into the possible behaviour of benzodiazepine users and abusers. The survey showed how benzodiazepine users were more likely to have been homeless at some point in their life and recently abused other depressants. The same survey revealed that they were less likely to be in full-time employment or alternatively, be working illegally and/or claiming benefits from the government (Loxley, 2007).
Benzodiazepines have been used by people suffering from Munchausen syndrome by proxy. This disorder occurs when the person with the illness causes pain and suffering to another person or to themselves with the intention of attracting attention (Artingstall, 1999). In 1997, several such cases involving benzodiazepines were reported where the drug was administered to children (Jones, Schexnayder et al) and to a husband (Osawa, Saito et al) resulting in poisoning. Due to their capacity to lower awareness and reactions, benzodiazepines are also used in cases of rape and even robbery (on the victims). In 1996, a survey was carried out among thirty-five people who claimed to have been drugged before being raped and/or robbed. Seventeen of these had traces of benzodiazepine in the urine sample taken following the commission of the crime (Beugnet, Boussairia et al).
This seems to suggest that when benzodiazepines are not used for medical reasons, the socio-psychological explanation behind their use is not one of personal reasoning, rather that of exploiting others through intoxication. Nonetheless, according to Weir in 2001, alcohol remains the top drug utilised for date rape and other sexual crimes where it is detected in 69% of available samples. This appears to indicate that benzodiazepines are not necessarily an offender’s first choice for use on their victims. In spite of its perception as a relatively safe drug when compared to other depressants and drugs in general, research seems to suggest otherwise.
In 2001 in the United Kingdom, figures released from the Home Office revealed that in Scotland one hundred and fifty-one (151) people died in 1998 from taking benzodiazepines while just one hundred and fourteen (114) died from overdoses in heroin and morphine. Furthermore, between 1990 and 1996, one thousand, eight hundred and ten (1810) people died as a result benzodiazepine use while a smaller figure of one thousand six hundred and twenty-three (1623) are reported to have overdosed on heroin, morphine and other opiates. In 2001, Margaret Bell also claimed that :
“Since 1960, the UK medical profession has turned at least three million adults and two million ‘Benzo Babies’— infants whose mothers took tranquillisers during pregnancy—into brain-damaged addicts. There are currently still some one million patients trapped in addiction and another million disabled by withdrawals”
(Bell, 2001)
This is primarily brought about due to the common misdiagnosis for benzodiazepines which, due to their capacity to develop dependence within the consumer, are dangerous when prescribed for long-term treatment and may conflict with a patient’s medical history.
Mah and Upshur conducted a study in 2002 with the aim of comparing the perceptions of patients and the physicians in relation to the prescription of benzodiazepine as a long-term solution to insomnia. All ninety-three patients were over sixty years old while the twenty-five physicians came from various sectors of the medical profession. The results concluded that the amount of perceived risk was less in the patients then in physicians. This is understandable as medical professionals would have a higher understanding of drugs and their effects than the common individual. Thus, in light of this difference in opinion, the authors suggest open dialogue as a method of clearing up queries.
As a final note in this section, it is worth noting that outside of clinical prescription, benzodiazepines seem to be rarely used for personal reasons. However, research shows that they are still used on others (victims) by perpetrators as a way of reducing the reactions of such people while a crime is committed. Furthermore, while benzodiazepines are generally perceived as comparatively safe drugs, statistics show that their high potential for dependence and paradoxical side effects with long-term use have resulted in the death (through both suicide and murder) of those who consume the drugs.
Punishment, Treatment and Prevention
In the United Kingdom, it is not illegal to possess benzodiazepines without a prescription. An exception is made for Temazepam. In this case, figures from the Home Office show that anyone in possession of Temazepam, a Class C drug, may be subject to a maximum sentence of two years in prison, a fine with no limit or both. Furthermore, if it is being prepared for injection it is upgraded to a Class A drug, increasing the punishment for its possession to up to seven years imprisonment, an unlimited fine or both. However, punishment is harsher for benzodiazepine dealers who could be subject to an imprisonment term of up to fourteen years and/or an unlimited fine. The limit of the term of imprisonment is raised to life if the drug is being prepared for injection at the dealing stage.
The Maltese Dangerous Drugs Ordinance does not make specific reference to benzodiazepines; however it does state that dealers or traders of drugs, if convicted by the Criminal Court, may be sentenced to a term of imprisonment of not less than four years and not more than thirty years and fined. For any other drug-related offences a prison sentence of not less than twelve months and not more than ten years and a fine applies. On the other hand, if dealers are convicted by the Court of Magistrates a prison term ranges from six months to ten years while punishment for other drug-related offences is between three and twelve months imprisonment.
With regards to treatment, withdrawing from benzodiazepines gives rise to the benzodiazepine withdrawal syndrome comprising of several side-effects which vary depending on the speed and abruptness of the withdrawal. In 2007, McConnell suggested that the best way to withdraw from benzodiazepines is to switch to Diazepam (a benzodiazepine derivative) which has a half-life of twenty to one hundred hours and is not very potent. He suggests replacing the former benzodiazepine drug with Diazepam a bit at a time while allowing for a period of stabilisation. C. Heather Ashton argues in favour of slow withdrawal schedules so as to minimise the withdrawal symptoms. She claims that benzodiazepine users who withdrew too quickly were significantly more likely to report the rarer and more severe side effects. Among these more severe side effects, one finds seizures, comas, suicides and suicidal thoughts, delusions and mania. Heather Ashton also claims that when withdrawal occurs too quickly, some people develop Post Traumatic Stress Disorder as they are not prepared for the side effects and are overwhelmed. In 2006 (reviewed in 2008), the President and Fellows of Harvard College added that following the successful withdrawal, one must undergo counselling or psychotherapy so as to prevent relapse.
The National Institute of Drug Abuse in the United States of America believes that prevention efforts can begin as a community activity in general, rather than just a personal process. A nine-stage analysis of community readiness was drawn up to enable one to better assess the situation in their community with regards to the awareness of drugs in such a community. The steps range from ‘No Awareness’ to ‘Professionalisation’. At each stage, suggestions are made as to how to best utilise the available resources such as creating motivation for those communities with ‘No Awareness’ and setting up programs targeted at all audiences for those societies at the level of ‘Professionalisation’ (Edwards et al, 1999). It would seem that the old adage that “prevention is better than cure” holds true for benzodiazepines since prevention avoids the whole experience while ‘cure’ (withdrawal) could leave the former user scarred physiologically and psychologically.
Throughout this assignment I have analysed the aspects surrounding benzodiazepines. Thus, I have explored the biological and medical reasons for their use and the potential for abuse as linked to benzodiazepines’ high risk of dependency. I went on to discuss the legal perspective when it comes to the drug both in terms of penalties for misuse and illegal trading of the drug as well as crimes which are committed because of benzodiazepine use. This was followed by an examination of the social and psychological reasons behind the use of benzodiazepines and with the help of published statistics deduced that outside of medical requirement, benzodiazepines are used to intoxicate victims. Finally, the punishment, treatment and prevention options suggested, available and used around the world were tackled. Hence, I can conclude that benzodiazepines are unique in the sense that they are not considered among the world’s most dangerous drugs but in recent years they have come to be regarded as more dangerous than some higher ranked drugs, possibly because of misconceptions about their use.
Courtesy of Darryl, from Malta - Online.
Labels: Criminology
