Alprazolam and wider benzodiazepine misuse in Australia – sources of supply and evidence of harms

To the Editor

Moylan et al. (2012) considered the potential impact of increasing prescription rates for alprazolam for the treatment of panic disorder in Australia and recommended further research into how alprazolam is used and accessed, including assessing rates and patterns of alprazolam diversion. An important indicator of misuse involves identifying whether there are changes in population-level harms associated with alprazolam prescribing. Analysing data from ambulance attendance records in metropolitan Melbourne over the period 2001 to 2010, Lloyd and McElwee (2011) reported a small decrease in general benzodiazepine-related ambulance attendances during this period (from 3397 to 3177 attendances, a decline of 6.5%); however, further analysis of the data has shown that alprazolam-related attendances increased substantially, from 373 to 864 (an increase of 132%) in the same period. Furthermore, examining benzodiazepine-related attendances per 10,000 public prescriptions indicated that there has been a more than twofold increase in rates over the same period, with rates of alprazolam-related attendances rising to double the rate of diazepam-related attendances in 2010. Such substantial increases were not found for any other benzodiazepine. This is the first data available at a population level that have identified acute harms associated with alprazolam compared with other benzodiazepines, and highlights the need to identify sources of supply among populations at elevated risk of harm.

Addressing this question, we recently examined the relationship between benzodiazepine use and crime by conducting 83 in-depth interviews with substance-using offenders recruited through the criminal justice system in Melbourne, who reported high rates of diazepam (84% in the month prior to the index offence) and alprazolam (75% for the prior month) use (Best et al., 2012). Sources of benzodiazepines are reported in Table 1, presenting a complex picture of multiple diversion points. There was widespread access to prescriptions for ‘fake’ as well as ‘real’ symptoms, as well as high levels of street purchasing – particularly for alprazolam. Additionally, there was considerable trading and sharing of benzodiazepines among substance-using networks.

Table 1.

Sources of benzodiazepines.

Acquisition source	General source (n = 83)	Source in last 6 months (n = 83)	Alprazolam in last 6 months (n = 77)
Prescribed (real symptoms)	79.5	72.3	22.1
Prescribed (fake symptoms)	50	14.5	9.1
Free (friend/partner)	83.1	51.8	37.7
Purchased (friend/partner)	68.7	38.6	36.8
Purchased (street)	74.7	53	66.2
Pharmacy theft	16.9	1.2	2.6
Prescription fraud	22.9	1.2	0
Internet	3.6	1.2	0
Trade for drugs	61.4	28.9	22.1
Trade for sex	3.6	0	1.3
Other	8.4	8.4	2.6

Data presented as percentage of recruited sample.

Our data suggest that high-risk populations have access to multiple sources of benzodiazepines, particularly alprazolam and that, in contrast to the overall trends for benzodiazepines, alprazolam use is associated with both drug-related offending and increased utilisation of emergency medical resources in Victoria. More research in this area is a priority, particularly in terms of determining how to limit opportunities for diversion and community harm.