Co-use of benzodiazepines and opioids in the UK:a qualitative study on co-use motivations, consumption patterns, and overdose prevention behaviours.

Background: Drug overdoses (OD) have substantially increased over the past decade in the UK, particularly in<br/>Scotland. Co-using prescribed and/or illicit opioids and benzodiazepines or z-drugs [BZ/z-drugs] contributes<br/>to overdose (OD) risk. It is, however, unclear why and how people co-use, and what strategies people use to<br/>minimise OD risk.<br/>Methods: Forty-eight semi-structured interviews were conducted with people who co-use opioids and BZ/zdrugs in community settings in Glasgow (n=28), Teesside (n=10) and Bristol (n=10). Most identified as male<br/>(77%), white British, Scottish or English (94%) with a mean age of 43 years. Eighteen (38%) interviews were<br/>(co-)facilitated by qualitatively trained local peer researchers. Reflexive thematic and framework analysis<br/>were used.<br/>Results: Participants’ motivations mapped onto functional and experiential motivations. Functional<br/>motivations included augmentation, self-medicating mental health symptoms and trauma and being able to<br/>generate income. Experiential motivations were (1) buzz, (2) glow, (3) feeling ‘gouchy’ and (4) oblivion. These<br/>were linked to six co-use patterns: (a) low-dose BZ/z-drugs (am and pm), (b) coming down with street BZ/zdrugs (am and pm, various doses), (c) co-use throughout the day (regular, high doses), (d) BZ/z-drugs/opioid<br/>binges (irregular, high doses), (e) curated co-use (structured, controlled) and (f) BZ/z-drugs use throughout the<br/>day (BZ unstructured, opioid use structured). Overdose risk perceptions ranged from self-efficacy driven ‘I can<br/>help myself’ to self-efficacy-lacking evaluations ‘there is nothing I can do’. Perceived lack of tailored support<br/>for co-use reinforced beliefs of help- and hopelessness. People expressing high self-efficacy employed their<br/>own risk reduction strategies, e.g., using a trusted seller, limiting alcohol co-use.<br/>Conclusions and Implications: Tailored harm reduction, and mental health support for people who co-use is<br/>desperately needed. Our findings identify opportunities for psychosocial and prescribing interventions tailored<br/>to people’s motivations and patterns of co-use that build upon their existing harm reduction behaviours and<br/>OD risk perceptions.<br/>