The impact of Brexit on our overdose epidemic
A trend has been developing among the UK’s heroin users, noticeable most around Glasgow and the west of Scotland. Pairing heroin with a hypnotic drug such as zolpidem, diazepam or alprazolam creates a synergistic effect and produces a much more intense high. In a time of economic hardship, this has been enormously effective in counterbalancing increased prices, reduced purities and ever-climbing tolerances among communities that have relied on the drug for decades.
It should go without saying that this is an extremely dangerous proposition but I’ll say it anyway for emphasis: this is an extremely dangerous proposition. Combining drugs in this manner is unbelievably risky at the best of times, let alone when using drugs as notoriously unpredictable as the British heroin supply.
Recent developments have added another wildcard into the situation, however: “Street Blues”. The UK is currently experiencing a glut of counterfeits pills, which contain none of the real active ingredient whatsoever. Rather than diazepam or alprazolam, these pills are made of formerly-legal highs like etizolam by illicit dealers. These untested, unregulated drugs are killing people on a daily basis.
People who have been relying on the microgram-accurate doses of pharmaceutical drugs instead find themselves taking identical pills which create anywhere between half to triple the expected effect, and even the most experienced of users now have no means to manage their habit.
This is already a crisis, contributing to a rise in drug deaths unprecedented in modern Scotland, and when the effects of Brexit hit our heroin supply, it is due to become a catastrophe.
The history of UK heroin and modern trade routes
The succinctly-titled European Monitoring Centre for Drugs and Drug Addiction, an EU body which monitors drugs and drug addiction, produced a study into the international heroin trade which features this map.
As you can see, the vast majority of Europe’s opium is produced in Afghanistan, then transported to Pakistan for processing into heroin, reducing the mass to be transported by around 90% before it is shipped on any further. At this point, most is transported over land through Iran and Turkey, before entering the EU through the Balkans.
This route, while much slower than direct freight transport, provides better security. After all, a plane full of off-white powder travelling directly from Pakistan to Glasgow might be subject to a fair wee bit of scrutiny. Less attention, meanwhile, would be paid to a truck travelling across often-unguarded borders from country to country in areas of little government oversight.
Once inside Europe, the majority of the cargo moves to the Netherlands, where it is repackaged and distributed throughout Europe. open borders and minimal custom controls allow it to move unmolested to its target markets.
As the UK approaches its departure from the EU, it runs the risk of interrupting this orderly flow. Even the softest proposed Brexit will introduce additional checks on EU imports, resulting in increased seizures given current practices or, more likely, reduced supply moving into the UK as appropriate stealth becomes more expensive. Harder Brexits, all the way up to the dreaded No Deal, will compound this effect. As supply chains dry up, dealers will have to do whatever it takes to meet demand, stepping ever harder on their already paper-thin products. Prices will skyrocket and purity plummet.
Polydrug use in heroin-using communities
Long before the very suggestion of Brexit, long-term heroin users have faced issues of low purity and high price as their tolerance climbed. It’s difficult to gauge exactly when the combination of heroin and drugs like diazepam became a consistent practice for many users, but it’s easy to see the logic. Medically speaking, we could consider this a form of adjunct therapy: using an additional drug to compound the effects of the primary treatment.
While this particular combination is, again, extremely dangerous and can easily kill the user with even a small error, we could technically consider it a form of ad-hoc harm reduction. By lowering the required dose of heroin, it enables users to reduce their consumption of the dangerously-impure drug to which they’re addicted (when Welsh analytical lab WEDINOS gets samples of heroin, heroin is rarely even the primary constituent). While the adjunct is dangerous and addictive in its own right, it can at least be trusted to be pure and consistently dosed — or at least, it used to be.
Legal highs and the Psychoactive Substances Act
Up until 2016, the UK experienced a strange drug renaissance in the form of the “legal high” boom. Clandestine chemists and legitimate researchers alike developed drugs faster than they could be banned and there was a free-for-all on the untested, unregulated, unbelievably cheap substances. All golden ages must end, however, and this one ended with the Psychoactive Substances Act 2016. All drugs are now banned by default, with specific exemptions made for alcohol, tobacco, coffee and chocolate.
However, there wasn’t much that could be done about the vast quantities of various drugs that were already in circulation. Many users and illicit suppliers hoovered up everything they could buy before the Act came into force. These stocks have fuelled an illegal market which persists to this day, primarily in the then-popular substances like the potent stimulant mephedrone and a host of new depressants, specifically benzos like etizolam.
Understandably, etizolam may not be on your radar yet. The long-term risks of its use remain uncertain, but there doesn’t seem to be anything about the drug which makes it intrinsically more dangerous than widely-accepted analogues like diazepam or alprazolam. During the legal high boom it was fairly under-the-radar, too: the media was far more excited about big dramatic drugs like mephedrone, MDPV (you may know it and its relatives as “bath salts”) and synthetic cannabis, which have more scope for spectacle.
However, it has come to prominence in the aftermath of the ban as one of the most heavily stockpiled of the no-longer-legal highs (reports abound of kilos purchased of a drug commonly dosed at 1–2mg, according to the venerable Psychonaut Wiki) and the deadliest by far.
It is impossible to know exactly how much has been stockpiled since the ban. What we do know is that the drug remains in circulation, it remains much cheaper than pharmaceutical alternatives and that imports appear to be minimal, based on the patterns of police seizures — etizolam seized inside the country drastically outweighs anything that’s caught coming in.
Do you see where this is going yet?
Etizolam, like its socially-accepted cousins, is also highly resistant to overdose. In isolation, even doses of 5 and 10 times the recreational dose are unlikely to kill the user (via overdose, that is. Users in the midst of a benzodiazepine-induced blackout often behave erratically, which has resulted in numerous deaths). It is when these drugs are taken in combination with other depressant drugs like alcohol or, say, heroin, that the risk of fatal overdose becomes not just plausible, but likely.
The primary benefit in selling etizolam as a product before the PSA lay specifically in its legality, which allowed it to be sold openly. Etizolam is now a class C drug, and its illicit trade is therefore subject to the same penalties as those of conventional benzos.
Now subject to the same legal risks as dealers of pharmaceutical benzos, etizolam suppliers have increased their profits to match by selling etizolam in the guise of diazepam or alprazolam. Most major suppliers even press them into the familiar baby-blue pills and white bars that users recognise as their branded forms.
These pills, often poorly-produced, are where the dangers of etizolam lie. Doses which are microgram-accurate in legitimate pills can vary by 50% or more in counterfeits, and dealers may advertise their own supplies as another dose entirely (I vividly recall “new Xanax” advertised at double the dose of the real thing, or “Xanax Hulks” sold in green). However suspicious or shoddy the pills, though, they can’t be beaten on price.
As etizolam has spread through the drug supply, it has been met with climbing death rates among such vulnerable populations as heroin users. The “Street Blue” media storm of late 2018 and early 2019, which brought attention to this crisis, came far too late for many victims, and achieved far too little for many to come.
Whenever Brexit comes, whatever Brexit comes, the existing issues facing our heroin supply will be exacerbated while our largely domestic etizolam stocks will be unaffected. Quite aside from the sobering fact that our drug dealers are apparently better at stockpiling drugs than our government, this is how our opioid crisis will escalate to a disaster. Heroin users will be pushed to rely more heavily on benzos just to survive, even knowing that every dose is a dice-roll. As scarce treatment funding continues to dwindle, people who had previously been avoiding heroin may find themselves out of treatment and back in the market, finding it a much more dangerous place than it was when they left it. Death rates will continue to soar until the sheer lack of living users renders them unsustainable. Whoever is in charge when they finally start to fall will call it a victory.
Or maybe not. Maybe the supply chains will adapt, maybe we’ll sign a free trade deal with Pakistan and cheap, pure heroin will solve these problems at a stroke (albeit while creating plenty of others). Maybe things will go back to normal, maybe. But the people who died in the meantime will still be dead.
Our political class has spent so long focusing on optimising Gross Domestic Product, arrest numbers and waiting times that they have reduced governing to day-trading and lived experience to a constant ticker of meaningless numbers. For drug users, this kind of disconnect has been the norm for decades. Decisions are made about their health, their legal status, even the value of their lives without their involvement, often by people who openly detest them. Every overdose death and blood-borne virus transmission is preventable, and they only happen because the only things that matter any more are KPIs and media optics: the science of the spectacle.