Etizolam: A rapid review on pharmacology, non‐medical use and harms

Impact of 'street' benzodiazepines on drug-related deaths in England, Wales and Northern Ireland

INTRODUCTION

'Street' benzodiazepines (BZD) are structurally and pharmacologically related to BZDs licensed for human use. In this study we investigated how street BZDs contribute to overall BZD use and death prevalences in England, Wales and Northern Ireland.

METHODS

Data were analysed from deaths reported to the National Programme on Substance Use Mortality with post-mortem BZD detections (1999-2021), BZDs seized from music festivals (2017-2021) and drug samples with BZD detections submitted to Welsh Emerging Drugs and Identification of Novel Substances (WEDINOS) (2017-2021).

RESULTS

About 14,837 deaths with BZD detections were identified, with polydrug use evident in 99.3% of cases (n = 14,733/14,837). Deaths following BZD use increased by over 200% from 2010 (n = 556) to 2020 (n = 1245). Most BZD detections were of those available via NHS prescription (96.2%), although in most cases (61.9%) the BZD-majority diazepam (77.3% of detections)-had been illicitly sourced. While street BZD deaths represented only 8.5% of overall BZD deaths, street BZD deaths increased by over 1200% between 2015 (n = 26) and 2020 (n = 326). There were increasing proportions of street BZD deaths in each geographical region but was more marked in Northern Ireland. The proportion of individual BZDs seized at music festivals and submitted to WEDINOS largely reflected that of individual BZDs detected in deaths.

DISCUSSION AND CONCLUSIONS

While deaths following street BZD use are increasing, most BZDs detected in deaths were prescribable BZDs that were often illicitly sourced. The types of BZD detected in post-mortem samples, festival seizures and WEDINOS submissions has evolved over time to reflect changes in BZD prevalence on the illicit drug market.

Management of preoperative hypertension and anxiety based on early monitoring of pulse rate before cataract surgery

PURPOSE

Few studies have addressed the clinical impact of fluctuation in pulse rate before cataract surgery. This study aimed to determine the effectiveness of prior pulse monitoring and intervention to prevent blood pressure changes in patients undergoing cataract surgery under local anesthesia.

STUDY DESIGN

Retrospective study METHODS: Patients who underwent cataract surgery under local anesthesia were included. In the pulse rate (PR) group, intervention was performed on the basis of early monitoring of blood pressure and PR changes. In the conventional group, blood pressure was managed on the basis of blood pressure alone. Systolic blood pressure, diastolic blood pressure, intraoperative nicardipine use, and physician consultation time were retrospectively compared between the groups.

RESULTS

The study included 684 eyes from 684 patients aged 73.5 ± 9.5 years (PR group: 297 eyes, conventional group: 387 eyes). No intergroup differences were found in systolic blood pressure or pulse and heart rates; however, diastolic blood pressure was significantly lower in the PR group than in the conventional group at both the beginning and the end of surgery (P <.001 and P = .0028, respectively). Intravenous nicardipine administration in the operating room was significantly less frequent in the PR group (P = .041), and physician consultation time after entering the operating room and at the beginning of surgery was significantly shorter in the PR group (both P <.001).

CONCLUSION

Early monitoring of PR with blood pressure and intervention were effective for preventing preoperative hypertension.

Systematic review: The relationship between gabapentinoids, etizolam, and drug related deaths in Scotland

In recent years Scotland has been experiencing a disproportionally high number of drug related deaths compared to other European countries, causing significant individual, societal and economic burden. A possible cause of this is the increase in average number of substances involved in Scottish drug related deaths, as well as the changing pattern of substances involved. Opioids, cocaine, and alcohol have been consistently involved in the culture of drug use in Scotland, however recently National Records Scotland have identified that designer benzodiazepines such as etizolam, and prescription drugs such as gabapentinoids are increasingly being detected in Scottish toxicology reports. A systematic literature review following PRISMA guidelines was conducted through searching PubMed and Google Scholar to identify peer-reviewed articles published in English between 2013 and 2023 that investigated Scottish population data on gabapentinoids and etizolam to establish their contribution to the rise in Scottish drug related deaths. 18 studies were included in the review. A high use prevalence of etizolam and gabapentinoids in Scotland has been identified, with both substance-related deaths showing recent increase, marked since 2015. This pattern is replicated in the Scottish prison system. There has also been a significant increase of gabapentinoids prescriptions in Scotland. Polydrug use was identified as the most common determinant of both etizolam and gabapentinoids related adverse effects and fatality in Scotland, especially concurrent opioid use. The results indicate the literature on individual characteristics of Scottish at-risk users of gabapentinoids and etizolam is limited, however the data shows both substances are being used by older cohort, with adverse effects seen more in older women.

Beyond Fentanyl Test Strips: Investigating Other Urine Drug Test Strips for Drug Checking Applications

Use of immunoassay test strips for the detection of fentanyl in drug samples has become commonplace in harm reduction, law enforcement, public health, customs, and forensic science settings for testing drug product. With the increase of xylazine in the drug supply in recent years, use of xylazine test strips has also increased. As use of test strips expands, a desire to implement them for other drugs may emerge. However, since these strips are designed for urine testing, it is important to understand their applicability to testing drug product. In this work, we investigate the utility of seven types of urine immunoassay test strips - amphetamine, benzodiazepine, cocaine, methamphetamine, nitazene, opiate, and xylazine - for drug checking applications. Reproducibility, sensitivity, cross-reactivity, and the effect of prolonged exposure to elevated temperatures were studied. Generally, the tests were found to be reproducible, able to detect trace (μg/mL) levels of the analyte of interest, and minimally affected by prolonged storage at elevated temperatures. Nearly all tests showed cross-reactivity with compounds other than the analyte of interest, highlighting the need to better understand these limitations prior to implementation in a drug checking scenario. The viability of expired cocaine, fentanyl, and methamphetamine test strips was also interrogated, and little to no change in sensitivity was found even though the tests were multiple years expired.

Fake Xanax: Designer Emerging Benzodiazepine Epidemic Linked to Morbidity and Mortality a Narrative Review

Etizolam is a thienodiazepine derivative which produces an anxiolytic effect similar to benzodiazepines such as alprazolam (Xanax). Like classic benzodiazepines, etizolam has a high affinity towards the GABAA receptor, and allosterically potentiates the effects of GABA resulting in neuronal hyperpolarization related to chloride influx. When taken in therapeutic doses, etizolam produces a similar effect to Xanax. Counterfeit Xanax tablets contain variable amounts of etizolam. Tablets with high amounts of etizolam can cause toxicity if ingested, especially when combined with other substances. When toxic symptoms occur in patients, they may include severe sedation, unconsciousness, and depression of the medullary respiratory center. In this regard, there is the potential for death. Additionally, the rise in fake Xanax tablets containing etizolam and other counterfeit medications has been exacerbated by the difference in regulations regarding these substances in different countries as well as the illegal drug trade. Healthcare providers may also play a role through the over- or underprescribing of certain medications. Thus, in order to combat the rise in counterfeit medications such as fake Xanax, international cooperation, regulation, and enforcement of laws pertaining to the manufacture, prescription, and distribution of these substances are needed.

Analysis on dynamic changes of etizolam and its metabolites and exploration of its development prospect using UPLC-Q-exactive-MS

As one of the most widely abused designer benzodiazepines in the world, etizolam has been found in many cases in many countries. In this study, UPLC-Q-Exactive-MS was used for the first time to establish a dynamic change model of etizolam and its metabolites in rats. Compared with previous studies, the detection sensitivity and reproducibility of the instrument were higher. In the experiment, we optimized the traditional pharmacokinetic model based on Gauss function. According to the significant difference of etizolam in the plasma elimination phase of rats, a new pharmacokinetic model based on Lorentz function was established to describe the dynamic changes of etizolam more rigorously, which made the error effects lower and the accuracy of the pharmacokinetic parameters was improved. At the same time, the pharmacokinetic parameters of etizolam were compared with four other designer benzodiazepines reported in previous studies in rats, and we found the direct reason for the popularity of etizolam in the NPS market and explored the future development of etizolam for the first time. In addition, 21 metabolites were found through rat experiments to effectively detect etizolam abuse for a long time, of which 4 metabolites had the longest detection window and could be used as long-acting metabolites for experiments, which greatly prolongs the detection window and extends the time range in which etizolam was detected in real cases. This study is the first to conduct a systematic and comprehensive study on the metabolism and pharmacokinetics of etizolam and find out the direct reason for the prevalence of etizolam abuse, and we also discuss the development trend of etizolam in the future market of new psychoactive substances, which is beneficial for forensic experts to assess the trend of drug abuse and can provide reference for relevant drug control and drug treatment.

Recent findings and advancements in the detection of designer benzodiazepines: a brief review

This review article takes a closer look at a new class of psychoactive substances called designer benzodiazepines (DBZs) and the challenges of their detection. These are adinazolam, clonazolam, deschloroetizolam, diclazepam, etizolam, flualprazolam, flubromazepam, flubromazolam, phenazepam, and pyrazolam. They are central nervous system depressants and sedatives that can cause psychomotor impairment and increase the overdose risk when combined with other sedatives. DBZs undergo phase I and II metabolism similar to traditional benzodiazepines, but their specific metabolic pathways and the influence of genetic polymorphisms are yet to be clarified. Advances in liquid chromatography-tandem mass spectrometry (LC-MS/MS) have enhanced the method's sensitivity for DBZs and their metabolites in biological samples and coupled with improved blood sampling methods require less blood for drug monitoring. Further research should focus on elucidating their pharmacokinetic properties and metabolism in humans, especially in view of genetic polymorphisms and drug interactions that could inform clinical treatment choices. Even though we have witnessed important advances in DBZ detection and measurement, further refinements are needed to expand the scope of detectable DBZs and their metabolites. All this should help toxicological research to better identify and characterise the risks of chronic and polydrug abuse and facilitate clinical, forensic, and regulatory responses to this growing issue.

Shifting drug markets in North America - a global crisis in the making?

Understanding drug market dynamics and their underlying driving factors is paramount to developing effective responses to the overdose crisis in North America. This paper summarises the distinct drug market trends observed locally and internationally over the past decade to extrapolate future drug market trajectories. The emergence of fentanyl on North American street markets from 2014 onwards led to a shift of street drug use patterns. Previously perceived as contaminants, novel synthetic opioids became the drugs of choice and a trend towards higher potency was observed across various substance classes. The diversification of distribution strategies as well as the regionalisation and industrialisation of production followed basic economic principles that were heavily influenced by prosecution and policy makers. Particularly, the trend towards higher potency is likely most indicative of what to expect from future illicit drug market developments. Nitazenes and fentanyl-analogues, several times more potent than fentanyl itself, are increasingly detected in toxicological testing and have the potential of becoming the drugs of choice in the future. The dynamic of drug import and local production is less clear and influenced by a multitude of factors like precursor availability, know-how, infrastructure, and the success of local drug enforcement strategies. Drug market dynamics and the current trajectory towards ultrapotent opioids need to be recognised by legislation, enforcement, and the health care system to prepare effective responses. Without significant improvements in treatment access, the implementation of preventative approaches and early warning systems, the mortality rate will continue to increase. Furthermore, there is no mechanism in place preventing the currently North American focused overdose crisis to spread to other parts of the globe, particularly Europe. A system of oversight, research, and treatment is needed to address mortality rates of historic proportions and prevent further harm.

Increased risk of non-fatal overdose associated with non-prescribed benzodiazepine use in Scotland, UK

BACKGROUND

Drug-related deaths (DRDs) in Scotland increased for seven years in a row between 2014 and 2020, consolidating Scotland's place at the top of the United Kingdom and European drug-related mortality charts. One of the defining features of this recent and rapid rise has been the role of benzodiazepines, which are now involved in the majority of all DRDs. These deaths are linked to use of non-prescribed, benzodiazepine-type novel psychoactive substances (NPS) which have been identified by the United Nations as a global threat to public health. This study aimed to estimate the prevalence and determinants of non-prescribed benzodiazepine use and its association with recent non-fatal overdose among a national sample of people who inject drugs (PWID).

METHODS

Data from the 2019-20 Needle Exchange Surveillance Initiative (NESI) was analysed using logistic regression. NESI is a voluntary, anonymous, biennial, cross-sectional, bio-behavioural survey of PWID attending community-based services providing injecting equipment in mainland Scotland.

RESULTS

Prevalence of non-prescribed benzodiazepine use in the past six months was 52% and significantly associated with age (aOR 0.97, 0.96-0.98), frequent incarceration (aOR 1.29, 1.07-1.57), recent public injecting (aOR 3.25, 2.33-4.55), a recent methadone prescription (aOR 1.87, 1.51-2.33), and a history of benzodiazepine prescription (aOR 1.92, 1.47-2.52). In addition, non-prescribed benzodiazepine use was significantly associated with non-fatal overdose in the past year among PWID (aOR 2.47, 1.90-3.21).

CONCLUSION

This study found a high prevalence of non-prescribed benzodiazepine use among a national sample of PWID in Scotland. Prevalence was highest among populations known to be at increased risk of drug-related death and use was strongly associated with overdose. These novel findings highlight the scale of the non-prescribed benzodiazepine issue Scotland faces, and the urgency required to expand its harm reduction infrastructure to address this unique element of its overdose crisis.

Fentanyl, etizolam, and beyond: A feasibility study of a community partnership using handheld Raman spectrometry to identify substances in the local illicit drug supply

Background:

The United States is currently experiencing an unprecedented rise in fatal drug overdoses, which is in part due to the arrival of fentanyl, fentanyl analogs, and other synthetic drugs into the illicit drug supply. Traditional urine drug testing is often unable to detect fentanyl analogs and other novel synthetic drugs, which places physicians and first responders in the difficult position of treating patients who are intoxicated with or overdosing on unknown substances.

Design and methods:

We report, as a feasibility study, the development of a novel program to use a handheld Raman spectrometry device in our hospital’s Emergency Department to surveil our local illicit drug supply in terms of what substances are being sold and used.

Results:

Using our novel program, we were able to detect 27 substances in our illicit drug supply over a 10 month period, including fentanyl analogues. We shared, through our local opioid safety coalition, real-time information to first responders, substance use treatment programs, and physicians about the novel substances we detected using the handheld Raman spectrometer.

Conclusions:

A community partnership of using handheld Raman spectrometry in our hospital’s Emergency Department was successful in providing information to health care providers about novel substances in our illicit drug market. Additionally, the implementation of this program improved collaboration between local health care providers and local law enforcement.

Etizolam and Its Major Metabolites: A Short Review

Etizolam is a benzodiazepine (BZD). Etizolam is structurally different from BZDs as a thiophene replaces the benzene ring and a triazole ring is fused to the diazepine ring, but etizolam's pharmacological profile is similar. Etizolam has been used to treat anxiety and panic disorders, to reduce depressive and somatization symptoms and to induce muscle relaxation. Etizolam is used recreationally due to its reinforcing and sedative effects. Etizolam is available in tablet or powder form or administered on blotter paper that can be placed on the tongue for oral absorption. Etizolam metabolizes into two major metabolites: α-hydroxyetizolam and 8-hydroxyetizolam, and all three compounds can be detected in different biological specimens using various common analytical techniques such as immunoassay, chromatography and mass spectrometry. Etizolam is a controlled drug in many countries around the globe but is approved for medical use in some countries, such as Japan, South Korea and Italy. This work is a collation and review of available literature on etizolam to help improve the fundamental understanding of its toxicology, outline best analytical practice, and aid interpretation of toxicology results.

New Psychoactive Substances: Major Groups, Laboratory Testing Challenges, Public Health Concerns, and Community-Based Solutions

Across communities worldwide, various new psychoactive substances (NPSs) continue to emerge, which worsens the challenges to global mental health, drug rules, and public health risks, as well as combats their usage. Specifically, the vast number of NPSs that are currently available, coupled with the rate at which new ones emerge worldwide, increasingly challenges both forensic and clinical testing strategies. The well-established NPS detection techniques include immunoassays, colorimetric tests, mass spectrometric techniques, chromatographic techniques, and hyphenated types. Nonetheless, mitigating drug abuse and NPS usage is achievable through extensive community-based initiatives, with increased focus on harm reduction. Clinically validated and reliable testing of NPS from human samples, along with community-driven solution, such as harm reduction, will be of great importance, especially in combating their prevalence and the use of other illicit synthetic substances. There is a need for continued literature synthesis to reiterate the importance of NPS, given the continuous emergence of illicit substances in the recent years. All these are discussed in this overview, as we performed another look into NPS, from differentiating the major groups and identifying with laboratory testing challenges to community-based initiatives.

Designer benzodiazepines: an update

INTRODUCTION

Designer benzodiazepines (DBs) are a subclass of novel psychoactive substances (NPS). DBs mimic the properties of approved and prescribed benzodiazepines.

AREA COVERED

A systematic search of literature on DB classification, structure-activity relationships, pharmacologic properties, and adverse effects.

EXPERT OPINION

The prevalence of DB use has increased substantially over the last decade. All DBs are full-agonist ligands at the gamma-aminobutyric acid type A-benzodiazepine (GABA_A-BZ) receptor system. This is not surprising, since DBs largely represent either minor structural modifications, or well-recognized active metabolites, of existing approved benzodiazepines. As such, the pharmacologic profile and associated risks and hazards of DBs are similar or identical to clinically approved and legitimately prescribed benzodiazepines, most of which have been in use for decades. Concurrent use of DBs along with other abusable or recreational drugs (alcohol, opioids, cocaine, stimulants, hallucinogens, other sedative-hypnotics) represents the principal public health risk. The increasing illicit availability and use of DBs is of concern and requires regulatory attention, but DBs do not rank highly among designer psychotropic agents in terms of health risk to humans.

Treatment of concurrent etizolam and tianeptine withdrawal following accidental overdose

Background

The availability of nonapproved psychoactive substances with addiction potential from internet sources poses a significant threat to public health. Polysubstance abuse or inadvertent contamination of preparations may result in clinically challenging intoxication and withdrawal syndromes.

Case Report

We report a case of a 32-year-old male with an approximate 2-year history of taking internet-obtained etizolam and tianeptine who presented to the hospital following an overdose. He experienced subsequent withdrawal symptoms consistent with benzodiazepine and opioid withdrawal. Initial attempts at managing symptoms with chlordiazepoxide 25 mg every 6 hours did not relieve his symptoms. On day 3 of admission, addiction medicine was consulted and his regimen was changed to diazepam 80 mg daily with additional as-needed diazepam based on etizolam equivalence. He also received a 5-day methadone taper with plans to transition to buprenorphine in the outpatient setting. Upon discharge he was referred to an addiction medicine specialist who was willing to continue a slow diazepam taper and initiate medications for opioid use disorder to manage both substance use disorders.

Discussion

This case report demonstrates the effectiveness of diazepam in managing benzodiazepine withdrawal from etizolam while concurrently using methadone to manage opioid withdrawal symptoms from tianeptine in a hospitalized patient following overdose. We highlight the importance of a warm handoff in considering the outpatient discharge plan.

Evidence of the emergence of illicit benzodiazepines from online drug forums

Illicit or 'designer' benzodiazepines are a growing contributor to overdose deaths. We employed natural language processing (NLP) to study benzodiazepine mentions over 10 years on 270 online drug forums (subreddits) on Reddit. Using NLP, we automatically detected mentions of illicit and prescription benzodiazepines, including their misspellings and non-standard names, grouping relative mentions by quarter. On a collection of 17 861 755 posts between 2012 and 2021, we searched for 26 benzodiazepines (8 prescription; 18 illicit), detecting 173 275 mentions. The rate of posts about both prescription and illicit benzodiazepines increased consistently with increases in deaths involving both drug classes, illustrating the utility of surveillance via Reddit.

Trace residue identification, characterization, and longitudinal monitoring of the novel synthetic opioid β-U10, from discarded drug paraphernalia

Empirical data regarding dynamic alterations in illicit drug supply markets in response to the COVID-19 pandemic, including the potential for introduction of novel drug substances and/or increased poly-drug combination use at the "street" level, that is, directly proximal to the point of consumption, are currently lacking. Here, a high-throughput strategy employing ambient ionization-mass spectrometry is described for the trace residue identification, characterization, and longitudinal monitoring of illicit drug substances found within >6,600 discarded drug paraphernalia (DDP) samples collected during a pilot study of an early warning system for illicit drug use in Melbourne, Australia from August 2020 to February 2021, while significant COVID-19 lockdown conditions were imposed. The utility of this approach is demonstrated for the de novo identification and structural characterization of β-U10, a previously unreported naphthamide analog within the "U-series" of synthetic opioid drugs, including differentiation from its α-U10 isomer without need for sample preparation or chromatographic separation prior to analysis. Notably, β-U10 was observed with 23 other drug substances, most commonly in temporally distinct clusters with heroin, etizolam, and diphenhydramine, and in a total of 182 different poly-drug combinations. Longitudinal monitoring of the number and weekly "average signal intensity" (ASI) values of identified substances, developed here as a semi-quantitative proxy indicator of changes in availability, relative purity and compositions of street level drug samples, revealed that increases in the number of identifications and ASI for β-U10 and etizolam coincided with a 50% decrease in the number of positive detections and an order of magnitude decrease in the ASI for heroin.

The importance of non-fatal overdose in reducing drug related deaths characteristics of non-fatal overdoses and associated risk factors in patients attending a specialist community-based substance misuse service

This commentary piece reviews the paper by Cowden et al. on Characteristics on Non-fatal overdoses.

Outpatient Treatment of Chronic Designer Benzodiazepine Use: A Case Report

BACKGROUND

Novel psychoactive substances, such as designer benzodiazepines unapproved for therapeutic purposes, are an emerging concern worldwide. They have unknown or unpredictable pharmacological properties. Using a case example, we discuss the use of "Xanax bars," which now generally do not contain the pharmaceutical alprazolam. We describe the difficulty in detecting these substances and the development of a use disorder including adverse outcomes such as seizures when stopped. The evidence for management is anecdotal.

CASE

We describe the case of a male of approximately 25 years of age with alcohol and sedative-hypnotic use disorder related to illicit "Xanax bars," whose point of care urinalysis did not identify benzodiazepines and whose broad-spectrum urinalysis identified the presence of flualprazolam, a novel designer benzodiazepine. He suffered a subacute withdrawal seizure and responded to treatment with loading doses of diazepam and naltrexone.

DISCUSSION

Although previous literature has focused on poisoning and intoxication (including coma), there are few studies examining treatment options for chronic designer benzodiazepine use. Standard approaches, such as conversion to a longer-acting benzodiazepine with a prolonged taper, are risky with designer benzodiazepines due to the unknown level of tolerance and risk of overdosing the patient. Illicit "Xanax" is not equivalent to prescribed alprazolam and cannot be converted and tapered. To be cautious, supervised benzodiazepine tapers or anticonvulsants should be explored as treatment strategies, based on their use in pharmaceutical benzodiazepine use disorders. Inpatient acute withdrawal management should be considered, and anticonvulsants may play a role in the first 4 to 6 weeks of treatment.

Excipient lung disease in a patient taking the benzodiazepine derivative etizolam: A case report

Excipient Lung Disease is an inflammatory response to the intravenous administration of oral formulations of drugs and their excipients (additives). Previously described offenders include opioids and Ritalin, whose excipients, when crushed and administered intravenously, lead to inflammation and are demonstrated by centrilobular nodules and ground-glass formations on Chest Computed Tomography. In this case report, we demonstrate Chest CT findings of excipient lung disease in a patient using etizolam, a benzodiazepine derivative commonly used as an anxiolytic in Japan. Of note, the patient acquired etizolam for purchase through online retailers without prescription, which is becoming more common occurrence and offers the additional risk of unknown formulations.

A new quantitative drug checking technology for harm reduction: Pilot study in Vancouver, Canada using paper spray mass spectrometry

INTRODUCTION

Drug checking services for harm reduction and overdose prevention have been implemented in many jurisdictions as a public health intervention in response to the opioid overdose crisis. This study demonstrates the first on-site use of paper spray mass spectrometry for quantitative drug checking to address the limitations of current on-site drug testing technologies.

METHODS

Paper spray mass spectrometry was used to provide on-site drug checking services at a supervised consumption site in the Downtown Eastside of Vancouver, British Columbia, Canada during a 2-day pilot test in August 2019. The method included the targeted quantitative measurement of 49 drugs and an untargeted full scan to assist in identifying unknown/unexpected components.

RESULTS

During the pilot, 113 samples were submitted for analysis, with 88 (78%) containing the client expected substance. Fentanyl was detected in 45 of 59 expected fentanyl samples, and in 50 (44%) samples overall at a median concentration of 3.6% (w/w%). The synthetic precursor of fentanyl, 4-anilino-N-phenethyl-piperidine (4-ANPP), was found in 74.0% of all fentanyl samples at a median concentration of 2.2%, suggesting widespread poor manufacturing practices. Etizolam was detected in 10 submitted samples anticipated to be fentanyl at a median concentration of 2.5%. No clients submitting these samples expected etizolam or a benzodiazepine in their sample. In three instances, it was co-measured with fentanyl, and in seven cases it was detected alone.

DISCUSSION AND CONCLUSIONS

The quantitative capabilities and low detection limits demonstrated by paper spray mass spectrometry offer distinct benefits over existing on-site drug checking methods and harm reduction services.

Invited Commentary: Drug Checking for Novel Insights Into the Unregulated Drug Supply

Tobias et al. (Am J Epidemiol. 2022;191 (2):241-247) present a novel analysis of time trends in fentanyl concentrations in the unregulated drug supply in British Columbia, Canada. The preexisting knowledge about unregulated drugs had come from law-enforcement seizures and postmortem toxicology. As both of these data sources are subject to selection bias, large-scale drug-checking programs are poised to be a crucial component of the public health response to the unrelenting increase in overdose in North America. As programs expand, we offer 2 guiding principles. First, the primary purpose of these programs is to deliver timely results to people who use drugs to mitigate health risks. Second, innovation is needed to go beyond criminal justice paradigms in laboratory analysis for a more nuanced understanding of health concerns. We provide examples of the role adulterants play in our understanding of drug harms. We also describe the applications and limitations of common laboratory assays, with implications for epidemiologic surveillance. While the research and direct service teams in British Columbia have taken groundbreaking steps, there is still a need to establish best practices for communicating results to sample donors in an approachable yet nonalarmist tone.

Characteristics of fatal 'novel' benzodiazepine toxicity in Australia

INTRODUCTION

The study aimed to determine: 1. The characteristics of all recorded cases of fatal drug poisoning involving 'novel' benzodiazepines (NBZDs) in Australia; 2. The toxicology of cases; and 3. The major autopsy findings.

METHODS

Retrospective study of all deaths due to drug toxicity in Australia in which NBZDs were present in blood toxicology, retrieved from the National Coronial Information System (2000-2021). Information was collected on case characteristics, toxicology and major organ pathology.

RESULTS

A total of 40 cases were identified, the first occurring in 2015, with a median age of 26.5 years and 87.5% being male. Death was due to accidental toxicity in 92.5% of cases. There were extensive histories of substance use problems (80.0%) and mental health problems (32.5%). Etizolam was the most common NBZD (87.5%), followed by flubromazolam (15.0%), with other NBZDs detected in 20.0% (delorazepam, diclazepam, flualprazolam, flubromazepam, lormetazepam). Multiple NBZDs were present in 27.5%. Other drugs were present in 97.5%, most commonly opioids (70.0%), registered benzodiazepines (62.5%), psychostimulants (45.0%) and gabapentinoids (32.5%). A CNS depressant other than a NBZD was detected in 95.0% (n = 38). Autopsies were conducted and available for 30 cases, with pulmonary oedema (76.7%, n = 23), aspiration of vomitus (46.7%, n = 14) and acute bronchopneumonia (36.7%, n = 11) the most common diagnoses.

CONCLUSIONS

The 'typical' NBZD-related death was a young male who died due to accidental toxicity. Deaths most frequently involved etizolam and multiple substances, particularly depressants.

An unusual detection of 2-amino-3-(2-chlorobenzoyl)-5-ethylthiophene and 2-methylamino-5-chlorobenzophenone in illicit yellow etizolam tablets marked "5617" seized in the Republic of Ireland

Benzodiazepines are a class of compounds used clinically to treat a variety of conditions including anxiety and insomnia. Their potential for abuse has led to a surge in their availability on the illegal drugs market. End users often rely on markings on illicit tablets to identify their contents. However, falsified tablets mimicking genuine pharmaceutical preparations often contain ingredients that differ from what people believe they are taking. The absence of any quality control of the content, purity, or strength of fake tablets can result in adverse effects or even fatal outcomes. In recent years, drug seizures involving illicit round yellow tablets marked "5" on one side and "5617" below a scoreline on the reverse have been submitted to Forensic Science Ireland (FSI) by An Garda Síochána (Irish Police) from throughout the Republic of Ireland. These findings relate to 26 different seizures; the cumulative tablet total seized was in excess of 20,000, and the total number of tablets of this description analyzed at FSI was 141. Irish users assume that the active ingredient present was diazepam. The qualitative analytical results for these tablets are reported. All tablets were found to contain 2-methylamino-5-chlorobenzophenone. In addition, the tablets contained either 2-amino-3-(2-chlorobenzoyl)-5-ethylthiophene or etizolam or both. The constituents were present in varying relative amounts in visually similar tablets. Neither 2-amino-5-chlorobenzophenone nor 2-amino-3-(2-chlorobenzoyl)-5-ethylthiophene had previously been found in tablets analyzed at FSI.

From the clinic to the street: the changing role of benzodiazepines in the Scottish overdose epidemic

Drug-related deaths in Scotland increased for seven years in a row between 2014 and 2020 consolidating Scotland's place at the top of the United Kingdom and European drug-related mortality charts. One of the defining features of this recent and rapid rise has been the role of benzodiazepines which are now involved in two-thirds of all cases. Policy decisions over four decades have contributed to the supply and demand drivers of this unique element of the Scottish overdose crisis. An illicit market once populated by diverted prescription medications is now dominated by a toxic supply of NPS-type benzodiazepines or so-called 'street benzos' which have increased the risk environment for people who use drugs. In response, Scotland needs to urgently expand its harm reduction infrastructure and implement safer supply, drug testing and drug consumption rooms. Such a response should be made in parallel to addressing the socioeconomic inequalities which are fuelling an epidemic of global significance.

Deaths from novel psychoactive substances in England, Wales and Northern Ireland: Evaluating the impact of the UK psychoactive substances act 2016

BACKGROUND

'Legal highs' began appearing in the UK in the mid-2000s. Whilst many of these substances were controlled under the 1971 Misuse of Drugs Act, novel compounds and new variants of controlled compounds were continuously being introduced to the recreational drug market. The Psychoactive Substances Act (PSA) was therefore implemented in 2016 as a blanket ban on all novel psychoactive substances (NPS).

AIM

To evaluate the impact of the PSA on deaths following NPS use in England, Wales and Northern Ireland.

METHODS

Cases reported to the National Programme on Substance Abuse Deaths where death had occurred 3 years pre- or post-implementation of the PSA were extracted. Cases with NPS detected at post-mortem were analysed and compared against cases non-NPS cases.

RESULTS

293 deaths with NPS detected were identified; 91 occurring before the PSA and 202 afterwards, indicating an 222.0% post-PSA increase. Contrastingly, non-NPS drug-related death case reporting increased by only 8.0%. Synthetic cannabinoid, anxiolytic/sedative and stimulant NPS were detected in the largest proportions of deaths pre-PSA; post-PSA stimulant NPS detections reduced whilst synthetic cannabinoid and anxiolytic/sedative detections increased.Post-PSA, average decedent age increased significantly (mean age pre-PSA 34.4 ± 10.8 vs post-PSA 38.3 ± 9.4), and they were significantly more likely to have been living in deprived areas (pre-PSA 50.0% vs post-PSA 65.9%).

CONCLUSIONS

Reporting of deaths following NPS use has risen despite introduction of the PSA. Whilst deaths amongst younger individuals and those living in more affluent areas has reduced, additional approaches to prohibition are needed to curb their persistence in deprived demographics.

What's in fake 'Xanax'?: A dosage survey of designer benzodiazepines in counterfeit pharmaceutical tablets

The identification of a range of different drugs within counterfeit benzodiazepine tablets has been widely reported; however, limited information is available on the dosage of these products. A rapid dosage survey of 46 counterfeit benzodiazepine tablets from 20 seizures was conducted over a 6-month period between April and September 2020. Existing methods utilised for the determination of benzodiazepines in toxicology specimens were applied to assess the dosage of four benzodiazepines detected across five different counterfeit benzodiazepine presentations. The highest dosage variation was observed for etizolam with a range of 0.7-8.3 mg per tablet. This report demonstrates the variability in drug content and dosage that can occur between visually similar counterfeit tablets, even when co-packaged within the same seizure, highlighting the potential public harm posed by these counterfeit medications.

Designer Benzodiazepines: A Review of Toxicology and Public Health Risks

The rising use of designer benzodiazepines (DBZD) is a cat-and-mouse game between organized crime and law enforcement. Non-prohibited benzodiazepines are introduced onto the global drug market and scheduled as rapidly as possible by international authorities. In response, DBZD are continuously modified to avoid legal sanctions and drug seizures and generally to increase the abuse potential of the DBZD. This results in an unpredictable fluctuation between the appearance and disappearance of DBZD in the illicit market. Thirty-one DBZD were considered for review after consulting the international early warning database, but only 3-hydroxyphenazepam, adinazolam, clonazolam, etizolam, deschloroetizolam, diclazepam, flualprazolam, flubromazepam, flubromazolam, meclonazepam, phenazepam and pyrazolam had sufficient data to contribute to this scoping review. A total of 49 reports describing 1 drug offense, 2 self-administration studies, 3 outpatient department admissions, 44 emergency department (ED) admissions, 63 driving under the influence of drugs (DUID) and 141 deaths reported between 2008 and 2021 are included in this study. Etizolam, flualprazolam flubromazolam and phenazepam were implicated in the majority of adverse-events, drug offenses and deaths. However, due to a general lack of knowledge of DBZD pharmacokinetics and toxicity, and due to a lack of validated analytical methods, total cases are much likely higher. Between 2019 and April 2020, DBZD were identified in 48% and 83% of postmortem and DUID cases reported to the UNODC, respectively, with flualprazolam, flubromazolam and etizolam as the most frequently detected substances. DBZD toxicology, public health risks and adverse events are reported.

New Designer Drugs

In recent years, there has been an emergence of numerous novel drugs. Such toxicity may occur in both adolescents and adults. This article discusses the opioid epidemic and several emerging opioids, including buprenorphine, loperamide, fentanyl, fentanyl derivatives, and others. Kratom, a plant occasionally used for opiate detoxification, along with the sedatives etizolam and phenibut, will be discussed. Lastly, this article discusses the phenethylamines and marijuana.

The Development and Validation of a Novel Designer Benzodiazepines Panel by LC-MS-MS

Novel illicit benzodiazepines are among the most active areas of new illicit drug manufacture and use. We describe a method for the detection and quantification of etizolam and its metabolite α-hydroxyetizolam, flubromazolam, clonazolam, diclazepam, delorazepam, bromazepam, flubromazepam, phenazepam, flualprazolam, flunitrazolam, and nitrazolam in human whole blood. After addition of internal standards, samples are buffered and extracted using a liquid-liquid extraction. Analysis is performed using positive-ion electrospray tandem mass spectrometry for detection and quantitation. Calibration ranges were established based on the method performance and differed from compound to compound. Replicates at the lowest calibration point for each compound performed within 5% of CV (Coefficient of Variation). The correlation coefficient was >0.990 for all compounds. Relative standard deviation for all compounds was ≤10% of CV and accuracy was  ±10% for both within- and between-run experiments. The maximum average intra- and inter-run imprecision were 5.7%. The maximum average intra- and inter-run imprecision was -8.7%. As part of evaluating the scope for relevancy, samples testing positive in immunoassay but confirmed to be negative in traditional benzodiazepine confirmation method were re-analyzed using this method. The presence of at least one novel benzodiazepine was identified in 70% of these samples. The appearance of these novel "designer" benzodiazepines demonstrates the challenge for toxicology testing and the need for continually updated confirmation methods.

High-Dose Dependence and Cognitive Side Effects to Medical Prescription of Etizolam

Introduction: The use of novel designer drugs has increased worldwide over the years. Etizolam is a designer benzodiazepine (BZD) that has raised concern because of its growing non-medical use, liability to tolerance and dependence, and related harms. Studies exploring the abuse liability and cognitive effects of etizolam outside the therapeutic doses are lacking. Aims: To explore the abuse liability of etizolam and the characteristics of patients affected by etizolam high-dose dependence in a nationwide tertiary referral addiction unit. To document the cognitive changes to etizolam high-dose use. Design and Methods: Sociodemographic and clinical data on subjects with etizolam high-dose use were retrospectively collected from a database of 1,293 patients consecutively admitted to the Addiction Medicine Unit, Verona University Hospital, Italy for detoxification from high-dose BZDs or Z-drugs dependence. Thorough neuropsychological testing explored the cognitive side effects of high-dose etizolam use. Results: We found eleven etizolam high-dose users, of which eight used etizolam only, and three used etizolam with other BZDs/zolpidem. All the patients were prescribed etizolam for medical reasons, i.e., anxiety and/or insomnia. Neuropsychological evaluation showed deficits of working memory, visuospatial memory and executive function in a 27-year-old woman who used etizolam 15 mg daily. Discussion: Our findings suggest that abuse and dependence liability of etizolam should be considered a public health and social problem. They offer preliminary evidence on the cognitive side effects of etizolam high-dose use. Conclusions: This report offers new information on the potential harms of etizolam in patients who are prescribed this drug for medical reasons.