1. The problem
- Benzodiazepines increasingly contributing to complex opioid overdoses and illicit drug toxicity deaths in BC.
- Benzos (mostly etizolam) detected in 50% of illicit drug toxicity deaths between Dec 2020-Jan 2021.
- Increasing contamination of illicit opioids with benzos: 20% of all drug samples checked by BC Centre on Substance Use and 50% of samples from Vancouver Island in Jan 2021.
2. What does this mean for your patients?
- Opioid overdoses may be more difficult to reverse if benzos are on board: Naloxone will reverse opioid effects, but patients’ level of consciousness may remain depressed.
- Overdose may be prolonged due to long half-life of etizolam (~7-15 hours); especially in patients with liver disease (liver metabolism).
- Patients who use illicit opioids may present with benzo withdrawal that can be hard to differentiate from opioid withdrawal or stimulant toxicity (anxiety, sleeplessness, autonomic instability).
- SUPPORTIVE CARE is paramount! Support patients’ ventilation/oxygenation, monitor (O2 saturation, end-tidal CO2 where available), treat symptoms.
- Note: urine toxicology screens will not detect all benzos. Point-of-care screens in BC will detect etizolam but reported sensitivity is 50-70%. **Treat patients clinically**
3. Should I give Naloxone?
- YES. This will reverse the opioid component of mixed opioid/benzo overdoses.
- Give more if an incomplete response is seen.
4. Should I give Flumazenil?
- NO. High risk of seizures and dysrhythmias.
5. What else can I do?
- Don’t forget to check a glucose: hypoglycemia may occur in opioid overdose.
- Harm reduction counseling: avoid using drugs alone, use small test doses of substances, use supervised consumption sites/overdose prevention services.
- Offer take-home naloxone kits.
- Don’t forget buprenorphine: safe and effective when started from emergency departments, and recent study shows protection against opioid overdose when benzos are co-prescribed. See: Buprenorphine (Suboxone) Initiation for Opioid Use Disorder Patients clinical summary.
- Call for help. BC Drug and Poison Info Centre (DPIC; 604-682-5050 or 1-800-567-8911) or 24/7 Addiction Medicine Clinician Support Line (778-945-7619).
- Benzodiazepines found in Opioids in BC – Summary Sheet for Health Professionals (BCDCD / Towards the Heart)
- Etizolam in British Columbia’s Illicit Drug Market – Fact Sheet (BCDCD / Towards the Heart)
- Responding to an Opioid Overdose Involving Benzos (Opioids and Benzos or Etizolam) – Overdose Resource (BCDCD / Towards the Heart)
- Using Benzodiazepine Urine Test Strips for Drug Checking
- ED Response to the Opioid Overdose Crisis (EM Network Research Initiative)
Add public comment…