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).

Resources

• 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)