Notes from the Field : Illicit Benzodiazepines Detected in Patients Evaluated in Emergency Departments for Suspected Opioid Overdose — Four States, October 6, 2020–March 9, 2021

• Published in: MMWR. Morbidity and mortality weekly report 2021-08, Vol.70 (34), p.1177-1179
• Main Authors: Aldy, Kim, Mustaquim, Desiree, Campleman, Sharan, Meyn, Alison, Abston, Stephanie, Krotulski, Alex, Logan, Barry, Gladden, Matthew R., Hughes, Adrienne, Amaducci, Alexandra, Shulman, Joshua, Schwarz, Evan, Wax, Paul, Brent, Jeffrey, Manini, Alex
• Format: Article
• Language: English
• Subjects: Benzodiazepines; Buprenorphine; Carbon dioxide; Codeine; Complications; Consciousness; Consortia; Drug abuse; Drug dosages; Drug overdose; Drug withdrawal; Emergency medical care; Emergency medical services; Emergency services; Enforcement; Federal legislation; Fentanyl; Forensic sciences; Heroin; Hospitals; Intoxication; Intubation; Mechanical ventilation; Medical laboratories; Medicine; Methadone; Naloxone; Narcotics; Notes from the Field; Opioids; Overdose; Oxygenation; Patients; Psychotropic drugs; Respiration; Respiratory rate; Substance use; Toxicology
• ISSN: 0149-2195; 1545-861X
• DOI: 10.15585/mmwr.mm7034a4

[...]in cases of co-exposure to opioids and benzodiazepines, including illicit benzodiazepines, symptoms of benzodiazepine intoxication (e.g., profound sedation) are unaffected by naloxone, leading to risk for respiratory failure or death (1). Additional case information was obtained through chart review.* This activity was reviewed by CDC and was conducted consistently with applicable federal law and CDC policy.† During October 6, 2020–March 9, 2021, 141 biologic samples§ were analyzed from five clinical sites in four states (Missouri, New York, Oregon, and Pennsylvania).¶ The presence of illicit benzodiazepines was identified in 21 (14.9%) patients (Table); the substances identified included clonazolam (11 patients; 52.4%), etizolam (10; 47.6%), and flubromazolam (two; 9.5% [co-identified in patients with etizolam]). Detection of illicit benzodiazepines and opioids, initial naloxone administration, and outcomes among patients with suspected opioid overdose (N = 21) — Toxicology Investigators Consortium Fentalog Study Group, four states, October 6, 2020–March 9, 2021Return to your place in the text Characteristic No. (%) of patients Illicit benzodiazepines detected Clonazolam 11 (52.4) Etizolam 10 (47.6) Flubromazolam* 2 (9.5) Opioids detected Co-detected opioids† 20 (95.2) Methadone 12 (60.0) Fentanyl 6 (30.0) Heroin 4 (20.0) Codeine 2 (10.0) Para-fluorofentanyl 2 (10.0) Buprenorphine 1 (5.0) Acetyl fentanyl 1 (5.0) Medical course and outcome Naloxone administration§ 16 (76.2) Only 1 dose administered 9 (56.3) ≥2 doses administered 7 (43.8) Known naloxone indication¶ 15 (71.4) Depressed level of consciousness 9 (60.0) Respiratory depression 7 (46.7) Decreased oxygenation 3 (20.0) Decreased carbon dioxide expiration 2 (13.3) Known naloxone response** 13 (61.9) Improved level of consciousness 6 (46.2) Increased respiratory rate 4 (30.8) Improved oxygenation 1 (7.7) Precipitated withdrawal†† 1 (7.7) No response 5 (38.5) Respiratory and cardiac intervention Endotracheal intubation/Mechanical ventilation 1 (4.8) Cardiopulmonary resuscitation 1 (4.8) Hospital course Discharge from emergency department 17 (81.0) Admission to hospital floor 3 (14.3) Admission to intensive care unit 1 (4.8) Disposition Discharged without sequelae 18 (85.7) Transferred to higher level of care 1 (4.8) Transferred to substance use treatment 1 (4.8) Left against medical advice 1 (4.8) Died 0 (—) * Flubromazolam was only detected in two of the cases that also included etizolam. † At l