Increase in Fatal Benzodiazepine Overdoses

Editorial Team

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According to the latest research data from the U.S. Centers for Disease Control & Prevention (CDC), 2020 saw a dramatic and alarming increase in the number of U.S. deaths involving benzodiazepines (like Xanax and Valium), commonly known as BZDs or “benzos.” 

 

Even more concerning, the increase in fatalities was driven by designer benzos (illegally manufactured modified versions of the drugs), many of which are now being laced with the synthetic opioid fentanyl.

 

Benzo Overdoses on the Rise

 

Even though the total number of U.S. deaths is considered low (less than 3,000 during the year), the actual percentage increase from 2019 to 2020 is definitely not – 42.9%.

 

Clearly, this is seen as a growing and alarming drug trend and another public health issue, as the U.S. continues to battle against the national opioid crisis, not to mention the coronavirus pandemic. 

 

It raises the question: Is there a “U.S. Benzo Crisis” on the near-horizon?

 

What are Benzodiazepines?

 

Benzodiazepines (often called BZDs or “Benzos”) are a group of prescription sedative medications. They are prescribed to treat people with anxiety and stress, as well as insomnia, as they encourage better sleep patterns.

 

These prescription drugs are some of the most commonly prescribed medications in the U.S. In fact, between 1996-2013, BZD prescriptions increased by 67% across the nation.

 

However, they are also used and abused by recreational drug users.

 

Well-known legal brands of BZDs include Valium, Xanax, Ativan, Klonopin, and Rohypnol (also commonly known by the slang term – “the date-rape drug”). 

 

Benzodiazepines can be known either by their chemical (generic) name or their brand name.

 

Approved Common Benzodiazepines (BZDs) Available in the U.S.

 

Generic

Name:

Brand

Name:

Generic

Name:

Brand

Name:

  • alprazolam 
Xanax
  • chlordiazepoxide
Librium
  • clonazepam 
Klonopin
  • diazepam
Valium
  • flurazepam 
Dalmane
  • lorazepam
Ativan
  • estazolam
Prosom
  • temazepam 
Restoril
  • flunitrazepam
Rohypnol
  • oxazepam
Serax
  • midazolam 
Versed
  • triazolam
Halcion
  • temazepam 
Restoril
  • clorazepate 
Tranxene

 

Benzodiazepines are normally taken orally, and come in the form of pills, capsules, and liquids. However, drug users usually add the liquid to drinks, either alcoholic or sodas, or even inject the liquid.

 

As their action is as a central nervous system (CNS) depressant – which slows down natural communications between the body and the brain – they are used recreationally.

 

Other CNS depressants include alcohol, cannabis, prescription painkillers, and illegal opioids, such as heroin and fentanyl

 

The Medical Uses of Benzodiazepines:

 

  • Anxiety and Panic Disorders
  • Seizures/convulsions (caused by epilepsy)
  • Insomnia or sleeping difficulties
  • General anesthesia
  • Muscle relaxation
  • Depression
  • Sedation prior to surgery or diagnostic procedures
  • Alcohol withdrawal and drug-associated agitation
  • Nausea & Vomiting
  • Panic attacks

 

Apart from being a CNS depressant, benzodiazepines are also mild tranquilizers, so they can also be used to treat alcohol withdrawal and epilepsy. 

 

Even after a short period of use, they are known to have an addictive effect, which is why they are not normally used as an initial prescription for anxiety, stress, and insomnia.

 

How are Benzodiazepines Abused?

 

Benzos are used and abused recreationally because not only do they have the sought-after euphoric effect, they are used by drug users to “come down” from the effects of stimulant drugs, such as cocaine or amphetamines.

 

In recent years, benzodiazepines have been frequently detected in drug cocktails taken by abusers (when more than one substance is abused, it is known as polydrug use). 

 

Additionally, illegal chemically altered versions made in basement laboratories, and often called “designer benzodiazepines” (or DBZDs) have recently entered the illegal drug market.

 

Benzo pills in a hand

 

Examples of these designer benzos* include clonazolam, etizolam, flualprazolam and flubromazolam – all of which are intended to sound similar to legal generics.

 

*For more information on these drugs, see the section below:

 

Illicit Modified Benzodiazepines: “Designer Benzos

 

How Do Benzodiazepines Affect the Brain?

 

The human body has a natural chemical called gamma-aminobutyric acid (GABA). Benzodiazepines work by increasing the amount of GABA in the brain and the body, which reduces (or sedates) the activity in the areas of the brain responsible for:

 

  • Reasoning
  • Memory
  • Emotions
  • Essential functions, such as breathing 

 

Benzodiazepine: Side Effects

 

Common Effects:
  • Sedation
  • Dizziness
  • Fatigue
  • Light-headed feeling
Other Effects:
  • Drowsiness
  • Depression
  • Headache
  • Confusion
  • Loss of orientation
  • Sleep disturbance
  • Irritability
  • Memory impairment
  • Excitement
  • Aggression

 

Benzodiazepines: Varying Potency and Half-Life

 

Benzodiazepines vary in both potency and the length of time the effects of each can last. As a way of measuring duration, the half-life of a drug is used, and is defined as the length of time half of the consumed dose takes to leave the body.

 

High-potency benzodiazepines 

with a short half-life

Low-potency benzodiazepines

with a short half-life

  • alprazolam – Xanax
  • oxazepam – Serax
  • lorazepam – Ativan
  • temazepam – Restoril
  • triazolam – Halcion
High-potency benzodiazepines 

with a long half-life

Low-potency benzodiazepines

with a long half-life

  • clonazepam – Klonopin
  • chlordiazepoxide – Librium
  • clorazepate – Tranxene
  • diazepam – Valium

 

Short-acting benzodiazepines (those with a short half-life) have stronger immediate effects and are more addictive than long-acting ones.

 

IMPORTANT: Benzodiazepines are not recommended for:

 

  • Pregnant women or those breastfeeding, or
  • People with:
    • Acute asthma, emphysema or sleep apnoea
    • Advanced liver or kidney disease
  • People with a history of substance use disorders (SUDs), as their use, can lead to addiction

 

Benzodiazepine Slang / Street Names

 

Benzodiazepines/benzos are available in either prescription or counterfeit form via illegally purchasing the drugs in the street, as with any other illegal street drug, or purchasing them online.

 

Common slang/street names for benzos in general include:

 

  • Bars
  • Chill Pills
  • Planks
  • Benzos
  • Downers
  • Tranks
  • Blues
  • Nerve Pills
  • Zannies

 

However, in addition to these, specific benzos also have their own commonly known street names:

 

Generic

Name:

Brand

Name:

Slang & 

Street Names:

lorazepam Ativan Candy, Downers, Sleeping Pills, Tranks
triazolam Halcion Candy, Downers, Sleeping Pills, Tranks
clonazepam  Klonopin K, K-Pin, Pin, Super Valium
chlordiazepoxide Librium Candy, Downers, Sleeping Pills, Tranks
flunitrazepam Rohypnol Circles, Date Rape Drug, Forget-Me Pill, La Rocha, Lunch Money, Mexican Valium, Mind Eraser, Roofies, Wolfies
diazepam Valium Eggs, Jellies, Moggies, Vallies
alprazolam  Xanax Bars, Bicycle Handle Bars, Footballs, French Fries, Hulk, Ladders, School Bus, Xan, Xanies, Zan, Zannies, Zanbars, Z-Bars

 

Massive Increase in Benzo-Involved Overdoses

 

On August 26, 2021, the U.S. Centers for Disease Control & Prevention (CDC) released their Morbidity and Mortality Weekly Report (MMWR), which revealed a dramatic increase of 42.9% in recent drug overdose deaths involving benzodiazepines (BZDs). 

 

Even more alarmingly, the increase was driven by overdoses where illegally manufactured designer benzos (or DBZDs), such as etizolam and flubromazolam, were involved.

 

This CDC MMWR included multi-state research by its own analysts which studied deaths involving benzodiazepines from April to June 2019 to the same period in 2020. Although the absolute number of fatalities reported is considered low (less than 3,000), the dramatic near-43% rise is certainly not.

 

“The growing use of illicit benzodiazepines requires a better understanding of the synergistic toxicity when these drugs are used along with opioids.
Raising awareness among clinical, public safety, and community partners about dangers associated with the use of illicit benzodiazepines, including co-use with opioids, is critical.” – Kim Aldy, DO, American College of Medical Toxicology, Phoenix, Arizona

 

Additionally, the total number of drug overdoses with benzodiazepines detected and treated in U.S. emergency departments (EDs) also increased sharply. Benzodiazepine-related ED visits rose by 23.7%, and those which also involved opioids increased 34.4%.

 

Summary of CDC Benzodiazepine Report’s Main Findings

Benzodiazepine-involved overdose deaths were actually dropping in recent years and decreased continuously from 2017–2019.

 

However, since 2019, the illegal counterfeit and “designer” benzodiazepine drug supply has increased rapidly, and the latest CDC figures show the stark impact of this.

 

Here are the main findings of this latest CDC report, entitled: “Trends in Nonfatal and Fatal Overdoses Involving Benzodiazepines – 38 States and the District of Columbia, 2019–2020”:

 

  • From 2019 to 2020, benzodiazepine overdose visits per 100,000 to emergency departments increased by 23.7%; both with – 34.4% – and without – 21.0% – opioid co-involvement
  • From April-June, 2019 to April-June, 2020:
    • Prescription benzodiazepine-involved overdose deaths increased by 21.8%
    • Illicit benzodiazepine-involved overdose deaths increased by 519.6%
  • During January-June, 2020, 92.7% of benzodiazepine-involved deaths also involved opioids, and 66.7% involved illicitly manufactured fentanyl

 

Illicit Modified Benzodiazepines: “Designer Benzos”

 

Illegally manufactured and modified benzodiazepines purchased from criminal drug dealers, either in-person or online, are becoming an increasing public health issue in the U.S., primarily because the people who buy these drugs have no idea what the actual product contains.

 

Multicolored Benzos

 

Clearly, as shown by the recent CDC report described previously, many of these drugs are now being contaminated by the synthetic opioid fentanyl.

 

These drugs are known as designer benzodiazepines (or DBZDs), and they are illegally manufactured in basement laboratories, either abroad, eg. in Mexico, or inside the U.S.

 

They are chemically described as “derivatives,” meaning they are made using a similar chemical structure to existing benzodiazepines. 

 

Examples of designer benzos or DBZDs (all of which are intended to sound similar to legal generics name) include:

 

  • Clonazolam
  • Etizolam
  • Flualprazolam and
  • Flubromazolam

 

So what more do we know about designer benzodiazepines?

 

The Dangerous Risks of Designer Benzos (DBZDs)

 

Between 1996 and 2013, there was a 67% increase in adults filling BZD prescriptions. During the same period, the total quantity of BZDs filled increased by 3.3 times, and overdose mortality involving BZDs increased 5.3 times.

 

An estimated 75% of the overdose deaths involved the use of opioids in addition to BZDs. 

 

Additionally, during this period, U.S. concern was growing over the rise in popularity of designer benzodiazepines (correctly termed as non-Food and Drug Administration (FDA)-approved BZDs or, alternatively, DBZDs). 

 

BZDs available in the U.S. (legally or otherwise) fall into 2 groups:

  1. FDA-approved compounds
  2. Non-FDA-approved compounds

 

Non-FDA-approved BZDs can be divided into 2 further groups:

  • BZDs approved in other countries, and
  • Designer BZDs (DBZDs), often called synthetic, novel, or novel psychoactive substances, and are not approved for medical use anywhere in the world.

 

The Difficulty in Regulating DBZDs as Controlled Substances

 

Chemically, non-FDA-approved BZDs retain a similar structure to FDA-approved BZDs. However, they are then modified by either the addition and/or deletion of certain functional elements of the chemical compound.

 

Like all illicit drugs that can be bought on the street or online (particularly the dark web), users have little to no idea what the products contain or how safe they are.

 

The situation is worsened further because DBZDs are exceptionally difficult to “police” by federal authorities like the FDA and the DEA.

 

For every illegal drug prosecution, the authority has to provide evidence it is the same identical chemical compound as the one they have regulated as a controlled substance.

 

Furthermore, if the authority is successful in identifying a specific DBZD, those who manufacture the designer benzos simply go back to their basement laboratories and change the chemical structure of the compound slightly.

 

It constantly leaves agencies like the DEA having to start all over again – with every new BZD variation that becomes available.

 

Unsurprisingly, the disappearance of a DBZD from the illicit drug supply chain often coincides exactly with the same DBZD’s controlled substance classification.

 

Benzodiazepine Use & Abuse: Short & Long Term Effects

 

Benzodiazepines can affect different people in different ways, depending on a range of factors. The possible effects listed here are the most commonly experienced.

 

Possible Short-Term Effects of Benzodiazepine Use:

 

  • Depression
  • Confusion
  • Headache
  • Feelings of isolation or euphoria
  • Impaired thinking and memory loss
  • Drowsiness, sleepiness, and fatigue
  • Diarrhoea/constipation
  • Dry mouth
  • Double / blurred vision
  • Impaired coordination, dizziness, and tremors
  • Nausea and loss of appetite
  • Slurred speech or stuttering

 

Possible Short-Term Effects of Benzodiazepine Use by Injection:

 

  • Vein damage and scarring
  • Infection, including hepatitis B, hepatitis C, HIV, and AIDS
  • Deep vein thrombosis and blood clots, which if left untreated can result in:
    • Loss of limbs
    • Organ damage
    • Stroke and
    • Possibly death

 

Possible Long-Term Effects of Benzodiazepine Use:

 

  • Impaired thinking and memory loss
  • Anxiety and Confusion
  • Irritability, paranoia, and aggression
  • Personality change
  • Headaches
  • Nausea
  • Weakness, lethargy, and lack of motivation
  • Difficulty sleeping/disturbed dreams
  • Drowsiness, sleepiness, and fatigue
  • Skin rashes and weight gain
  • Benzodiazepine use disorder (addiction)
  • Withdrawal symptoms [see below]

 

Benzodiazepines: Overdose & Addiction

 

According to the CDC report detailed above, 2020 saw a huge rise in both fatal bezo-involved overdoses and visits to the Emergency Department (ED). An overdose solely on BZDs is definitely possible if large enough quantities of the drug are taken.

 

If you believe you may have overdosed or you are with someone exhibiting the symptoms described below, it is imperative you call 911 immediately:

 

  • Over-sedation or sleep
  • Excitability and jitters/tremors
  • Rapid mood swings
  • Aggression
  • Slow, shallow breathing is a sign of respiratory depression, medically termed as hypoventilation, which can be life-threatening if left untreated
  • Unconsciousness or coma

 

Benzodiazepines & Polydrug Use

 

Polydrug use” is the term used to describe the recreational use of more than one substance at a time, or one substance after another. It can involve both illicit drugs and legal substances, such as alcohol and prescription medications.

 

two shots of alcohol on a counter

 

Although overdoses from solely benzodiazepines are possible, the vast majority of those that prompted the CDC’s report involved BZDs and at least one other substance, predominantly either opioids or alcohol.

 

BZDs, alcohol, and opioids all have one thing in common – they are central nervous system (CNS) depressants.

 

The polydrug use involving either 2 or all 3 of these substances will amplify the depressive effects, which can result in respiratory depression, a severe lack of oxygen to the brain and body, and potentially death:

  • BZDs & Alcohol: The same thing that makes BZDs a treatment for alcohol withdrawal also makes them highly unsuitable for mixing with alcohol. Not only do people who drink alcohol while taking benzos feel the effects of the alcohol faster, but the interaction between them can lead to a significant increase in respiratory failure, overdose, and death.
  • BZDs & Opioids: The same dangers apply again to mixing BZDs with opioids.

 

Benzodiazepines: Withdrawal Symptoms

 

One clear sign of benzodiazepine use disorder (or addiction) is the onset of withdrawal symptoms if you abruptly stop taking the drug.

 

Benzodiazepine withdrawal can be dangerous, especially for those with severe dependence and those with pre-existing health issues. 

 

More serious withdrawal symptoms can include psychosis and seizures – if left untreated, withdrawal seizures can worsen, become difficult to control, and potentially prove fatal.

 

Withdrawal symptoms do vary from person to person and can differ depending on the type of BZD being taken, and in their severity. The symptoms can last from a few weeks to a year, and generally include:

 

  • Headaches
  • Fatigue
  • Anxiety
  • Tremors
  • Dizziness
  • Irritability
  • Nausea/vomiting
  • Abdominal pains
  • Heightened senses
  • Aching and/or twitching muscles
  • Decreased level of concentration
  • Difficulty sleeping (bizarre dreams when sleeping)
  • Delusions and hallucinations
  • Paranoia/psychosis
  • Seizures

 

Long-term benzodiazepine users can experience a prolonged withdrawal, known as post-acute withdrawal syndrome (PAWS), which can last for several months or more.

 

Common symptoms of PAWS include:

  • Chronic anxiety
  • Depression
  • Sleep difficulties

 

A professional medically supervised detox (or detoxification) is advised for long-term abusers, and those with severe dependence and / or with pre-existing health issues. 

At SpringBoard Recovery, located in Scottsdale (nr. Phoenix), Arizona, we understand that although it can be incredibly challenging, with the right professional approach and specialist treatment, a long-term and sustainable recovery from benzodiazepine addiction is definitely possible.

 

Contact us today to learn more about benzodiazepine addiction treatment and recovery.

 

External Sources:

 

  1. U.S. Centers for Disease Control & Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR) – August 26, 2021: “Trends in Nonfatal and Fatal Overdoses Involving Benzodiazepines – 38 States and the District of Columbia, 2019–2020.” August 2021. Available at CDC.gov.
  2. MIND. What are Benzodiazepines?  April 2021. Available at MIND.org.uk.
  3. Alcohol & Drug Foundation, Australia: Benzodiazepines Drug Facts. July 2021. Available at ADF.org.au.
  4. Drug Enforcement Administration (DEA). Emerging Threat Report 2020. 2020. Available at Cesar.UMD.edu.
  5. Drug Enforcement Administration (DEA). Flualprazolam. June 2020. Available at DEADiversion.usdoj.gov.
  6. U.S. National Library of Medicine: “Neurotransmitters as Food Supplements: The Effects of GABA on Brain and Behavior.” June 2015. Available at NLM.NIH.gov.
  7. U.S. National Library of Medicine: “Half-Life.” October 2020. Available at NLM.NIH.gov
  8. Drug Enforcement Administration (DEA). Benzodiazepines. June 2020. Available at DEA.gov.
  9. U.S. National Library of Medicine: “Designer Benzodiazepines.” June 2021. Available at NLM.NIH.gov.
  10. U.S. Food & Drug Administration (FDA). Benzodiazepine Drug Information. September 2020. Available at FDA.gov.
  11. U.S. National Library of Medicine: “Drug Laws & The ‘Derivative’ Problem.” July-August, 2014. Available at NLM.NIH.gov.
  12. Alcohol & Drug Foundation, Australia: Benzodiazepines. July 2021. Available at ADF.org.au.
  13. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). 2002 Annual Report on the State of the Drugs Problem in the European Union and Norway: Chapter 3: Polydrug Use. 2002. Available at EMCDDA.europa.eu.
  14. MIND. Withdrawal Effects of Benzodiazepines. April 2021. Available at MIND.org.uk.
  15. Semel Institute for Neuroscience & Human Behavior. Post-Acute Withdrawal Syndrome (PAWS). 2021. Available at Semel.ucla.edu.
  16. National Institute on Drug Abuse (NIDA). What is Drug Addiction Treatment? January 2018. Available at DrugAbuse.gov.

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WRITTEN BY GERARD BULLEN
SEPTEMBER 3, 2021

Gerard has been writing exclusively for the U.S. substance addiction treatment industry for many years, providing a range of medically-reviewed work, including white papers, long-form, and short-form content articles, and blog posts for accredited addiction treatment centers. A member of the American Medical Writers Association, Gerard’s specific focus is substance addiction (an area that has impacted Gerard’s personal life in several ways), and he is particularly drawn to the topics of professional, evidence-based treatment, new and alternative therapies, and enabling readers to find their own sustainable, long-term recovery. Gerard lives and works in Maryland, U.S., he’s happily married, and a proud father. His interests include hiking with the family, reading fiction (from the classics to virtually all of the current NYT bestseller list), American and British film classics, and his beloved dogs, Toby and Coco, both rescued from the local pound.

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