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Author Topic: [Canada] Benzodiazepine-laced drugs (Benzo dope) text and video  (Read 2727 times)

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source: https://www.sciencedirect.com/science/article/pii/S0955395922003498

The increase in benzodiazepine-laced drugs and related risks in Canada: The urgent need for effective and sustainable solutions

January 2023

Highlights

• Overdose rates in Canada continue to rise and are now primarily driven by illicitly manufactured fentanyl.

• Policies to reduce risks have been ineffective and have led to unintended consequences including an unprecedented rise in adulterants in the illegal drug supply.

• Most recently, the drug supply has become contaminated with synthetic benzodiazepine-laced opioids (i.e., 'benzodope') , which poses amplified risks for people who use drugs.

• Effective and sustainable policies developed in partnership with people who use drugs must be implemented and evaluated to address this issue.

Abstract

The overdose crisis in Canada has continuously evolved and is increasingly challenging to contain, while efforts from governments and policymakers to address it have often fallen short and resulted in unintended consequences. One of the main repercussions has been an unprecedented rise in adulterants in the illegal drug supply, including a wide array of pharmacological and psychoactive compounds and chemicals, which has resulted in a progressively toxic drug supply.

Most recently, there has been a stark increase in synthetic benzodiazepine-laced opioids (i.e., ‘benzodope’) in some Canadian jurisdictions. This unique combination carries distinct and amplified risks for people who use drugs including fatal and non-fatal overdoses, increased dependence and withdrawal symptoms, and places them in extremely vulnerable positions. The emergence of benzodiazepines within the illicit drug supply has substantially contributed to drug-related morbidity and mortality in Canada, and has further complicated current public health initiatives and overdose prevention efforts.

This reality underscores the need for effective and sustainable policy solutions to address the evolving overdose epidemic including increased knowledge and education on the specific harms of opioid and benzodiazepine co-use (especially in regards to the complexity of opioid/benzodiazepine overdoses), scaling-up harm reduction measures, and eliminating the toxic drug supply altogether.

Background

As Canada grapples with an evolving overdose epidemic, characterized by the emergence of numerous challenges, government officials and policymakers continue to scramble to develop new and effective solutions, the majority of which tend to lag far behind the complex and multifaceted realities of drug use. Over the past decade, Canadian governments have undertaken a number of measures aimed at curbing the rise in prescription opioid use, as well as reducing related harms and overdose deaths associated with illegal drug use (Government of Canada, 2021). These efforts initially included clamping down on the over-prescription of opioids through delisting specific opioids from drug benefit plans (e.g., OxyContin) and introducing prescription monitoring programs (PMPs) to more closely monitor risky prescribing practices, repeat prescriptions, and ‘doctor shopping’ among patients (Fischer & Keates, 2012; Furlan et al., 2014; Karamouzian et al., 2022; Sproule, 2015).

However, researchers have pointed out that the impacts of these piecemeal policy solutions have facilitated unintended consequences such as increases in drug use-related morbidity and mortality (Fischer et al., 2020; Fischer & Rehm, 2017; Fischer & Wood, 2020). For instance, many individuals who were taking these prescriptions and found themselves suddenly cut off had to subsequently resort to the illegal drug market to obtain substitute opioids in order to avoid any adverse effects from having their prescriptions discontinued, such as withdrawal. The increase in demand for illegal opioids was resourcefully filled by suppliers with more affordable, accessible, and potent alternatives, such as illicitly-produced fentanyl and fentanyl-related analogues (e.g., carfentanil) (Hasegawa et al., 2022; Norton, 2008).

Over the past few years, synthetic fentanyl has predominantly replaced prescription opioids and is now the leading cause of opioid-related toxicity deaths in Canada (Belzak & Halverson, 2018; Government of Canada, 2022a; Palamar et al., 2022; Payer et al., 2020). While various sources of synthetic fentanyl exist such as the Darkweb cryptomarket and organized crime syndicates and/or drug cartels that smuggle these drugs over the US-Mexican border, data from the United States’ Drug Enforcement Agency has implicated China as the primary source (Greenwood & Fashola, 2021; Mars et al., 2019).

More recently, the COVID-19 pandemic and subsequent public health mandates appear to have exacerbated changes in the illegal drug supply and related harms (Ali et al., 2021; Canadian Centre on Substance Use and Addiction (CCSA), 2020; Davis & Samuels, 2020). Drug shortages, increases in prices, decreases in availability, stockpiling, and reductions in drug purity have all been reported, while economic and financial issues have caused many people who use drugs to source cheaper, and at times, more potent, substances (Catalani et al., 2021).

Qualitative data obtained from people who use drugs corroborate fluctuations in the quality and potency of substances since the onset of COVID-19 (Ali et al., 2021; McAdam et al., 2022). Specifically, there has been an unprecedented increase in adulterants, contaminants, and diluents or cutting agents (informally referred to as ‘buff’) in the illegal drug supply, which are often mixed in by dealers to add weight (i.e., ‘bulk up’) to the substances so that they can sell less product for the same price (Government of Canada, 2022a; Payer et al., 2020). These adulterants include a vast array of pharmacological and psychoactive compounds and chemicals, such as tranquilizers (e.g., Xylazine), nitazines, antipsychotics/antidepressants, analgesics, sedatives/muscle relaxants, stimulants (e.g., caffeine), hallucinogens, various composites, and novel psychoactive substances (NPS) (Browne et al., 2021; Friedman et al., 2022; Singh et al., 2020).

The addition of these contaminants to the drug supply may pose significant health risks and is concerning since accidental poisoning is more likely to occur when people who use drugs are unaware of the content, quality, and quantity of their drugs (Payer et al., 2020). For instance, levamisole, a medication used to treat parasitic worm infections, is often buffed into cocaine and has been associated with blood and vascular issues, and even necrosis of the skin (Brunt et al., 2017). Phenacetin, an analgesic that has been withdrawn from medical use but was historically used to treat pain and fever, has been buffed into the opioid and stimulant supply and has been associated with cancer and kidney disease (Payer et al., 2020). These risks may be particularly amplified for illegal drugs that have been ‘buffed’ with benzodiazepines.

Role of benzodiazepines

Benzodiazepines are a class of psychoactive medications that are among the most widely prescribed substances for conditions such as anxiety, sleep disorders, and seizures. Some of the most commonly prescribed benzodiazepines in Canada include clonazepam (Rivotril), lorazepam (Ativan), alprazolam (Xanax), and diazepam (Valium) (Canadian Centre on Substance Use and Addiction (CCSA) & the Canadian Community Epidemiology Network on Drug Use (CCENDU), 2021). Available evidence indicates that the illegal drug supply in Canada, particularly in jurisdictions that have been hardest hit by the overdose crisis (e.g., BC and Ontario), is becoming increasingly adulterated with the presence of benzodiazepines (Laing et al., 2021; Scarfone et al., 2022). New and/or counterfeit benzodiazepines, benzodiazepine analogues or derivatives, and benzodiazepine-like substances have also appeared in the illegal drug market (Edinoff et al., 2022; Orsolini et al., 2020). These ‘designer’ benzodiazepines can be significantly more potent than their prescription counterparts and have poorly-described and poorly-understood pharmacological and toxicological profiles (European Monitoring Center on Drugs and Drug Abuse (EMCDDA), 2015).

These benzodiazepines are primarily presenting in the drug supply and sold as opioids (usually as ‘heroin’, ‘down’ or ‘fent’), the combination of which has colloquially become referred to by people who use drugs as ‘benzodope’ (Canadian Centre on Substance Use and Addiction (CCSA) & the Canadian Community Epidemiology Network on Drug Use (CCENDU), 2021).

While it is difficult to identify the source of these benzodiazepines, it is likely that they are manufactured illicitly as opposed to being diverted from the medical supply considering many are not legally prescribed or medically available in Canada, such as flualprazolam and flubromazolam (British Columbia Centre on Substance Use (BCCSU), 2020). For instance, etizolam, a benzodiazepine analogue which is not approved for medical use in Canada and is multifold in potency compared to diazepam, has emerged in many drug samples in Ontario and BC (Thompson H, 2022). Among urine samples submitted for testing that screened positive for benzodiazepines in BC, the presence of etizolam increased from 40% to 70% between April 2020 and July 2021 (Payer et al., 2020). Benzodiazepines were also detected in approximately 50% of overdose deaths that occurred in BC in January 2021, up from 21% in August, 2020 (British Columbia Centre on Substance Use (BCCSU), 2021). In Ontario, nearly half (46%) of opioid-related deaths that occurred during the pandemic (March-December, 2020) contained a benzodiazepine, compared to 30% pre-pandemic (March-December, 2019), primarily driven by a ten-fold increase in etizolam (Gomes T et al., 2021). Data from the city of Toronto further substantiate an increase in the presence of benzodiazepines in the illicit substance supply (Scarfone et al., 2022; Thompson H, 2022).

This reality poses several distinct risks to people who use drugs. As sedative-hypnotics, benzodiazepines slow down brain activity and result in varying levels of drowsiness, impaired coordination, decreased heart rate and blood pressure, as well as diminished memory including confusion, memory loss, and occasionally hallucinations (Canadian Centre on Substance Use and Addiction (CCSA), 2022). Furthermore, qualitative evidence suggests that people who use drugs are vulnerable to experiencing anterograde amnesia or ‘blackouts’ where they lose track of time and do not remember their actions (Liebrenz et al., 2016). This places them in uniquely vulnerable positions where they can be easily victimized (e.g., robbed, taken advantage of, etc.) and/or may unintentionally engage in riskier behaviors and harm themselves or others.

Additional risks relate to the prolonged use of benzodiazepines (whether intentional or not) which increases tolerance and can cause dependence, making it extremely difficult to cease use. Benzodiazepine withdrawal can be especially difficult and can include agitation, paranoia, delirium, and seizures, which may have unintended long-term impacts on brain function and can also result in death (Canadian Centre on Substance Use and Addiction (CCSA), 2022; Lann & Molina, 2009; Murphy et al., 2016).

Moreover, when the sedative effects of benzodiazepines are combined with those of opioids, the risk for adverse health problems such as respiratory depression, coma, overdose, and mortality is markedly higher (Canadian Centre on Substance Use and Addiction (CCSA), 2022). For example, a recent study conducted in Canada showed that concurrent use of opioids and benzodiazepines carried a 13% higher risk of hospitalization or emergency department visits, and almost doubled the risk of death (Sharma et al., 2020). Between 2019 and 2020, benzodiazepine overdose emergency department visits in the US increased 23.7% both with and without opioid co-involvement, while prescription and illicit benzodiazepine-involved overdose deaths increased 21.8% and 519.6%, respectively, the majority of which also involved opioids, including illicitly manufactured fentanyl (Liu et al., 2021).

The urgent need for effective and sustainable policy solutions

The risks and corresponding increase in the prevalence of benzodiazepines within the illegal drug supply therefore necessitates the need for the implementation and sustainability of effective and proactive policy solutions to address these complex dynamics. Firstly, greater knowledge and education, as well as awareness and messaging for both people who use drugs and healthcare professionals is required. For instance, benzodiazepine and opioid overdose symptoms are similar, yet the mainstay pharmacotherapy used to reverse an opioid overdose (i.e., Naloxone) will not revive someone experiencing a benzodiazepine overdose, further complicating overdose response efforts (British Columbia Centre on Substance Use (BCCSU), 2021). Additionally, the primary treatment for acute benzodiazepine toxicity is ‘supportive care’, and the one pharmacotherapeutic alternative (flumazenil – a benzodiazepine antagonist that can reverse benzodiazepine-induced sedation) is characterized by risks that outweigh the benefits such as seizures, cardiac dysrhythmias, and mortality, and is not recommended for use (An & Godwin, 2016; Kang et al., 2021; MacDonald et al., 2022). Hence, it is necessary to foster awareness in regard to the heightened risk for overdose in the case of concurrent opioid and benzodiazepine use. People who use drugs, health care providers, first responders, and others who are involved with overdose response efforts should be made aware of the complexity of opioid-benzodiazepine overdoses through directed educational campaigns that provide explicit evidence-based recommendations on how to handle and respond to these complicated overdose typologies. These messages could be developed by public health agencies in collaboration with people who use drugs, and delivered throughout harm reduction organizations and networks.

Secondly, a number of promising measures that have been implemented across the country to varying degrees need to be scaled up. Conventional treatment options should continue to be expanded such as opioid agonist treatment (OAT), and injectable opioid agonist treatment (iOAT), which are safe and effective treatments that have been associated with decreased illicit substance use and related harms (Bruneau et al., 2018). While these treatments do not address the root cause of the toxic substance supply, they can help support people who use drugs to reduce their substance use and need to resort to and rely on the unregulated substance supply. However, engagement and retention rates remain insufficient, and these treatment modalities are not always the most suitable nor preferable (Blanco & Volkow, 2019; Ivsins et al., 2020; Ker et al., 2021; Socías et al., 2020). Thus, other beneficial harm reduction-based services and programs that meet people who use drugs where they are at also need to be bolstered, such as supervised consumption and overdose prevention sites, rapid access addiction medicine (RAAM) clinics, and drug checking services (Government of Canada, 2021).

Drug checking services may be particularly useful given the current tainted illegal drug supply and the risks related to the consumption of benzodiazepines and unknown drugs with unknown purity. These programs allow individuals to ascertain the makeup of their drugs, typically in under ten minutes, and can foster relationships between clients and healthcare providers (Beaulieu et al., 2021; Biggar et al., 2021). Data also highlights willingness to use drug checking services among people who use drugs in locations where these are non-existent or in their early stages (Rammohan et al., 2022). However, the range and level of detectable substances varies substantially among different drug checking techniques and systems, and benzodiazepines and related analogues are not always identified and can appear as ‘unknown’ or ‘unidentifiable’ constituents. This may have important implications if individuals erroneously believe that their substances do not contain benzodiazepines (or other adulterants) and are thus safe to consume (Payer et al., 2020).

In addition to supporting people who use drugs in a range of ways, these low-barrier interventions can also help track local drug trends and improve data, which can then be used to further inform policies and programming. Efforts should be made to better fund and implement these programs into existing harm reduction and community health organizations that have the capacity, willingness, and established relationships with people who use drugs so that they feel comfortable to submit their drugs for testing.

Thirdly, eliminating the toxic drug supply altogether is crucial for preventing further overdose deaths. As such, the distribution of legal and regulated pharmaceutical-grade drugs through alternative ‘safe supply’ programs should be implemented across the country in order to provide nontoxic alternatives to the tainted drug supply and minimize the risk for unintentional overdose and drug use-related harms (Bonn et al., 2020; Fleming et al., 2020; Ivsins et al., 2020).

Safe supply programs are interventions that consist of the provision of prescriptions of regulated dosages of substances (typically opioids, but also stimulants and/or benzodiazepines) by primary care providers to people who use drugs as an alternative to street-sourced and contaminated substances (Government of Canada, 2022b).
Patients may receive a daily or weekly supply of their substance, which they can consume on- or off-site, depending on the location and program specifics. Formally introduced in 2020, these programs have been implemented in a number of jurisdictions across Canada, with ten time-limited pilot projects established in three provinces including BC, Ontario, and New Brunswick, primarily located within community health or harm reduction centers (Government of Canada, 2022b). An increasing number of prescribers are becoming involved in this practice, however, safer supply programs have yet to be rolled out systematically and many people who use drugs are not able to access them or have indicated that these programs do not meet their needs or preferences in their current format (Palis et al., 2022).

Preliminary data from Ontario indicate that safe supply program access resulted in decreases in rates of emergency department/hospitalizations, as well as costs associated with health care, highlighting the important role these programs can play as an additional tool to help address the health burden of opioid use (Gomes et al., 2022).

Despite evidence of its benefits, the concept of safe supply remains controversial and difficult to promote, and numerous barriers continue to hinder its uptake (Brothers et al., 2022; Klaire et al., 2022). This underscores the need to evaluate these programs, especially for potential unintended consequences. For instance, anecdotal evidence suggests that once medical grade drugs became available, drug market prices dropped and new iterations of drugs appeared. Other possible adverse impacts include the possibility for diversion, which may be of particular concern if prescribed medications end up in naive users, which poses potential health risks.

Other innovative community-based initiatives include vending machines (e.g., MySafe) that use biometrics to identify individuals and safely and discreetly dispense prescriptions to those who may be unable to store their medication or are hesitant to attend clinics/pharmacies to obtain their prescriptions (Tyndall, 2020). Most recently, ‘social’ or ‘compassion’ clubs have also emerged in BC. These programs allow people who use drugs to co-operatively take ownership of their supply by legally obtaining their drugs from a pharmaceutical manufacturer, or by taking illicit drugs, testing them, and repackaging/labeling them to be reintroduced into the market with restricted dispensation to members (British Columbia Centre on Substance Use (BCCSU), 2019).

These programs have been implemented successfully in various jurisdictions, both nationally and internationally, for a variety of prescriptions and substances (antiretroviral drugs for HIV or Hepatitis, cannabis, etc.) (Belackova & Wilkins, 2018; Decorte et al., 2017; Vernaz et al., 2018). This model aims to reduce opioid overdoses through the provision of regulated substances while also disrupting the black market's stronghold on the substance supply by shifting the economic control to the users. Drug user advocacy groups have put forth formal requests for federal exemptions to legally run compassion clubs in Canada, but these have been rejected to-date, resulting in the continued operation of unsanctioned clubs (Drug Users Liberation Front (DULF) and Vancouver Area Network of Drug Users (VANDU), 2022).

Many of these programs are low-barrier, flexible, and can be easily integrated within existing harm reduction and community health services and subsequently scaled-up to increase engagement among people who use drugs. As people who use drugs relentlessly contend with the changing and increasingly toxic drug supply, more must be done to reduce the risk of drug toxicity events and death, enhance connections to health and social supports, and improve the overall health and wellness of people who use drugs.

As the overdose crisis persists and the illicit substance supply continues to be contaminated with toxic, potent, and harmful adulterants, it is imperative that a wide range of policy solutions and interventions are considered, implemented, and evaluated, in order to comprehensively address this paramount public health issue. Failure to utilize all possible and available solutions continues to place people who use drugs at extreme risk; a risk that has never been higher than in the current context of benzodiazepine-tainted drug supply.



What is Benzo Dope? | The New Overdose Crisis

Premiered Apr 9, 2023  #tranq #tranqdope

What is Benzo Dope? Benzo dope is a dangerous combination of Benzodiazepines and Opioids, typically Fentanyl mixed with NPS benzodiazepines such as Etizolam and flualprazolam. Benzo dope and Tranq dope are causing overdoses at an alarming rate.

« Last Edit: June 03, 2023, 04:04:50 PM by Chip »
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