From signal to alert: A cluster of exposures to counterfeit alprazolam tablets containing five novel benzodiazepines

Abstract

Objective To illustrate the toxicosurveillance role of the Emerging Drugs Network of Australia – Victoria (EDNAV) project in informing timely harm minimisation interventions. Methods Utilisation of an ethics approved clinical registry storing de‐identified clinical and analytical data on Victorian ED illicit drug‐related presentations. Results In April 2022, six adults presented to hospital with varying levels of sedation, following the use of counterfeit benzodiazepines. Comprehensive toxicological analysis identified five separate novel benzodiazepines within blood samples from each patient. A public ‘Drug Alert’ was subsequently issued, and local emergency physicians were notified. Conclusion Toxicosurveillance projects, such as EDNAV, are critical to the continued monitoring and reporting of illicit substance use in the community.

Real or fake? Sourcing and marketing of non‐prescribed benzodiazepines amongst two samples of people who regularly use illicit drugs in Australia

“…Despite a decline in dispensing rates in Australia [ 10 ], most respondents in these samples (about two‐in‐three) self‐reported last obtaining non‐prescribed benzodiazepines through diverted prescriptions from people close to them (friends/relatives/partners). While use without clinical oversight undeniably presents health risks, it nevertheless avoids risks associated with the unregulated market, such as counterfeit products containing higher potency novel compounds [ 14 ]. In Scotland and the US, greater restrictions on benzodiazepine prescribing in the absence of increased demand reduction efforts has resulted in markets being dominated by higher toxicity novel benzodiazepines and increased rates of overdose, with health experts now advocating for safer supply/prescribing [ 5 ].…”

“…We also found those who did not report sourcing through a diverted prescription were twice as likely to obtain alprazolam relative to diazepam. This is unsurprising given alprazolam was reclassified as a Schedule 8 poison (‘controlled drug’) in Australia in 2014 [ 8 ], while most other benzodiazepines (including diazepam) remain Schedule 4 (‘prescription only medicine’); however, it is concerning given alprazolam's high risk profile [ 8 ] and tendency to be counterfeited [ 14 ]. Indeed, most counterfeit benzodiazepine products in Australia appear to be being sold/marketed as alprazolam (e.g., [ 17 ]), placing people who use non‐prescribed alprazolam at particular risk of consuming something unexpected.…”

“…Self‐reported use of non‐medical/non‐prescribed benzodiazepines has increased in Australian household surveys [ 12 ] and sentinel samples of people who use illicit drugs [ 13 ]. Risk of harm is exacerbated by increasing detection of counterfeits (fake or imitation products which may contain unexpected compounds and/or dose of compounds) in Australia, with multiple alerts issued for products containing multiple high‐risk novel benzodiazepines [ 14 , 15 ] and some with entirely different classes of drugs [ 16 , 17 ]. Indeed, novel benzodiazepines (and opioids) are increasingly detected globally [ 18 ] and are driving overdose deaths in some countries (e.g., [ 5 , 19 ]).…”

“…While some people seek out these more potent novel compounds—made increasingly available with the emergence of cryptomarkets [ 21 ]—those seeking non‐prescribed classic/registered pharmaceutical benzodiazepines are at risk of being sold more dangerous counterfeits. Further, while public health warnings are emerging [ 14 ], it remains unclear to what extent people are aware of the complex risk environment associated with the non‐prescribed benzodiazepine market. Thus, amongst two sentinel samples of people who regularly use illicit drugs in Australia, this paper aims to investigate: (i) how and which non‐prescribed benzodiazepines are being sourced, and whether the type of benzodiazepine differs according to the source; (ii) aesthetic characteristics of non‐prescribed benzodiazepines being sourced; and (iii) awareness of risks associated with non‐prescribed benzodiazepine use (e.g., unknown content and/or dose).…”

A multicentre case series of analytically confirmed gamma‐hydroxybutyrate intoxications in Western Australian emergency departments: Pre‐hospital circumstances, co‐detections and clinical outcomes

“…The ED is an important setting for identifying and managing GHB overdose and other related harms. There is also growing evidence supporting the integration of clinical and toxicological data to facilitate public health surveillance and detection of emerging drug related threats [17][18][19][20]. The Emerging Drugs Network of Australia (EDNA) [21] is a prospective toxicosurveillance system of illicit and emerging drugs involved in sentinel EDs across Australia established to address the need for a coordinated national approach.…”