What's in fake ‘Xanax’?: A dosage survey of designer benzodiazepines in counterfeit pharmaceutical tablets

Abstract

The identification of a range of different drugs within counterfeit benzodiazepine tablets has been widely reported; however, limited information is available on the dosage of these products. A rapid dosage survey of 46 counterfeit benzodiazepine tablets from 20 seizures was conducted over a 6-month period between April and September 2020. Existing methods utilised for the determination of benzodiazepines in toxicology specimens were applied to assess the dosage of four benzodiazepines detected across five different counterfeit benzodiazepine presentations. The highest dosage variation was observed for etizolam with a range of 0.7-8.3 mg per tablet. This report demonstrates the variability in drug content and dosage that can occur between visually similar counterfeit tablets, even when co-packaged within the same seizure, highlighting the potential public harm posed by these counterfeit medications.

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

“…This case cluster identified counterfeit alprazolam exposures resulting in hospitalisation. However, unlike previous alerts which predominately involved a single NBZN adulterant, 1,2 five separate NBZNs were detected in each blood sample obtained from six patients exposed to a single tablet formulation.…”

“…1 Visually these products are often indistinguishable from government-approved pharmaceutical products, meaning individuals may unknowingly consume unidentified substance(s) at variable dosages. 2 Additionally, changes in the content of counterfeit benzodiazepine products over time makes it difficult for emergency physicians to accurately estimate clinical risk following human exposure to benzodiazepines.…”

“…Regulatory agencies in Australia have documented the availability of counterfeit benzodiazepines in the community, noting these products are often adulterated with other psychotropic substances, most commonly novel benzodiazepines (NBZNs) 1 . Visually these products are often indistinguishable from government‐approved pharmaceutical products, meaning individuals may unknowingly consume unidentified substance(s) at variable dosages 2 . Additionally, changes in the content of counterfeit benzodiazepine products over time makes it difficult for emergency physicians to accurately estimate clinical risk following human exposure to benzodiazepines.…”

Alprazolam-related deaths in Scotland, 2004–2020

“…Those prescribed alprazolam or individuals considering acquiring it illicitly for recreational purpose should be aware of the dangers of using the drug with other substances, especially opiates/opioids and other benzodiazepines. Recreational users should be aware that tablets sold as Xanax may contain a variable amount of alprazolam (if any) as well as potentially fatal cutting agents ( Blakey et al, 2021 ; Tobias et al, 2021 ; Wedinos, 2018 , 2021 ). Public health alerts by NHS agencies and the police were aimed at both clinicians and drug users.…”

Addressing the challenges in forensic drug chemistry II

“…Blakey et al report the results from the analysis of 46 tablets from 20 seizures passed on as various benzodiazepine‐containing specimen. Their survey included the assessment of dosage levels of four benzodiazepines across five different types of tablets and involved the detections of other non‐declared benzodiazepines including those considered new psychoactive substances or “designer” benzodiazepines 18 . Although these results were reported from Queensland (Australia), the work on the analysis of seized benzodiazepine tablets presented by Downey et al from Ireland also gives fascinating insights into the types of tablets that might be encountered during seizures.…”