forensic paramedic

Alert ref: CEM/CMO/2020/030

Date: 24 July 2020

Evidence of harm from illicit or fake benzodiazepines

This alert advises of the availability of, and harm from, illicit drugs sold as benzodiazepines particularly when used in conjunction with alcohol and drugs with a respiratory depressant effect including gabapentinoids and opioids.

There is significant evidence from toxicology results of illicit tablets being sold as diazepam, temazepam and alprazolam linked to recent hospitalisations and deaths, and from police seizures, that some illicit drugs sold as benzodiazepines are causing harm. This includes tablets known as and/or marked with ‘DAN 5620’ (on one side) and ‘10’ (on the other), ‘T-20’, ‘TEM 20’, ‘Bensedin’ and ‘MSJ’ which may contain dangerously potent benzodiazepines or their analogues such as flubromazolam, flualprazolam and etizolam. Most of the tablets causing concern are blue (but they come in various colours) and these may stain people’s mouths.

Those of you in contact with people who use drugs should be alert to the increased possibility of overdose arising from these illicit drugs sold as benzodiazepines, raise awareness and be able to recognise possible symptoms of overdose and respond appropriately.

There are two different sub-populations which appear to be increasingly using illicit benzodiazepines: dependent opioid users; and teenagers and young adults.

This alert includes the following sections:

• A) Information for professionals on illicit drugs sold as benzodiazepines
• B) Harm reduction advice and information for wider circulation
• C) Actions advised
• D) Other sources of information
• E) Reporting intelligence

Sections A, C, D, and E provide information, and advise on the appropriate actions to take, for professionals. Section B is for professionals to share with people who use drugs or are at risk of taking these drugs.

A. Information for professionals on illicit drugs sold as benzodiazepines

Illicit drugs sold as benzodiazepines (often referred to as “street benzos”) have been found to contain some very harmful substances and are increasingly reported to be causing hospitalisations and deaths in the UK.

These illicit products are often available in blister packs or pharmacy tubs to make them appear to be genuine medicines. Packaging, or markings on tablets and capsules, might say pills contain a certain dose of diazepam (often referred to as ‘Valium’) or alprazolam (often referred to as ‘Xanax’) but they may not actually contain any of those substances at all. Instead they may contain other high-potency benzodiazepines or their analogues, or other dangerous substances not for medical use.

Since the strength and ingredients of these tablets and capsules varies widely, people who use “street benzos” cannot be sure how strong they are or what they are taking.

Alcohol and some drugs depress the central nervous system, which affects a person’s breathing. The drugs that do this include:

• benzodiazepines
• gabapentinoids (including pregabalin and gabapentin)
• heroin and other opioids

This means that using any combination of these types of drugs with or without alcohol increases the risk of overdose and death. This risk may be greater with high- potency benzodiazepines or their analogues.

Benzodiazepine use can negatively affect mental health and increase the risk of suicidal thoughts, particularly in young adults and those who are alcohol or opioid dependent.

B. Harm reduction advice and information for wider circulation

People who use drugs or are believed to be at risk of taking these drugs should be offered the following harm reduction advice and information:

• avoid buying or using tablets sold as benzodiazepines, most often diazepam (often referred to as ‘Valium’), temazepam and alprazolam (often referred to as ‘Xanax’). This includes tablets known as and/or marked with ‘DAN 5620’ (on one side) and ‘10’ (on the other), ‘T-20’, ‘TEM 20’, ‘Bensedin’ and ‘MSJ’, which may contain dangerously potent benzodiazepines, or other dangerous substances not for medical use
• don’t use any combination of benzodiazepines, opioids such as heroin and gabapentinoids such as gabapentin and pregabalin, with or without alcohol.
• if you’re going to use any drugs, make sure someone is around when you take them (if you overdose alone nobody can help you)
• be extra cautious about the sources from which you get your drugs, and about the drugs you take, test the dose by starting with a small test dose (1/2 a pill) and waiting at least an hour before taking more
• seek treatment for your drug use if it is causing you problems and you are not already in treatment

If you are with someone when taking drugs:

• watch carefully for the signs of an overdose like drowsiness, shallow breathing, dizziness, poor balance, muscle weakness, fainting and unconsciousness.
• If someone overdoses:
  • call 999 immediately for an ambulance
  • give them any available naloxone if you think they have taken opioids and are competent to do so
  • give immediate first aid basic life support (recovery position and monitor the airway, breathing and pulse)
  • do not assume that a person who is still functioning normally will not worsen later – stay with them until the ambulance arrives

C. Actions advised

1. Those in contact with people who use drugs or are believed to be at risk of taking these drugs should advise them to:
   • give the harm reduction advice and information outlined above
2. Those with people who use drugs when and after they use drugs (including other people who use drugs) should:
   1. follow the harm reduction advice and information outlined above
3. Adult and young people’s drug and alcohol treatment and recovery services should:
   • warn their service users, and where possible others not in contact with services, about the risks of taking illicit drugs sold as benzodiazepines and provide harm reduction advice including:
     • advising against using any combination of drugs with a respiratory depressant effect, including benzodiazepines, opioids and gabapentinoids, with or without alcohol
     • give basic harm reduction advice and information including how to test doses (see section 1 above)
   • supply naloxone so that it is available for all those at risk of an opioid overdose
   • ensure they provide rapid access to drug treatment
4. Local authority and health commissioners should:
   • take steps to ensure that this information is made available to people who use drugs who are not in contact with drug and alcohol treatment and recovery services
   • make efforts to ensure that other relevant services – homelessness hostels and young people’s services, for example – are also aware of the current risk
5. Emergency departments and paramedics should:
   • be alert to the symptoms of benzodiazepine, opioid, alcohol and gabapentinoid overdoses in cases of known and suspected use
   • be aware of the risk of severe toxicity resulting from people taking potent benzodiazepines or their analogues
   • treat suspected cases involving benzodiazepines as for any benzodiazepine overdose, using appropriate supportive care and the antidote flumazenil as recommended by the National Poisons Information Service (NPIS, for details TOXBASE).

D. Other sources of information

Information for people considering using drugs, including advice on reducing risk, is available from www.talktofrank.com or from the FRANK helpline on 0800 77 66 00. For further advice, medical professionals can use the National Poisons Information Service 24-hour telephone service on 0344 892 0111 or its online database, TOXBASE.

E. Reporting intelligence

To report any additional intelligence about the use of and harm from illicit drugs sold as benzodiazepines, please email drug.alerts@phe.gov.uk at Public Health England. This will enable suitable information to be shared with relevant agencies, and help in assessing if further action is needed.