A wave of sedatives is adulterating Toronto’s illegal opioid market, raising risks for users and imposing extra burdens on a COVID-stretched emergency response system.
“Benzo-dope” now represents more than half of all fentanyl samples brought to Toronto’s Drug Checking Services, which offers free tests of samples brought into the city’s five safe-injection sites. Two years ago, 38 per cent of fentanyl samples tested contained benzodiazepines. That number jumped to 81 per cent in the last three months of 2020 and was at 65 per cent in the fourth quarter of 2021. Conversely, in “expected fentanyl” substances, pure fentanyl was only found 5 per cent of the time. This pervasive contamination and its effects are exacerbating Canada’s toxic drug crisis.
Benzo-dope has been showing up as far west as Vancouver, as well as in pockets of the United States. A coroner’s report from British Columbia saw a rise in the presence of benzodiazepines in drug toxicity deaths to 53 per cent in October 2021 from 15 per cent in July 2019.
Benzodiazepines, a class of drugs commonly prescribed as sedatives, slow brain activity by acting on the brain’s inhibitory GABA receptors, causing reduced reaction to stimulus. Common brands include Valium (diazepam), Xanax (alprazolam) and Ativan (lorazepam). Benzos are particularly dangerous when mixed with opioids, according to Health Canada. The combination increases the risk of overdose, as well as side effects including dizziness, confusion, drowsiness and seizures.
The arrival of benzos in the drug supply complicates life for health-care workers fighting the opioid epidemic. While a standard fentanyl overdose lasts between 10 and 20 minutes, a benzodiazepine overdose can last hours. At a time where the medical system is already stretched thin by COVID-19, pharmacists, nurses and harm reduction workers struggle to find the six to eight hours of monitoring required for these complex cases.
“We can rouse people a little bit. But this person is so sedated, they may walk into traffic, or pass out on the street. People on opioids, if they’re rousable, they can generally be pretty safe on their own. With benzos, that is not the case at all,” says Matt Johnson, a health promoter for the Safe Consumption Site at Parkdale Queen West CHC.
And when opioids are combined with benzodiazepines, the naloxone kits that can be lifesaving tools to combat overdose become less effective at best and can cause users discomfort at worst. If naloxone is repeatedly administered to a person overdosing on benzo-dope, there is potential for that user to enter into opioid withdrawals while still suffering the effects of the benzo-overdose.
Hayley Thompson, project manager of Toronto’s Drug Checking Service, is particularly concerned about the volatility of the unregulated supply.
“For a long time, people didn’t know benzos were in their fentanyl,” she says. “Some still don’t. Benzodiazepine dependency is problematic because if the unregulated drug market shifts, which we know it does frequently, and benzos were to no longer present in fentanyl, we would have a large group of people who (would be) going through benzodiazepine withdrawals. If things change, it could drastically change people’s lives.”
Current literature suggests that patients co-dependent on opioids and benzodiazepines have more severe withdrawal symptoms and that opioid withdrawal symptoms are exacerbated in the co-dependent group. Unlike opioid withdrawal, which can be done in outpatient care, benzodiazepine withdrawal must be done in a hospital setting. Urine drug screenings typically take five days to be processed, and until then it is impossible for health-care professionals to know from what exactly the patient is withdrawing. Even if a patient wants to withdraw from drugs, medical professionals have a delayed and incomplete picture of what the patient’s drug history is and what the withdrawal process should look like.
There are two likely explanations for the arrival of benzos into the opioid supply. First, dealers may be intentionally introducing benzos into the supply to create a longer lasting and more intense high. They can mimic and even enhance an opioid’s effects, allowing less opioid to be used for the same street-value sample. Second, benzos are less strictly monitored and therefore easier to manufacture than are opioids.
Benzos can also make their way into the supply before it reaches the hands of dealers. This is highlighted nowhere more clearly than in the pervasiveness of Etizolam, a benzodiazepine-analogue, in Ontario. In 2021, Etizolam was the most common benzodiazepine found in fentanyl samples analyzed by Toronto’s Drug Checking Service. Etizolam is banned in Canada and the U.S., meaning it may be blended with opioids long before it reaches North America.
“You can’t trust your drug dealer anymore,” says Mark Barnes, a pharmacist on the front lines of the opioid epidemic and an advocate for safer supply in Ontario. “We’ve had drug dealers themselves come in and say ‘Can I have three naloxone kits? I have no idea what I’m selling.’”
One thing many experts agree on is the myriad problems that benzo-dope can cause come down to unregulated supply. While measures like naloxone kits and safe consumption sites can work as lifesaving interventions, the volatility in the contents of street drugs force medical personnel to be working partially blind and put an unnecessary burden on a health-care system already on the brink.
“There’s only one way forward, which is decriminalization of all drugs,” says Johnson. “Across the board, safe supply needs to be standardized in medicine. There’s a philosophical shift that needs to happen. We need to stop looking back at what we’ve done, at what has failed us.”