Abstract
Introduction
Polydrug use involving heroin and benzodiazepines is common. The potential risk of additive pharmacological effects may be associated with poorer outcomes in patients who use benzodiazepines together with heroin. The aim of this study was to determine the clinical picture of patients presenting to the emergency department following acute drug toxicity involving heroin and benzodiazepines.
Methods
Exposure information, clinical data and outcome of acute drug toxicity presentations were collected between 1 October 2013 and 30 September 2014 as part of the European Drug Emergencies Network (Euro-DEN) project. The database was interrogated to identify patients who had taken heroin with or without benzodiazepine(s).
Results
A total of 1345 presentations involving acute heroin toxicity were identified: 492 had used one or more non-heroin/benzodiazepine drug and were not further considered in this study; 662 were lone heroin users and 191 had co-used heroin with one or more benzodiazepines. Co-users were more likely than lone heroin users to have reduced respiratory rate at presentation 12.7 ± 4.9 vs 13.6 ± 4.4 (p = 0.02) and require admission to hospital 18.3 vs 9.8% (p < 0.01). There were no differences in critical care admission rates 3.1 vs 3.9% (p = 0.83) or length of stay 4 h 59 min vs 5 h 32 min (p = 0.23). The 3 most common benzodiazepines were clonazepam, diazepam, and alprazolam. No differences were observed for clinical features between the three benzodiazepines.
Conclusion
This study shows that co-use of heroin and benzodiazepines is common, although the overall outcomes between co-users of heroin and benzodiazepines and heroin-only users were similar.
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References
Zador D, Sunjic S, Darke S. Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances. Med J Aust. 1996;164:204–7.
Ross J, Darke S, Hall W. Benzodiazepine use among heroin users in Sydney: patterns of use, availability and procurement. Drug Alcohol Rev. 1996;15(3):237–43.
Darke S, Ross J, Hall W. Overdose among heroin users in Sydney, Australia: I. Prevalence and correlates of non-fatal overdose. Addiction. 1996;91:405–11.
Darke S, Ross J, Mills K, Teesson M, Williamson A, Havard A. Benzodiazepine use among heroin users: baseline use, current use and clinical outcome. Drug Alcohol Rev. 2010;29:250–5.
Darke S, Marel C, Mills KL, Ross J, Slade T, Burns L, et al. Patterns and correlates of non-fatal heroin overdose at 11-year follow-up: findings from the Australian Treatment Outcome Study. Drug Alcohol Depend. 2014;144:148–52.
Iguchi MY, Handelsman L, Bickel WK, Griffiths RR. Benzodiazepine and sedative use/abuse by methadone maintenance clients. Drug Alcohol Depend. 1993;32:257–66.
Ross J, Darke S. The nature of benzodiazepine dependence among heroin users in Sydney, Australia. Addiction. 2000;95:1785–93.
Vogel M, Knöpfli B, Schmid O, Prica M, Strasser J, Prieto L, et al. Treatment or “high”: benzodiazepine use in patients on injectable heroin or oral opioids. Addict Behav. 2013;38:2477–84.
Darke S, Ross J, Zador D, Sunjic S. Heroin-related deaths in New South Wales, Australia, 1992–1996. Drug Alcohol Depend. 2000;60:141–50.
EMCDDA, Perspectives on drugs. Opioid trafficking routes from Asia to Europe, in European Monitoring Centre for Drugs and Drug Addiction. 2015. http://www.emcdda.europa.eu/topics/pods/opioid-trafficking-routes [last accessed 27th April 2018].
White JM, Irvine RJ. Mechanisms of fatal opioid overdose. Addiction. 1999;94:961–72.
Puntillo K, Casella V, Reid M. Opioid and benzodiazepine tolerance and dependence: application of theory to critical care practice. Heart Lung: J Acute Crit Care. 1997;26:317–24.
Rooney S, Kelly G, Bamford L, Sloan D, O’Connor JJ. Co-abuse of opiates and benzodiazepines. Ir J Med Sci. 1999;168:36–41.
Darke S, Ross J, Teesson M, Lynskey M. Health service utilization and benzodiazepine use among heroin users: findings from the Australian Treatment Outcome Study (ATOS). Addiction. 2003;98:1129–35.
EMCDDA, The misuse of benzodiazepines among high-risk opioid users in Europe, in European Monitoring Centre for Drugs and Drug Addiction. 2015. http://www.emcdda.europa.eu/topics/pods/benzodiazepines [last accessed 27th April 2018].
Frauger E, Pauly V, Pradel V, Rouby F, Arditti J, Thirion X, et al. Evidence of clonazepam abuse liability: results of the tools developed by the French Centers for Evaluation and Information on Pharmacodependence (CEIP) network. Fundam Clin Pharmacol. 2011;25:633–41.
Barnas C, et al. Benzodiazepines and other psychotropic drugs abused by patients in a methadone maintenance program: familiarity and preference. J Clin Psychopharmacol. 1992;12:397–402.
Fernandez Sobrino AM, Fernandez Rodriguez V, Lopez Castro J. Benzodiazepine use in a sample of patients on a treatment program with opiate derivatives (PTDO). Adicciones. 2009;21:143–6.
Gelkopf M, Bleich A, Hayward R, Bodner G, Adelson M. Characteristics of benzodiazepine abuse in methadone maintenance treatment patients: a 1 year prospective study in an Israeli clinic. Drug Alcohol Depend. 1999;55:63–8.
Navaratnam V, Foong K. Adjunctive drug use among opiate addicts. Curr Med Res Opin. 1990;11:611–9.
Bramness JG, Kornor H. Benzodiazepine prescription for patients in opioid maintenance treatment in Norway. Drug Alcohol Depend. 2007;90(2–3):203–9.
EMCDDA, Trendspotter summary report, in European Monitoring Centre for Drugs and Drug Addiction. 2011. http://www.emcdda.europa.eu/scientific-studies/2011/trendspotters-report [Last accessed 27th April 2018].
United Nations Office of Drugs and Crime, World drug report 2012. 2012. https://www.unodc.org/unodc/en/about-unodc/index.html?ref=menutop [Last accessed 27th April 2018].
Backmund M, Meyer K, Henkel C, Soyka M, Reimer J, Schütz CG. Co-consumption of benzodiazepines in heroin users, methadone-substituted and codeine-substituted patients. J Addict Dis. 2005;24:17–29.
Wood DM, Heyerdahl F, Yates CB, Dines AM, Giraudon I, Hovda KE, et al. The European Drug Emergencies Network (Euro-DEN). Clin Toxicol (Phila). 2014;52:239–41.
Dines AM, Wood DM, Yates C, Heyerdahl F, Hovda KE, Giraudon I, et al. Acute recreational drug and new psychoactive substance toxicity in Europe: 12 months data collection from the European Drug Emergencies Network (Euro-DEN). Clin Toxicol (Phila). 2015;53:893–900.
Hoiseth G, et al. Has previous abuse of flunitrazepam been replaced by clonazepam? Eur Addict Res. 2015;21:217–21.
Acknowledgments
Euro-DEN Research Group Collaborators: Chevillard L, Eyer F, Galicia M, Homar C, Jürgens G, Kabata PM, Liakoni E, Liechti ME, Markey G, Mégarbane B, Miro O, Moughty A, O’ Connor N, Paasma P, Persett PS, Pold K, Puiguriguer J, Shields G, Vallersnes OM, Waring WS, Waldman W, Yeung S-J.
Sources of Funding
This study received a financial support from the DPIP/ISEC Programme of the European Union.
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Ethical approval was obtained by each centre to collect the data as part of Euro-DEN project.
Conflicts of Interest
PID and DMW work with the European Monitoring Centre for Drugs and Drug Addiction and the UK Advisory Council for the Misuse of Drugs. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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Yamamoto, T., Dargan, P.I., Dines, A. et al. Concurrent Use of Benzodiazepine by Heroin Users—What Are the Prevalence and the Risks Associated with This Pattern of Use?. J. Med. Toxicol. 15, 4–11 (2019). https://doi.org/10.1007/s13181-018-0674-4
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DOI: https://doi.org/10.1007/s13181-018-0674-4