Trends in Nonfatal and Fatal Overdoses Involving Benzodiazepines - 38 States and the District of Columbia, 2019-2020

Abstract

Nonfatal and fatal drug overdoses increased overall from 2019 to 2020 (1).* Illicit benzodiazepines (e.g., etizolam, flualprazolam, and flubromazolam)^† were increasingly detected among postmortem and clinical samples in 2020, often with opioids,^§ and might have contributed to overall increases in drug overdoses. Availability of recent multistate trend data on nonfatal benzodiazepine-involved overdoses and involvement of illicit benzodiazepines in overdoses is limited. This data gap was addressed by analyzing annual and quarterly trends in suspected benzodiazepine-involved nonfatal overdoses^¶ treated in emergency departments (EDs) (benzodiazepine overdose ED visits) during January 2019-December 2020 (32 states and the District of Columbia [DC]) and benzodiazepine-involved overdose deaths (benzodiazepine deaths), which include both illicit and prescription benzodiazepines, during January 2019-June 2020 (23 states) from CDC's Overdose Data to Action (OD2A) program. From 2019 to 2020, benzodiazepine overdose ED visits per 100,000 ED visits increased (23.7%), both with opioid involvement (34.4%) and without (21.0%). From April-June 2019 to April-June 2020, overall benzodiazepine deaths increased 42.9% (from 1,004 to 1,435), prescription benzodiazepine deaths increased 21.8% (from 921 to 1,122), and illicit benzodiazepine deaths increased 519.6% (from 51 to 316). During January-June 2020, most (92.7%) benzodiazepine deaths also involved opioids, mainly illicitly manufactured fentanyls (IMFs) (66.7%). Improving naloxone availability and enhancing treatment access for persons using benzodiazepines and opioids and calling emergency services for overdoses involving benzodiazepines and opioids, coupled with primary prevention of drug use and misuse, could reduce morbidity and mortality.

FIGURE 1

Number of benzodiazepine overdose and co-involved opioid overdose emergency department visits, by quarter — Drug Overdose Surveillance and Epidemiology, 32 States and the District of Columbia, 2019–2020^,, Abbreviations: ED = emergency department; Q = quarter. * Alabama, Arizona, Arkansas, Connecticut, Delaware, Florida, Georgia, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Utah, Virginia, Washington, West Virginia, and Wisconsin. ^† All analyses were restricted to facilities with a coefficient of variation ≤45 and average weekly discharge diagnosis informative ≥75% during the study period, including consistently reporting facilities with consistent data quality. ^§ Relative rate changes from 2019 to 2020 were calculated based on total benzodiazepine overdose visits per 100,000 ED visits (15,547/64,200,344 and 15,830/52,816,815, respectively; 23.7% increase); benzodiazepine overdose visits co-involving opioids (3,271/64,200,344 and 3,612/52,816,815, respectively; 34.4% increase); and those with no opioid co-involvement (12,276/64,200,344 and 12,218/52,816,815, respectively; 21.0% increase). ^¶ Relative rates increased from Q4 2019 to Q4 2020 for total benzodiazepine overdose visits by 24.9% (3,727/16,279,535 and 3,739/13,080,832, respectively), those co-involving opioids by 34.0% (791/16,279,535 and 851/13,080,832, respectively), and those without opioids by 22.5% (2,936/16,279,535 and 2,888/13,080,832, respectively).

FIGURE 2

Benzodiazepine Overdose Deaths with Opioid Co-involvement — State Unintentional Drug Overdose Reporting System, 23 States, January 2019–June 2020 Abbreviations: co = co-involved; IMFs = illicitly manufactured fentanyls; Q = quarter; Rx = prescription. * Alaska, Connecticut, Delaware, Georgia, Illinois, Maine, Massachusetts, Minnesota, Missouri, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin. IMFs include fentanyl and illicit fentanyl analogs.