New street drug mix can’t be reversed with naloxone, officials warn

Alberta the first province to reclassify Suboxone in bid to improve accessibility

CALGARY The latest deadly drug being mixed with opioids is causing concern among health officials because naloxone won’t reverse the effects of an overdose if someone ingests it.

Etizolam is part of the benzodiazepine drug class, which affects the central nervous system and is commonly used to treat anxiety, panic attacks, insomnia and seizures. It’s similar to other drugs like Valium, Xanax or Ativan.

As early as 2016, Alberta practitioners have seen cases of death where etizolam was detected, said Dr. Nick Etches of Alberta Health Services.

In June, AHS issued a public notice about the drug, warning Albertans they have started to see cases of the drug being mixed with street opioids.

“It’s not something we are seeing all the time but certainly more frequently than we had maybe a year or two ago,” said Etches.

He said what’s particularly concerning about etizolam is it can increase the likelihood of an overdose when mixed with opioids.

“Opioids and benzodiazepines are both central nervous system depressants. They both decrease level of consciousness. They both suppress breathing and so, in combination, they are much more likely to result in an overdose,” said Etches.

The mixture first cropped up in British Columbia and was present in some urine drug screens. Then it made its way into Alberta and has been seen in overdoses at supervised consumption sites, for example, which haven’t been fully reversed with the life-saving antagonist naloxone.

Etches said etizolam has always been used in combination with another drug and most frequently cocaine. He added that more often than not, people won’t know it has contaminated their drugs.

The doctor stressed, however, that people should always administer naloxone regardless of the type of overdose.

“The reason is when someone overdoses you don’t know what drug they have taken and naloxone can still reverse the opioid component of the overdose, which is often extremely helpful and life-saving even if the person’s level of consciousness remains decreased,” he said, adding naloxone has no adverse effects.

In the case of an overdose, Etches said people should first call 911, then perform rescue breathing and inject naloxone. He said rescue breathing is the most important part of an overdose response, even more so than naloxone.

“The person can breathe for that person. That’s the way that an overdose, whether it’s fentanyl or etizolam or any other opioid or benzodiazepine, kills someone. It suppresses their breathing, so if you can breathe for them you can keep someone alive until help arrives,” he said.

Each naloxone kit comes with a barrier mask to prevent the transmission of communicable diseases.

Etches also recommends users do not mix drugs and test a smaller portion to ensure the potency isn’t more than expected.

However, he said the drug problem in Alberta isn’t all doom and gloom.

“One hopeful sign is we’ve seen a reduction in the number of overdose deaths related to fentanyl in the first quarter of 2019,” said Etches, noting it applies to the entire province and Calgary, specifically. “There are still far too many people dying from this and we still have a lot of work to do but it is one of the first hopeful signs in a long time.”

CALGARY A key medication in reducing dependency on opioids has become more accessible in Alberta, partly with an eye to fighting a crisis that’s taken thousands of lives in the province.

Starting July 15, the drug Suboxone, which is a replacement substance for pain-killing opioids, was taken from the Schedule 1 category to a Schedule 2, which makes it easier for patients to access.

A spokeswoman for the College of Physicians and Surgeons of Alberta (CPSA) said the move is a first for Canada.

The prescription simplification will increase access to Suboxone while easing damaging misconceptions, said Dr. Monica Wickland-weller, senior medical adviser to the CPSA.

“Having that medication in the Type 1 category caused some challenges to physicians who were managing patients with opioid use disorder,” she said.

“Moving it from Type 1 to Type 2 means it can be ordered as a normal prescription while reducing stigma.”

It’s a step that could save lives by easing access and lowering stigma, she added.

The perception of Suboxone, or buprenorphine/naloxone, as a high-risk medication for abuse has eroded over time and contributed to the change, said Wickland-weller.

“It’s not the kind of medication that’s likely to be misused, it’s not like you can overdose on it,” she said.

“It’s been an evolution ... it wasn’t as well-known or understood as it is today.”

The decision was crafted by the Triplicate Prescription Program (TPP) Steering Committee comprised of various stakeholders in Alberta’s medical community.

Between 6,000 and 7,000 Albertans have been prescribed Suboxone to manage their opioid disorder by reducing cravings.

Evidence exists of its effectiveness, but the medication is just one tool in a program to manage opioid dependency, said Wickland-weller.

And she said it’s important not to demean those who stick with opioids to control pain.

“This (Suboxone policy) is a completely separate issue — it would be a disservice to chronic pain patients to imply they should all be on Suboxone, that’s not where we want to go,” she said.

At 789 deaths, last year was the deadliest in Alberta for fatal overdoses of fentanyl, a synthetic opiate that’s often produced and supplied illegally, though many of those succumbing to it were initially introduced to opiates for medical reasons.

The number of such fatalities in Alberta appears to be decreasing, with 137 deaths known of so far in the first quarter of this year compared to 160 in the same time period in 2018.

While there’s still plenty of bad news on that front, “at least we’re heading in the right direction,” said former NDP health minister Sarah Hoffman.

She applauded the move to adjust the classification and prescription protocol for Suboxone, saying it’s a potential lifesaver.

“Anything that’s based on evidence, saving lives and reducing harm is a good thing,” said Hoffman.