While most drug poisoning deaths across Europe involve opioids, benzodiazepines are implicated in many deaths and are frequently present in deaths involving opioids.1

The benzodiazepines involved in these deaths are not always prescribable benzodiazepines; indeed, one driver behind an increase in drug poisoning deaths, particularly in Scotland, is the emergence of benzodiazepine-type new psychoactive substances (NPS) such as etizolam.2 Scotland’s experience with etizolam, and the implications for Irish drug poisoning deaths, were addressed in a letter published in the Irish Journal of Psychological Medicine in 2024.3

While etizolam is legally prescribed in some countries, such as Italy and India, it is not sold commercially for medicinal use in most European countries; however, it has appeared on the NPS market and in counterfeit benzodiazepine tablets or ‘street benzos’.2 Prior to the emergence of etizolam, phenazepam was the predominant NPS benzodiazepine in the United Kingdom (UK). When phenazepam was regulated in 2012, etizolam, a drug five times more powerful than diazepam,4 emerged in its place.5

Between 2014 and 2020, Scotland recorded its highest rates of drug poisoning deaths and higher rates than other UK or European countries.2 In the past, drug poisoning deaths in Ireland broadly followed the same trends as Scotland; however, in recent years, Ireland has not mirrored the trend nor the record numbers of drug poisoning deaths observed in Scotland. While several factors may explain this divergence in mortality rate trends, one possible element is that the number of deaths where etizolam was implicated remains low in Ireland,6 unlike Scotland, where almost 60% of drug misuse deaths involved etizolam in 2021.7

The prescribable benzodiazepines diazepam and alprazolam contribute to a greater proportion of deaths in Ireland than they do in Scotland. In 2021, the most seized benzodiazepine in Ireland was alprazolam, followed by diazepam, and a small amount of delorazepam.8 The number of drug poisoning deaths in Ireland where a prescribable benzodiazepine was implicated has risen since 2011, 6 while the number of such deaths in Scotland has decreased.

In the mid-2000s, due to concerns around the increased prescribing of benzodiazepines, diversion to street markets, and the level of dependence in Scotland, a policy change led to a reduction in prescribing of these drugs. This coincided with the emergence of the NPS drug market, which moved to fill the gap for benzodiazepine-type drugs in Scotland.3 Although a similar change in policy was not implemented in Ireland, a change to the Misuse of Drugs Regulations 20179 did lead to some tightening of benzodiazepine prescription-writing. However, this does not appear to have had an impact on the role of benzodiazepines in poisoning deaths in Ireland.

Scotland has made efforts to address increasing numbers of drug poisoning deaths by expanding treatment access, naloxone availability, and toxicology testing, which seem to have had some effect.2 However, while a significant decrease in etizolam-related deaths was recorded in 2022,7 bromazolam – another benzodiazepine-type NPS – has increased in use10 following the control of etizolam.

While the role of benzodiazepines in drug poisoning deaths in Ireland needs to be addressed, the regulation of benzodiazepines is challenging because as soon as one drug is regulated, another NPS can emerge. Any significant change to prescribing practices for benzodiazepines in Ireland must consider the Scottish experience, and any change should include intensive and evidence-based wrap-around psychosocial supports for those who currently use non-prescribed benzodiazepines.

1    European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2023) European Drug Report 2023: Trends and Developments. Available from: https://www.emcdda.europa.eu/publications/european-drug-report/2023_en

2    McAuley A, Matheson C and Robertson JR (2022) From the clinic to the street: the changing role of benzodiazepines in the Scottish overdose epidemic. Int J Drug Policy, 100: 103512.

3    Keenan E, Kelleher C, Lyons S and Sweeney N (2024) Etizolam and Irish drug poisoning deaths. Ir J Psychol Med, 41(4): 506–507. Available from: https://doi.org/10.1017/ipm.2024.38

4    Nielsen S and McAuley A (2020) Etizolam: a rapid review on pharmacology, non-medical use and harms. Drug Alcohol Rev, 39(4): 330–336. Available from: https://doi.org/10.1111/dar.13052

5    Home Office (2011) Import ban of new ‘legal high’ phenazepam introduced. Available from:
https://www.gov.uk/government/news/import-ban-of-new-legal-high-phenazepam-introduced

6    Health Research Board (2023) Health Research Board reports latest drug-related deaths figures. Dublin: Health Research Board. Available from: https://www.drugsandalcohol.ie/39036/

7    National Records of Scotland (2023) Drug-related Deaths in Scotland in 2022. Available from: https://www.drugsandalcohol.ie/39424/1/drug-related-deaths-22-report.pdf

8    Health Research Board, Irish National Focal Point to the European Monitoring Centre for Drugs and Drug Addiction (2023) Focal Point Ireland: national report for 2022 – drug markets and crime. Dublin: Health Research Board. Available from: https://www.drugsandalcohol.ie/40534/

9    Office of the Attorney General (2017) S.I. No. 173/2017 – Misuse of Drugs Regulations 2017. Dublin: Irish Statute Book. Available from: https://www.irishstatutebook.ie/eli/2017/si/173/made/en/print

10  Public Health Scotland (2023) Rapid Action Drug Alerts and Response (RADAR) quarterly report. Available from: https://publichealthscotland.scot/publications/