Advisory notice by HSE Social Inclusion to Addiction Services in Ireland

Advisory notice by HSE Social Inclusion on new combinations of substances being sold as benzodiazepines to the Irish Drug Market (1st May 2020)

In December 2019, HSE Social Inclusion circulated and advisory note to services in Ireland in relation a concern around the emergence of new benzodiazepines or fake tablets onto the Irish market. These substances were being sold as ‘Xanax’ (trade name for a preparation of alprazolam) or ‘Xanax bars/sticks’ and were found to contain a variety of substances including Flualprazolam which is one of the Novel benzodiazepines recently emerged in Europe.

Over the last decade, the EU Early Warning System on new psychoactive substances (NPS) has detected an increasing number of ‘new’ benzodiazepines in Europe’s drug market. The European
Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is currently monitoring 28 new benzodiazepines. Some 23 of these have been first detected in Europe over the last 5 years.

NPS benzodiazepines appearing on the market are of concern due to high potency at low doses.  Risks are increased if one or more substances are used by the person, or if tablets are pressed to contain one or more substance.

Flualprazolam is a potent substance which has sedative effects similar to other benzodiazepines but much higher potency and a relatively short onset of action, similar to alprazolam (Xanax).

Since that time the Advisory Council for the Misuse of Drugs (ACMD) in the UK has produced a review of the evidence of use and harms of novel benzodiazepines. This review includes the drug flualprazolam among 13 novel benzodiazepines that they considered. They noted that flualprazolam had been associated with 12 deaths in the UK and that all of the substances considered had the potential to cause harm if they emerged onto the drug market in the UK.

They recommended that 3 of the substances that had been seized in the UK, (Flualprazolam, Flunitrazolam and Norfludiazepam) would be placed under Schedule 1 of the Misuse of Drugs Act 2001, as they had no medicinal use. The full report and recommendations arising from the report is available here.

In light of this new report and recent reports in the media in Ireland concerning tablets/substances that may have been implicated in overdose deaths, the National Social Inclusion Office is asking managers to disseminate this note and the attached poster to services in conjunction with the updated information on Overdose Awareness that has been developed as part of the response to the Covid-19 crisis and the ACMD report above.

Yours sincerely,

Dr Eamon Keenan
National Clinical Lead – HSE Addiction Services

Download notice for Addiction Services in Ireland here

Recommended resources for professionals to use during this time

Harm reduction 

Download the overdose and COVID-19 poster here

Drug Watch Factsheet, Alprazolam

International Overdose Awareness Day: Depressant overdose factsheet

International Overdose Awareness Day: Depressant overdose poster

HSE COVID-19 harm reduction section 

Overdose and OST information for professionals

Overdose Response and Naloxone Guidance during the Coronavirus (COVID-19) Pandemic

Drugs.ie Naloxone 

Evidence sources 

McNamara, Sinead and Stokes, Siobhan and Nolan, J (2019), The emergence of New Psychoactive Substance (NPS) benzodiazepines. A survey of their prevalence in opioid substitution patients using LC-MS. Irish Medical Journal , 112 , (7) , pp. 970-976

European Monitoring Centre for Drugs and Drug Addiction (2019), European Drug Report 2019: Trends and Developments, Publications Office of the European Union, Luxembourg.

European Monitoring Centre for Drugs and Drug Addiction (2018) Perspectives on drugs, The misuse of benzodiazepines among high-risk opioid users in Europe.