Table VIII.

NPS Benzodiazepine Case Histories with Clinical Symptoms, Autopsy Findings and Primary Drug and Additional Drug Concentrations

Drug	History	Clinical symptoms/Field Sobriety Testing/Autopsy findings	Drug results (ng/mL unless specified)	Reference
Flualprazolam	16 y/o M presented to ED after ingesting counterfeit Xanax tablet	Lethargy and slurred speech	Urine: 72.1 +cannabinoids	(179)
	16 y/o M presented to ED after ingesting counterfeit Xanax tablet	CNS depression, slurred speech and mild respiratory depression; unresponsive to 0.4 mg IV naloxone	Blood: 14.6 Urine: 19.4	(179)
	16 y/o F presented to ED after ingesting counterfeit Xanax tablet	Lethargy and slurred speech	Urine: 3.0	(179)
	23 Swedish postmortem cases	N/A	Femoral blood: Mean: 17.2 ng/g Median: 17 ng/g Range: 3–45 ng/g	(180)
	10 Finnish postmortem cases	N/A	Femoral blood: Mean: 25.0 ng/g Median: 22.5 ng/g Range: 6.6–68.0 ng/g	(180)
	167 US/Canadian postmortem cases	N/A	Blood: Mean: 20 ± 63 Median: 8.2 Range: 2–620	(181)
	22 US DUID cases* *24 y/o M in MVC with bus	*Standard Field Sobriety Test was uncoordinated, had delayed comprehension and reaction times and lethargic behavior	Blood: Mean: 22 (± 18) Median: 14 Range: 4.4–68 *13	(181)
	30 y/o M IV drug user with suspected OD	COD attributed to mixed drug toxicity	NaF/KOx preserved blood: 2.8 Unpreserved blood: 3.0 pregabalin 12,000, +morphine, +codeine, +6-AM, +noscapine, +papaverine, +diazepam, +mirtazapine, +THC	(182)
	44 y/o M with hx of depression and possible heroin use discovered dead at home with drug paraphernalia: packet Xanax (alprazolam) tablets, empty pill dispenser, prescription medications and empty syringes	N/A	NaF/KOx preserved blood: 30.3 Unpreserved blood: 35.1 +methadone, +MDMA, +MDA, +pregabalin, +mirtazapine, +BZE, +diazepam, +morphine, +gabapentin	(182)
	40 y/o F with hx of mamba use (presumed SCRA), found deceased on floor of home	N/A	Unpreserved blood: 14.5 +methadone, +EDDP, +pregabalin, +mirtazapine, +4F MDMB-BINACA metabolites, +MDMB-4en-PINACA and metabolites	(182)
	37 y/o M found face down in mud	N/A	NaF/KOx preserved blood: 3.5 Unpreserved blood: 14.1 +methadone, +pregabalin, +etizolam, +MMB-PINACA metabolites, +carbamazepine, +THC-COOH	(182)
	40 y/o M with hx of alprazolam use, IV drug use and anxiety and depression, found lying on river embankment with rigor mortis. Bottle of methadone on him, 30 mL bottle nystatin in river and green herbal material and white pills in wallet	N/A	Unpreserved blood: 26.5 +diazepam, +nordiazepam, +methadone, +EDDP, +pregabalin	(182)
	51 y/o M with hx of depression and heroin use found deceased in his bathroom. Hepatitis C positive and in methadone program	N/A	NaF/KOx preserved blood: 3.1 +morphine, +codeine, +methadone, +EDDP, +alprazolam, +diazepam, +nordiazepam, +temazepam, +oxazepam, +sertraline, +pregabalin, +risperidone, +BZE	(182)
	57 y/o M with hx of chronic obstructive pulmonary disease, chest infections, heart problems and crack cocaine and heroin use	N/A	NaF/KOx preserved blood: 4.7 Unpreserved blood: 5.7 +cocaine, +BZE, +citalopram	(182)
	42 y/o F with hx of heroin abuse found unresponsive at home	N/A	NaF/KOx preserved blood: 15.1 +morphine, +codeine, +pregabalin	(182)
	42 y/o M with hx of IV drug use and self-harm found unconscious on pathway, CT scan: severe hypoxic brain injury	N/A	Antemortem citrate preserved blood: 8.5 +cocaine, +BZE, +mirtazapine, +nitrazepam, +alprazolam, +diazepam, +nordiazepam, +morphine, +codeine, +clonazepam, +pregabalin, +buprenorphine Serum: 4.9	(182)
	123 DUID investigations, Sacramento County, CA	N/A	Blood: Mean: 25 Median: 18 Range: 5–154	(183)
	Ten antemortem cases	N/A	Blood: Range: 3.3–56 Median: 8.0	(184)
Diclazepam	334 antemortem cases	N/A	Blood: Range: 1.6–250 Median: 9.6	(184)
Diclazepam/Flubromazepam	28 y/o M with hx of illicit drug use found deceased at home, believed he was taking benzos (etizolam)	N/A	Blood: diclazepam: 70 flubromazepam: 10 methylamphetamine 290, amphetamine 150, U-47700 330, +lorazepam Urine: +etizolam	(185)
Etizolam	38 y/o M driving SUV in MVC	Observed having trouble maintaining speed and failing to come to smooth stop prior to MVC, slurred speech, bloodshot eyes, slow to respond and repeated questions/comments, failed field sobriety tests	Blood: 40 (∼2 h post incident) +Amphetamine	(186)
	20 y/o F in noninjury 1-car collision after driving over median. Marijuana roaches in car	Officer observations: poor balance, failed field sobriety tests	Blood: 88 (∼1.75 h post incident) THC 11 ng/mL	(186)
	35 y/o M noninjury 1-car MVC	Officer observed: slurred speech, slow to respond, balance problems, droopy, bloodshot, glazed and watery eyes	Blood: 330 (∼3.5 h post incident) +methamphetamine, +amphetamine	(186)
	51 y/o M found deceased at home after consuming alcohol night prior, hx of alcohol dependence, chronic opioid use, anxiety, depression and hypertension	Nose and mouth had dark colored emesis	Cardiac blood: 29 ethanol 0.02, +methadone, +EDDP, +oxycodone, +oxymorphone, +norfentanyl, +mirtazapine Urine: 2 Vitreous humor: +	(187)
	29 y/o M with hx of alcohol abuse, hypertension anxiety and gastroesophageal reflux, found deceased at home, last known alive 3 days prior	Cardiomegaly and moderate pulmonary congestion/edema. No pill or pill fragments found in stomach	Cardiac blood: 45 fentanyl 6, ethanol 0.23, alprazolam 228, +alpha-hydroxyalprazolam, +chlordiazepoxide, +nordiazepam, +norfentanyl Urine: 13 Vitreous humor: +	(187)
	27 y/o F with hx of mental health issues found with suicide note and other medications on scene. Last known alive 1 week prior	Pulmonary anthracosis and drug material in stomach	Peripheral blood: 237 fentanyl 21, ethanol 0.12, alprazolam 282, cocaine 302, +BZE, +cocaethylene, +diphenhydramine, +methamphetamine, +nordiazepam, +norfentanyl Cardiac blood: 813 Vitreous humor: 2,921	(187)
	34 y/o M with hx of illicit drug use found unresponsive on street, paramedics unable to revive. Syringe, spoon, tourniquet and alcohol located near decedent	Mild macrovesicular steatosis in liver, left ventricular hypertrophy and hepatoduodenal lymph adenopathy	Peripheral blood: 9 ethanol 0.23, 6-AM 11, morphine 185, +citalopram, +codeine, +diphenhydramine, +desalkylflurazepam, +nordiazepam Cardiac blood: <5	(187)
	36 y/o M with hx of benzodiazepine and heroin abuse found lying in front of building, EMS unable to revive, pronounced dead at scene. Drug paraphernalia found on individual included white pills, syringe plunger, tourniquet and a cooker	Pulmonary edema and cerebral edema	Peripheral blood: 10 fentanyl 31, alprazolam 27, methamphetamine 1,212, +amphetamine, +EDDP, +methadone, +norfentanyl Urine: 8	(187)
	30 y/o M with hx of heroin abuse found by girlfriend in hotel room snoring, EMS unable to revive. Small amount of green vegetable material, lighter, needle, cooker and bundles of possible illicit substances found at scene	Pulmonary edema and congestion and cerebral edema	Peripheral blood: 25 codeine 17, morphine 219, +6-AM, +alprazolam, +THC-COOH, +THC-OH, THC, +diphenhydramine Urine: 13	(187)
	28 y/o M found deceased in car. Attended party a day prior and left by friend in car to ‘sleep it off’. No paraphernalia at scene. Family reported seeing him with pills of unknown content	Pulmonary edema and congestion	Peripheral blood: 15 alprazolam 179, +fentanyl, +7-aminoclonazepam, +acetaminophen, +alpha-hydroxyalprazolam, +chlorpheniramine, +diazepam, +methamphetamine, +nordiazepam Cardiac blood: 20 Urine: 20	(187)
	30 y/o M found unresponsive in his room by housemate. Small bag with white substance, glass pipe, charred aluminum foil, lighter and plastic straw found at scene	Cardiomegaly, moderate pulmonary congestion/edema, and cerebral swelling	Peripheral blood: 6 fentanyl 5, cocaine 43, methamphetamine 246, +alprazolam, +amphetamine, +BZE, +cocaethylene, +carboxy-THC, +THC, +norfentanyl Urine: <5	(187)
	61 y/o M found unresponsive during wellness check. Syringe and other prescription medications found at scene	Cardiomegaly, moderate pulmonary congestion/edema and cerebral swelling	Cardiac blood: 22 fentanyl 13, +THC-COOH, +gabapentin, +morphine, +norfentanyl Urine: 26 Vitreous humor: <5	(187)
	30 y/o M with hx of cannabis, benzodiazepines and alcohol use, suicide ideations. Found unresponsive during wellness check, last known alive 1 day prior. Small bag with blue substance and scale with white powdery substance found on scene	N/A	Peripheral: 187 fentanyl 17, ethanol 0.02, flubromazolam 619, +alprazolam, +amphetamine, +delorazepam, +flualprazolam, +lorazepam, +methamphetamine, +norfentanyl Cardiac blood: 214 Urine: 64 Vitreous humor: 33	(187)
	40 antemortem cases	N/A	Blood: Range: 15–300 Median: 54	(184)
	49 y/o M found prone in bed		Femoral blood: 770 Cardiac blood: 2,820	(174)
Flubromazolam	17 y/o M stopped due to failure to maintain lane position, driving below speed limit and almost collided with officer’s vehicle. Admitted taking Xanax	Officer’s observations: sluggish, slow to respond to questions, slurred speech, lethargic, balance issues and droopy bloodshot eyes. Failed sobriety tests	Blood: 17 (∼1.5 h post incident) THC 6.1	(186)
	18 y/o M driving sedan involved in MVC	Officer’s observations: slow to respond, repeated questions/comments, balance issues, slurred speech and bloodshot eyes. field sobriety tests could not be conducted due to injury	Blood: 18 (∼1.75 h post incident) THC 2.2	(186)
	21 y/o M reported to highway patrol for erratic driving. Individual fell asleep in chair at hospital while waiting for blood draw	Officer’s observations: failed to maintain lane position and speed, improper lane changes, difficulty with motor control and inconsistent story. Failed field sobriety tests; DRE evaluation under the influence of cannabis	Blood: 19 (∼1 h post incident) BZE 348, THC 1.5	(186)
	17 y/o F stopped by officer for failure to maintain lane position and driving in opposing lane	Officer’s observations: faint odor of alcohol, slurred speech, slow to respond to questions, failed field sobriety tests	Blood: 14 (∼2.75 h post incident) PBT (22 min post incident) 0.014 g%	(186)
	19 y/o F in noninjury MVC when she struck a legally parked vehicle	Officer’s observations: slurred speech, slow to response to questions and balance issues	Blood: 21 (∼2.5 h post incident) BZE 749, THC 11, +cocaine	(186)
	19 y/o M stopped by officer for failure to maintain lane position, found with drug paraphernalia, lit cannabis cigarette and counterfeit Xanax tablet	Officer observations: slurred speech, dexterity issues and poor balance	Blood: 7 (∼1.75 h post incident) Clonazepam 17, 7-aminoclonazepam 26, THC 27, +oxycodone	(186)
	22 y/o F driver in 2-car MVC, drove off roadway and overcorrected striking another vehicle	Officer observations: cannabis odor	Blood: 12 (∼1.5 h post incident) THC 2.9	(186)
	35 y/o F stopped for failure to maintain lane position, almost driving into oncoming traffic, admitted smoking cannabis ∼30 min prior and cannabis in vehicle	Officer’s observations: cannabis odor and individual impaired, failed field sobriety tests	Blood: 31 (∼1.5 h post incident) THC 4.1	(186)
	21 y/o M in 2-car MVC stated he consumed two bars of Xanax 3.5 h prior to collision and 1 g cocaine and acid/LSD	Officer’s observations: slurred speech, slow to respond to questions and balance issues	Blood: 8.2 (∼2.25 h post incident) BZE 356, THC 1	(186)
	20 antemortem cases	N/A	Blood: Range: 4–36 Median: 5.6	(184)
	5 antemortem cases	N/A	Blood: Range: 7–700 Median: 37	(184)
Clonazolam	22 antemortem cases	N/A	Blood: Range: 1.7–53 Median: 4.1	(184)
Phenazepam	138 antemortem cases	N/A	Blood: Range: 1.8–850 Median: 22	(184)

DRE = drug recognition expert, MVC = motor vehicle collision, PBT = preliminary breath test, SCRA = synthetic cannabinoid receptor agonist, SUV = sport utility vehicle, THC-OH = hydroxy-tetrahydrocannabinol.