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Introduction:
Etizolam is a thienodiazepine which is chemically related to a
class of substances known as benzodiazepines. Benzodiazepines
produce central nervous system (CNS) depression and are
commonly used to treat insomnia and anxiety. Etizolam is currently a
prescription medication in Japan, India and Italy but has recently
emerged on the illicit drug market in Europe and the United States.
Etizolam is usually encountered in powder form or in tablet form.
Etizolam has also been encountered spiked onto blotter
paper.
Licit Uses:
Benzodiazepines are widely prescribed drugs; however, etizolam
is not approved for medical use in the United States. Additionally,
etizolam is used as a prescription medication in some countries.
Etizolam was introduced in 1983 in Japan as a treatment for
neurological conditions such as anxiety and sleep disorders. It is
currently available as 0.25 mg, 0.5 mg and 1.0 mg tablets in countries
where it is marketed for clinical use.
Chemistry:
Etizolam (4-(2-chlorophenyl)-2-ethyl-9-methyl-6H-thieno[3,2-
f][1,2,4]triazolo[4,3-a][1,4]diazepine) has a similar structure to the
benzodiazepine class of compounds. Etizolam has a thiophene ring,
in place of a benzene ring found in the benzodiazepine class, fused to
a seven-membered 1,4diazepine ring. Etizolam also contains a fused
triazolo ring. A 2-chlorophenyl ring is attached at the 4-position and an
ethyl group is attached at the 2-position of the thienodiazepine ring
structure. Etizolam has a molecular formula of C17H15ClN4S and a
molecular weight of 342.8 g/mol. The structure of etizolam is shown
below:
g/mol. The structure of etizolam is shown
below:
Pharmacology:
Etizolam, a thienodiazepine derivative, was approved for the
management of anxiety disorders associated with depression, panic
disorder and insomnia in some countries. Pharmacologically, etizolam
is a benzodiazepine and possesses CNS depressant effects, such as
anxiolytic, anticonvulsant, sedative-hypnotic and muscle relaxant
effects. Unlike diazepam (Valium®), it has some imipramine-like
neuropharmacological and behavioral effects in preclinical studies. In
animal experiments, etizolam is 6-10 times more potent than diazepam
in most of its pharmacological effects. Etizolam has been
demonstrated to have some reinforcing effects in monkeys. In
physical-dependence studies in animals, it substituted for barbital and
produced withdrawal signs typical of the sedative-hypnotic class. Drug
discrimination studies in monkeys indicated that it had pentobarbitallike effects. Clinical studies suggest that etizolam is approximately 10
times as potent as diazepam in producing hypnotic effects. In a singledose pharmacokinetic study in humans, etizolam was rapidly absorbed
with the maximum plasma concentration occurring within 0.5-2 hours
and the mean elimination half-life averaged 3.4 hours. Clinical
observations of physical dependence on etizolam were also reported.
Major adverse effects include drowsiness, sedation, muscle weakness
and incoordination, fainting, headache, confusion, depression, slurred
speech, visual disturbances and changes in libido and tremor.
Illicit Uses:
Despite the relative age of etizolam, in recent years there has been
a rise in its abuse, which has led to its classification as a novel
psychoactive substance benzodiazepine. Recently, etizolam has been
named an emerging substance of abuse and has been increasingly
identified in toxicology samples, as an adulterant in seized samples, and
has been involved in increased numbers of reported driving under the
influence of drugs (DUID) cases. In September 2014, the Blue Ridge
Poison Center called etizolam an emerging drug of concern.
Additionally they stated there has been an upward trend in Poison
Control Center calls. The United Nations Office on Drugs and Crime
(UNODC) Toxicology Portal reports for 2019 and 2020 indicate that
etizolam is being used in a number of countries in Europe including but
not limited to Switzerland, Sweden, Canada, and Australia. According
to the United Nations Office on Drugs and Crime (UNODC Current NPS
Threats, 2022), benzodiazepine-type novel psychoactive substances
(NPS) continue to constitute the greatest number of NPS reported to the
Tox-Portal, accounting for 47% of all NPS cases associated with
postmortem investigations, and 67% of all DUID cases. Of the
substances reported, etizolam was the most common, accounting for
141 reported cases. The Centers for Disease Control and Prevention
recently released “The Fentalog Study”, which utilizes data collected
from 10 geographically diverse hospitals in 9 states across the United
States. As of March 2023, out of 733 samples tested between
February, 2020 and December 2022, 9% of blood specimens from
suspected opioid-involved overdoses also tested positive for illicit
benzodiazepines. Etizolam was positively identified in twenty-two
percent of these illicit benzodiazepine, opioid-involved overdoses.
User Population:
Although it is a legitimate pharmaceutical product in Japan, Italy and
India, etizolam is used as a recreational substance in the United States.
Information suggests that a broad range of populations including youths,
young adults and older adults, use etizolam. The population likely to
abuse etizolam appears to be the same as those abusing prescription
benzodiazepines, barbiturates, and other sedative hypnotic substances.
This is evidenced by drug user reports associated with these substances.
Illicit Distribution:
Etizolam is purchased via the internet and at local retail shops
where it is promoted as a “research chemical.” It has been sold as a
powder, in tablet form and spiked onto blotter paper. The DEA’s National
Forensic Laboratory Information System (NFLIS) Drug database collects
scientifically verified data on drug items and cases submitted to and
analyzed by participating federal, state, and local forensic drug
laboratories. According to NFLIS-Drug, there were 1,722 reports of
etizolam submitted to NFLIS-Drug in 2018, 3,751 in 2019, 5,231 in 2020
4,325 in 2021, and 1,170 in 2022.
Control Status:
Etizolam is currently controlled under Schedule I of the Controlled
Substances Act. At the 2020 Commission on Narcotic Drugs Sixty-third
session, the Commission decided to include eti
Etizolam
Etizolam, 6–(o–chlorophenyl)–8–ethyl–1–methyl–1–methyl–4H–s–triazolo [3,4-c]–thieno [2,3-e]-[1,4]diazepine, is a thienodiazepine, with structure and effects similar to benzodiazepines. It was first developed in Japan, and has been prescribed in Japan since the 1980s [49]. It has also been legally prescribed for medical purposes in India and Italy; however, for years it was neither approved nor scheduled in most other countries. It was discussed at the 1989 and 1990 World Health Organization Expert Committee on Drug Dependence (ECDD) meetings, and at that time the committee did not recommended it be a scheduled drug. It is still not considered a controlled substance internationally. However, more recently etizolam has been scheduled as a controlled substance in Germany, Italy, Japan and the United Kingdom, as well as some states in the United States [7,50]. The higher level of control was followed by a proliferation in new benzodiazepine derivatives.
Some research suggests it causes less impairment of cognitive function while more selectively decreasing anxiety, due to its affinity for specific GABA-A receptors associated with anxiety [51]. A non-inferiority crossover study of 77 patients taking 0.5 mg etizolam twice daily showed no increase in somnolence when compared to placebo. However, this study also found no difference in anxiety level compared with placebo [51]. These results were contrary to an earlier study of 0.5 mg twice-daily etizolam which had demonstrated a significant reduction in anxiety and depressive symptoms, and also noted reports of mild to moderate daytime drowsiness [52]. In 2005, Sanna et al. found that mice chronically treated with etizolam did not develop tolerance to its anticonvulsant effects, whereas those treated with lorazepam did. Furthermore, treatment and withdrawal of etizolam did not result in GABA-A subunit alteration, and lorazepam did. The authors suggested a reduced potential for tolerance and dependence compared with classical benzodiazepines [53].
Etizolam has relatively quick onset, with peak plasma concentration reached between 30 min and 2 h after oral ingestion. In one study, elimination half-life was found to be 3.4 h [54]. The processes of hydroxylation and conjugation are responsible for metabolism. The primary metabolite, alpha-hydroxyetizolam, has similar clinical effects as etizolam in animals, and is more slowly cleared with an elimination half-time of 8.2 h [54]. Of note, metabolism is variable depending on the activity level of the cytochrome P450 system. The CYP3A4 and CYP2C19 systems have been shown to play a role in metabolism, with genetic polymorphisms making some people susceptible to prolonged effects [55]. Interestingly, the poorly metabolizing CYP2C19 trait is found in 18–23% of the Japanese population (where the rate of etizolam prescription has been higher than many other countries), compared with just 3–5% of Caucasians.
Sedatives and hypnotics
Kristine Sobolewski PharmD, BCPS, BCCCP, in Side Effects of Drugs Annual, 2021
Cognitive defects
Etizolam is a designer benzodiazepine that has caused concern given its growing usage for non-medical purposes. To investigate the abuse liability and cognitive effects outside the designed therapeutic arena, sociodemographic and clinical data on subjects with etizolam high dose use were retrospectively collected from a database from Verona University Hospital, Italy. High dose dependence of benzodiazepine use was determined as daily intake of equal to or greater than five times the recommended maximum daily dosage. From the available database of 1293 patients admitted to the Addiction Medicine unit (650 men, 643 women), 11 where on high dose etizolam. All patients had been prescribed the therapy for medical reasons, however, in neuropsychological evaluations, deficits of working memory, visuospatial memory and executive function were specifically identified in a 27-year-old female on 15 mg of etizolam daily. Of the 11 patients evaluated whom received etizolam for medical reasons, the average dose was e 27.3 ± 29.3 mg etizolam daily, which is nearly 10 times the maximum recommended daily dosage. These findings support the conclusion of abuse/dependence liability of etizolam and should be considered a public health concern. Etizolam shows preliminary evidence of cognitive side effects at high doses that have potential for harm, even in those prescribed the medication for medical reasons (Tamburin et al., 2020) [C].
Antifungal azoles [for systemic use]
In Meyler’s Side Effects of Drugs (Sixteenth Edition), 2016
Etizolam
The effects of itraconazole 200 mg/day for 7 days on the single oral dose pharmacokinetics and pharmacodynamics of etizolam have been examined in 12 healthy men [49]. Itraconazole significantly increased the total AUC and the half-life of etizolam, but had no effect on two pharmacodynamic measures, the Digit Symbol Substitution Test and Stanford Sleepiness Scale. The results suggested that itraconazole inhibits the metabolism of etizolam, providing evidence that CYP3A4 is at least partly involved.
Pediatric Emergency Medicine
Michael Levine MD, Frank Lovecchio DO, MPH, in Emergency Medicine Clinics of North America, 2021
Clinics care points
•
Use of illicit drugs, including opiates, is common among adolescents.•
Loperamide, an anti-diarrheal agent is commonly abused among opiate-addicted individuals seeking detox, and is associated with cardiac toxicity, including QT and and QRS prolongation.•
Emerging opiates include fentanyl and its derivatives, U47700, and MT45.•
Etizolam is similar to benzodiazepines, and produces central nervous system and respiratory depression, similar to benzodiazepines.•
Phenibut can produce either sedative effects or stimulant effects.•
Kratom is derived from a plant, and is commonly used to treat opiate withdrawal. Low doses are associated with mild stimulant effects, although higher doses are associated with opiate-like effects.
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