The rise of bromazolam in postmortem cases from Travis County, TX, and surrounding areas: 2021 to 2023

As novel psychoactive substances (NPSs) have continued to emerge over the past decade, NPS benzodiazepines have likewise increased in prevalence. They pose an evolving threat to public health and safety with regard to postmortem cases, particularly when used in combination with opioids. Bromazolam was first detected in Travis County, Texas, in April 2021. Given the recent onset of the fentanyl epidemic in this region, the international rise of bromazolam, and increased reports of "benzo-dope," a retrospective study was conducted to characterize bromazolam-positive deaths in Travis County and surrounding counties from 2021 to 2023. Bromazolam was identified in 112 deaths from 2021 to 2023, accounting for 1.57% of cases submitted for toxicology testing (n = 7129). During that interval, a 7.5-fold increase in postmortem bromazolam-related drug toxicities from 2021 (n = 7) to 2023 (n = 53) was observed. Fatalities primarily occurred in men in their early 30s. Postmortem concentrations ranged from 21 to 220 ng/mL, with mean (median) concentrations of 69.4 ± 48.4 (53.5) ng/mL. Polydrug use was present in 99% of bromazolam-positive deaths with co-occurrence with other drugs and drug classes widely varying over time. Bromazolam was attributed as the sole cause of death in one case with a postmortem blood concentration of 23 ng/mL. Polydrug use in bromazolam-related drug toxicities commonly involved fentanyl (82%), methamphetamine (41%), and cocaine (28%). Similarly, cases where bromazolam was an incidental finding and noncontributory to the cause of death often involved methamphetamine (38%), alprazolam (33%), and cocaine (33%). In light of the significant increase in fentanyl-related deaths in Travis County, the increasing prevalence of bromazolam accompanying fentanyl was particularly alarming due to the heightened risk of toxicity when used in combination. Identifying and evaluating bromazolam-related deaths clarify the impact of bromazolam on this population, promote awareness, and aid in identifying meaningful harm reduction strategies to decrease bromazolam-related morbidity and mortality.