Detection of alprazolam in three cases of methadone/benzodiazepine overdose

Benzodiazepine abuse is common among clients at methadone maintenance clinics. Diazepam and lorazepam are readily detected by immunological screening methods and confirmed by GC/MS. Alprazolam has been relatively difficult to confirm. We recently reported a modification of an existing serum HPLC procedure which allows us to analyze whole blood. We report here three cases of fatal drug overdose caused by co-ingestion of methadone and alprazolam. In all three cases, alprazolam was detected by HPLC and could not be identified by alkaline extraction GC/MS. Postmortem blood concentrations of methadone were at the lower range or below the concentrations previously identified in methadone overdose fatalities, suggesting an increased risk from co-ingestion of methadone and alprazolam.