Baltimore Warns Benzodiazepines Are Complicating Overdose Reversal

Baltimore City health officials issued a public health advisory this week warning that benzodiazepines are showing up more often in the region's illicit drug supply, and that naloxone — the reversal drug carried by first responders and handed out by outreach teams — does not touch their sedative effect. State testing found the compounds in 31 drug samples between April and July, more than double the 14 detected in the same months of 2025.

The samples came from Baltimore City and from Calvert, Charles, Frederick and Talbot counties, with Charles County recording the highest concentration of detections, according to the advisory. Officials described the increase as a supply problem rather than a prescribing problem: the drugs are being mixed into other substances, often without the buyer knowing.

That is the part that changes an overdose response. A person who has taken fentanyl cut with a benzodiazepine may be revived from the opioid half and still not wake up.

Why naloxone leaves someone asleep

Naloxone displaces opioids from their receptors. Benzodiazepines act on a different system — the GABA receptor — so the reversal drug has no binding site to compete for. The advisory states the point directly: standard doses will reverse any opioids mixed into a sample but will not counteract a benzodiazepine's sedative properties.

The clinical picture that follows is unfamiliar to people trained on fentanyl alone. Exposure can produce deep sedation, low blood pressure, a slow heart rate or compromised breathing, and the sedation may persist or return after naloxone has restored breathing. Patients can appear unresponsive and still be ventilating adequately, which makes "check for breathing, then responsiveness" the advisory's first instruction to responders rather than the reverse.

The advisory's guidance to clinicians is to keep giving naloxone during any suspected overdose, since opioids are frequently co-present, but to use the lowest effective dose, expect persistent sedation and prepare for airway management. It also recommends toxicology testing when a patient presents with unexplained sedation.

For lay responders, the instructions are the familiar ones with an added emphasis on time: call 911, give naloxone if opioids may be involved, give rescue breaths, place the person in the recovery position and keep watching their breathing until EMS arrives.

Four compounds, one unpredictable supply

Surveillance identified four benzodiazepines circulating in Maryland this year: bromazolam, deschlorodemethyldiazepam, ethylbromazolam and lorazepam. Their potency varies widely, and officials described their distribution as geographically specific — meaning a person's risk profile depends partly on which county the drugs came from.

The most common combination in the tested samples paired a benzodiazepine with fentanyl, cocaine, xylazine or gabapentin. Gabapentin is the less-discussed member of that list; it is widely prescribed for nerve pain and seizures, and it adds its own sedative load when it appears alongside the others.

Only one of the four is a prescription drug in the ordinary sense. Bromazolam and ethylbromazolam are designer compounds that were never approved for medical use in the United States, and the advisory notes that unapproved "novel" benzodiazepines are an expanding share of the unregulated market. Lorazepam, sold as Ativan, is a legitimate prescription medication that also circulates as diverted product.

The withdrawal problem that outlasts the overdose

The advisory spends unusual space on what happens after the emergency, because benzodiazepine withdrawal is one of the few conditions in addiction medicine that can kill a patient who has already survived the acute event. Symptoms run from anxiety, tremors and insomnia to hallucinations, palpitations, vomiting and seizures, and they can begin within 24 hours and persist for weeks.

Coming off benzodiazepines without medical supervision is dangerous, and the advisory points clinicians to withdrawal management guidance rather than describing a taper protocol of its own. For people who have been using heavily and daily, a supervised detoxification plan is the safer entry point than an attempted self-taper, and it is also the point where a treatment relationship can begin.

Test strips and a checking program built on trash

Maryland's response leans on infrastructure that has been built over the past several years. The Rapid Analysis of Drugs program lets participants in Opioid-Associated Disease Prevention and Outreach Programs turn in used paraphernalia, which is sampled and sent to the National Institute of Standards and Technology for analysis. Results come back to the person who submitted the sample and feed the state's picture of what is circulating.

That post-use model is slower than a syringe-service drug checking booth, and the advisory does not present it as a substitute for one. What it provides is near-real-time trend information from the actual supply rather than from seizure data, which lags by months.

Benzodiazepine test strips are available through Overdose Response Programs and through at least one community distributor, Behavioral Health Systems Baltimore, which mails them on request. The strips are not a guarantee — they detect the presence of a class, not a dose — but for someone who does not intend to consume a sedative, a positive result is actionable information.

The advisory builds on a Maryland Department of Health alert issued in late August about rising benzodiazepine detections in drug checking samples. That the city issued its own warning two months later, with a doubled sample count behind it, is itself the signal: the trend has not reversed.

What the numbers can and cannot show

Thirty-one samples is a small count, and it measures what was submitted for testing, not what is on the street. Testing participation varies by county, program capacity and how willing people are to hand over paraphernalia, so a rise in detections can reflect either a dirtier supply or better surveillance — usually some of both.

What the advisory does not claim is a death toll. It does not attribute specific fatalities to benzodiazepine contamination, and readers should not convert 31 detections into an implied body count. The document is a supply warning aimed at people who use drugs, the outreach workers who serve them and the clinicians who receive them in emergency departments.

The measurable test of whether it worked will be in the next rounds of RAD data and in whether emergency departments report more patients who remain sedated after naloxone. For families, the practical takeaway is narrower than the headline: naloxone still saves lives and should still be used, but it is not a complete antidote to what is in the supply now, and someone who does not wake up after a dose needs breathing support and an ambulance, not another assumption that the drug failed.

People seeking treatment for opioid use disorder can find medication-assisted treatment and naloxone access through most local health departments and community providers.