The Emergence of Bromazolam in Jefferson County AL. A Case Series.

Postmortem toxicology is an ever-changing landscape presenting challenges for toxicologists and medical examiners. Trends can vary for certain benzodiazepines. While diazepam use tends to remain constant, alprazolam and clonazepam ebb and flow depending on prescription trends and street popularity. Novel benzodiazepines like etizolam vary in casework depending on legal restrictions and black-market availability. In May 2022, the first case of the designer benzodiazepine, bromazolam, was detected in Jefferson County Coroner/Medical Examiner's Office (JCCMEO) casework. Between then and December of 2023, an additional nine cases have been observed. Bromazolam, is the brominated analog of the low dose benzodiazepine alprazolam and is likely similar in potency. As bromazolam is a potent benzodiazepine, low concentrations of this novel drug are likely to contribute to CNS depression in opioid overdose cases. We present ten cases in which bromazolam was detected in postmortem samples at the University of Alabama at Birmingham (UAB) toxicology laboratory. The decedents ranged in age from 20 to 41 years of age. Most of the decedents were White (n = 8; 80%) and male (n = 7; 70%). Bromazolam concentrations ranged from 21 to 3,220 ng/mL (mean 401 ng/mL). All but one case were polydrug and all deaths were related to drug toxicity. Fentanyl was detected in 8 of the 10 decedents, with concentrations ranging from <2.5 to 97 ng/mL (mean 30 ng/mL). Additional drugs detected were methamphetamine, ethanol, oxycodone, methadone, cocaine, amphetamine, morphine, and diphenhydramine. While all manners of death were ruled as accidental, bromazolam was included in the cause of death statements in nine of the ten cases. Capturing important emerging drug trends on the death certificate is critical to help inform public health and medical colleagues for preventive measures and treatment in the continued drug epidemic.