Overdose – Information and Response

About benzodiazepines

• Benzodiazepines are prescription medications, but they are also found on the illegal market. All benzodiazepines have depressant effects and act as sedatives and muscle relaxants.

• These medications are used for medical purposes to treat conditions such as anxiety disorders, seizures, sleep problems, and epilepsy. There are many different types of benzodiazepines, both legally and illegally manufactured. In recent years, more new benzodiazepine-like intoxicating substances, known as derivatives, have appeared on the market. These are sold on the black market or illegally online. A considerable number of counterfeit medications have also been identified that are sold as legally manufactured benzodiazepines.

Most common benzodiazepines in Iceland

• Alprazolam, which is also sold under the brand name Tafil®. On the black market, the drug is commonly traded under the brand name Xanax®, but it has not been registered in Iceland.

• Oxazepam, which is sold under the brand name Sobril® in Iceland.

• Diazepam, which is sold under the brand name Stesolid® in Iceland.

• Chlordiazepoxide, which is sold under the brand name Risolid® in Iceland.

• Clonazepam, which is sold under the brand name Rivotril® and is used to treat epilepsy.

About sleeping pills (benzodiazepine-like substances)

• Imovane (containing the active ingredient zopiclone) and Stilnoct (containing the active ingredient zolpidem) are not benzodiazepines, but rather benzodiazepine-like medications. Both are used to treat difficulty falling asleep, but their use is only recommended for a short period due to the risk of developing tolerance and dependence.

Routes of Administration

• The most common route of administration is in tablet form. It is known that individuals who misuse benzodiazepines may dissolve the tablets and inject them intravenously. It is also known that tablets may be crushed and snorted.

• When these substances are injected intravenously, undissolved excipients, such as binders, fillers, and flow agents, may enter the lungs as particles. These can block small blood vessels and cause a pulmonary embolism (a blood clot in the lungs) or lead to localized, chronic inflammation. There is also a risk of infection.

Effects and Side Effects of Benzodiazepines

• The effects of benzodiazepines appear relatively quickly after ingestion. Long-term use is not recommended because there is a considerable risk of developing tolerance and dependence, and withdrawal symptoms can occur even after short-term use.

• Common effects include relaxation, drowsiness, and sedation. Memory and reaction time are impaired. Increased impulsivity and aggression may occur, even at low doses. Concurrent use of other intoxicating substances increases the likelihood of such reactions. There is an increased risk of falls due to impaired balance. Studies show an increased risk of being involved in a traffic accident, even after taking a single dose.

• Benzodiazepines are highly addictive. Tolerance develops quickly, meaning that larger doses are needed to achieve the same effects.

Withdrawal Symptoms

• Withdrawal symptoms can occur even after short-term use, but are generally more severe following long-term use. Anxiety, nausea, seizures, heart palpitations, increased heart rate, and elevated blood pressure are among the withdrawal symptoms. In rare cases, withdrawal symptoms can be life-threatening.

• Gradually reducing the dose can help reduce withdrawal symptoms, and it is recommended that this be done in consultation with a doctor. In some cases, treatment at a medical facility may be necessary.

About Cannabis

• Cannabis is a collective term for products derived from the plants Cannabis sativa and Cannabis indica. The effects of cannabis can be described as depressant effects on the central nervous system combined with mild hallucinogenic effects. Cannabis is primarily a depressant and causes mild to significant changes in the state of consciousness.

• The cannabis plant is used to produce, among other things, hashish, marijuana, oil, and various other cannabis products.

THC

• The main active compound in cannabis is THC (delta-9-tetrahydrocannabinol). The intoxicating effects of cannabis are primarily caused by THC.

• The THC concentration in cannabis products varies considerably. It depends, for example, on which strain (hybrid) is used, how the plant is cultivated, and which parts of the plant are used in production.

• Analysis of seized substances shows that the average THC concentration in cannabis products has increased in recent years. The stronger the substance, the greater the risk of dependence and developing tolerance, as well as the risk of psychosis among people who use it.

Different Cannabis Products

• A wide range of products can be produced from the cannabis plant. They share a characteristic, sweetish smell that becomes particularly noticeable when smoked.

• Hashish (brown) is the resin of the plant, compressed together with plant material. Hashish is either eaten or smoked. It usually comes in thick, brown or black slabs that are broken down into smaller pieces or doses for consumption.

• Marijuana (weed, grass) generally consists of dried flowering tops, but may also contain varying amounts of leaves, stems, and seeds. The plant material is ground or crushed and is most commonly smoked.

• Cannabis oil is a plant oil extracted from the cannabis plant. The oil is liquid and is usually applied to tobacco, hashish, or marijuana and then smoked. The THC content of cannabis oil is often high. It is therefore generally the strongest form of cannabis product, with the associated risks and side effects reflecting this.

• Numerous other cannabis products are available on the market, such as the medication Sativex oral spray (containing THC and CBD), creams, beverages, vapes, and much more.

Synthetic Cannabinoids (Spice, “Legal Highs”)

• Synthetic cannabinoids are a large group of substances that are chemically manufactured and have cannabis-like effects. They are generally sprayed onto or applied to plant material that resembles cannabis in appearance. However, most of these substances have much stronger effects than natural cannabis products such as hashish and marijuana, which significantly increases the risk of negative consequences from their use.

About GHB and Derivatives

• GHB (gamma-hydroxybutyrate) is a depressant substance that occurs naturally in the body in small amounts. Its function is not fully understood, but it likely plays a role in regulating sleep. All GHB produced for use as an intoxicating substance is manufactured through chemical processes (chemical synthesis). It is mainly sold in liquid form, but also as a powder or in capsules. In liquid form, GHB is a clear liquid with a slightly salty taste.

• GHB derivatives (gamma-butyrolactone and 1,4-butanediol, 1,4-BD) are chemical precursors to GHB and have similar effects.

How does GHB work?

• The intoxicating effects depend on the purity of the substance, the amount taken, and the route of administration. At a typical dose, effects appear after approximately 15–30 minutes and usually last for 3–5 hours.

• GHB is a depressant, and its effects are in many ways similar to those of alcohol. Common effects include relaxation, impaired coordination, and impaired judgment.

Side Effects and Risk of Dependence

• Using GHB together with other substances can have unpredictable and serious consequences.

• Nausea, vomiting, seizures or muscle spasms, dizziness, sudden fatigue, and partial or complete loss of coordination may occur.

• GHB production can be impure and may contain corrosive substances such as lye. Drinking an impure product directly from the bottle or without diluting it can cause serious burns to the mouth and throat.

Symptoms of a GHB Overdose

• Loss of consciousness, slowed heart rate and lowered blood pressure, involuntary urination, muscle spasms, muscle twitching, and, in the worst cases, respiratory arrest and death. It is therefore particularly important that people with heart conditions, abnormal blood pressure, breathing difficulties, or epilepsy do not use GHB.

Dependence and Addiction

• GHB can cause dependence with regular use, and withdrawal symptoms can occur if use is stopped suddenly.

Common Withdrawal Symptoms

• Anxiety, sleep problems, nausea, seizures, tremors, sweating, and confusion.

About Opioids

• Opioids is a collective term for medications or intoxicating substances that act as depressants on opioid receptors in the brain, such as heroin, morphine, and methadone.

• Their effects are described as strongly sedating and pain-relieving and can cause a state of euphoria and apathy.

Opioids: Opiates, Heroin, Morphine, Methadone, and Buprenorphine

• Opioids that occur naturally and are derived from the opium poppy are called opiates. The term opioids includes both naturally occurring opioids and those that are chemically manufactured.

  • Morphine and codeine are examples of naturally occurring opioids.

  • Heroin is an example of both a naturally derived and synthetically produced opioid.

  • Methadone, buprenorphine (Subutex, Suboxone, Temgesic, etc.), oxycodone, tramadol, and fentanyl are examples of synthetic opioids.

Dependence, Addiction, and Withdrawal

• With regular opioid use, tolerance develops, meaning that larger doses are needed to achieve the same effects. Tolerance decreases quickly after a break from use, which increases the risk of overdose if a person takes the same dose they previously used.

• Opioids are highly addictive and cause severe withdrawal symptoms when use is stopped. The symptoms often resemble severe flu and may require hospital treatment. Gradual dose reduction is recommended. Maintenance treatment (buprenorphine, Buvidal®, Zubsolv®) is also available for opioid dependence. The medications used for maintenance treatment are milder than strong painkillers and are therefore well suited for gradual dose reduction.

Concurrent Use of Strong Painkillers and Buprenorphine

• If morphine is administered to relieve severe pain and buprenorphine is given shortly afterwards to increase the effects, this can reduce the pain-relieving effects of morphine. The individual may therefore experience more pain or less euphoria than if they had taken morphine alone.

Naloxone

• Naloxone reverses the effects of opioids on the central nervous system and is used to treat opioid overdoses. Naloxone can also prevent constipation, which is a common side effect of opioids.

• Because naloxone reverses the effects of opioids on the central nervous system, many users experience severe withdrawal symptoms after receiving naloxone for an overdose.

• Amphetamine is a stimulant substance, meaning that the individual experiences increased energy, a reduced need for sleep, and greater alertness.

• Amphetamine in powder form is usually white, but it can also be yellowish, brown, pink, or bluish.

• Amphetamine is most commonly taken intranasally (“snorted”), but it can also be taken orally, dissolved in liquid and consumed as a drink, or injected intravenously.

• The effects generally last for 3–6 hours, but may last longer with larger doses.

• Methamphetamine is chemically very similar to amphetamine, but is much more potent. Methamphetamine is most commonly sold in powder form as “strong” amphetamine, but can also occur in a solid form resembling crystals. In Iceland, amphetamine is much more common than methamphetamine.

• Most people do not know the difference between amphetamine and methamphetamine. The powder is usually odorless, but can sometimes have a strong chemical smell.

• Amphetamine is also known by street names such as speed, pepper, and makka. Methamphetamine is known by names such as meth, crystal, and meta.

• Cocaine is a stimulant substance that acts on the central nervous system and is derived from the leaves of the coca plant. Its effects are described as short-lived but highly stimulating.

• Cocaine is mainly distributed in powder form. The most common method of use is to snort it, but other routes of administration are also possible.

• Crack is a pure, crystallized form of cocaine that is smoked.

About MDMA

• Ecstasy, also known as “emma,” “molly,” and “knips,” is a stimulant with psychoactive effects. It increases levels of the neurotransmitters serotonin, dopamine, and noradrenaline in the brain, which can produce feelings of euphoria, increased energy, and emotional closeness. However, this can be followed by low mood or depression, as serotonin levels may drop sharply after use.

• MDMA is most commonly taken orally in tablet or powder form. It can also be snorted or taken rectally. Ecstasy tablets come in many different colours, shapes, and designs, and often look very different from conventional medications.

• The effects typically last for 4–6 hours.

What happens in the body when MDMA is taken?

• While the effects are present, levels of dopamine, noradrenaline, and serotonin increase at the synapses and affect the autonomic nervous system. This can make a person feel alert and energetic and may cause dilated pupils, an increased heart rate, and a rise in body temperature. This can lead to dehydration and, in severe cases, become life-threatening. Other symptoms may include muscle tension, jaw clenching, restlessness, feeling hot, sweating, nausea, and headache. These symptoms are usually strongest during the first few hours after taking MDMA.

• Because MDMA can place significant strain on the body, many people experience a mental “comedown” after using it, along with low mood or feelings of distress in the following days. Research has shown an increased risk of suicide among people who use these substances.

• LSD (lysergic acid diethylamide), commonly known as “acid,” is a powerful hallucinogen that can cause significant changes in perception, emotions, and thought.

• LSD is most commonly taken on small pieces of paper (“blotter”), in tablet form, on sugar cubes, or in liquid form. The effects usually begin after 30–90 minutes and typically last for 8–12 hours.

• LSD affects the brain’s serotonin system and can cause hallucinations, altered perception, and changes in the experience of time and space. Its effects are unpredictable and can range from feelings of euphoria to unpleasant and frightening experiences (“bad trips”).