Welcome to the MedLibrary.org Wikipedia Supplement on Temazepam -- Please Click to Return to Front Page

Temazepam
Systematic (IUPAC) name
7-Chloro-1,3-dihydro- 3-hydroxy-1-methyl-5-phenyl- 1,4-benzodiazepin-2-one
Identifiers
CAS number	846-50-4
ATC code	N05CD07
PubChem	5391
DrugBank	APRD00676
Chemical data
Formula	C16H13ClN2O2
Mol. mass	300.7 g/mol
SMILES	eMolecules & PubChem
Pharmacokinetic data
Bioavailability	96%
Metabolism	Hepatic
Half life	8-20 hours
Excretion	Renal
Therapeutic considerations
Pregnancy cat.	X(AU) X(US)
Legal status	Controlled (S8)(AU) Schedule IV(CA) Class C(UK) Schedule IV(US) Schedule I - Class A(SG)
Routes	Therapeutic: Oral Recreational Abuse: Intravenous (IV), Intramuscular (IM), Insufflated, Sprinkled in ethanol, smoked

Temazepam (marketed under brand names Restoril, Euhypnos, Normison, Remestan, Tenox and Norkotral) is an intermediate-acting 3-hydroxy benzodiazepine. Therapeutic and supratherapeutic doses can cause hypnosis, sedation, amnesia, and ataxia.^[1] In addition, temazepam is an effective anxiolytic, anticonvulsant, and skeletal muscle relaxant. After an oral dose of temazepam, absorption occurs rapidly to induce sleep and preserve sleep architecture. It is generally prescribed for the treatment of short-term severe or debilitating insomnia in patients who have difficulty falling asleep or maintaining sleep.^[2]

Contents 1 History 2 Indications 3 Contraindications 3.1 Special caution needed 3.1.1 Pregnancy 3.1.2 Patients at a high risk for abuse and dependence 4 Adverse effects 4.1 Common 4.2 Less common 5 Overdose 6 Pharmacology 6.1 Pharmacokinetics 7 Interactions 8 Tolerance 9 Dependence 10 Elderly 11 Legal status 12 Abuse 12.1 International trend 12.2 Illicit trafficing: manufacture and distribution 12.3 Australia 12.3.1 Border problem 13 Street terms 14 See also 15 References 16 External links

History

Temazepam first came into use in the 1960s, but it was not until 1969 that its usefulness to counter insomnia was realized, and by 1981, the Food and Drug Administration approved temazepam as a sedative-hypnotic for the treatment of insomnia and other sleep disorders under the trade name Restoril.

By the late 1980s, temazepam was one of the most effective hypnotics on the market and it became one of the most widely prescribed drugs for insomnia and other sleep disorders. The 1990s saw an increase in temazepam prescriptions in the United States.

Indications

Temazepam is a hypnotic agent. In sleep laboratory studies, temazepam dramatically decreased the number of nightly awakenings.^[3] Rebound insomnia was observed only occasionally after withdrawal of the drug. Temazepam decreased stage 3, and combined stage 3 and 4 sleep, accompanied by a compensatory increase in stage 2 sleep, but did not alter REM sleep.

Temazepam also possesses anticonvulsant properties and it has been used to manage seizures in adults. Though it is highly effective, its use as an anticonvulsant is rare due to its sedative and motor impairing properties. Temazepam is also a potent anxiolytic, skeletal muscle relaxant, and an amnestic. Its use as an anxiolytic and muscle relaxant is off-label, and its sedative, motor impairing, and hypnotic properties make it undesirable for such uses as well.

Temazepam is officially indicated for severe insomnia and other severe or disabling sleep disorders, where other sleep aids and treatments have failed. Despite this however, it is a widely prescribed first line hypnotic for short periods of time (usually no more than 7–10 days).

Contraindications

Use of temazepam should be avoided, when possible, in individuals with the following conditions:

• Ataxia
• Severe hypoventilation
• Acute narrow-angle glaucoma
• Severe hepatic deficiencies (hepatitis and liver cirrhosis decrease elimination by a factor of 2)
• Severe renal deficiencies (e.g. patients on dialysis)
• Severe sleep apnea
• Severe depression, particularly when accompanied by suicidal tendencies
• Acute intoxication with alcohol, narcotics, or other psychoactive substances
• Myasthenia gravis
• Hypersensitivity or allergy to any drug in the benzodiazepine class

Special caution needed

• Pregnant Women - temazepam may cause fetal damage when administered during pregnancy.
• Pediatric patients
  • Less than 18 years of age - Safety and effectiveness have not been established; temazepam should generally not be given to individuals under 18 years of age
  • Under 6 months of age - Safety and effectiveness have not been established; temazepam should not be given to individuals in this age group.

• Elderly and very ill patients - Possibility that apnea and/or cardiac arrest may occur. Concomitant use of other central nervous system depressants increases this risk. The smallest possible effective dose should be used for this group of patients.

Pregnancy

Temazepam belongs to the Pregnancy Category X of the FDA, and as such it is known to cause serious birth defects and fetal abnormalities. Temazepam increased risk of congenital malformations associated with the use of benzodiazepines during the first trimester of pregnancy has been suggested in several studies. Transplacental distribution has resulted in neonatal CNS depression following the ingestion of therapeutic doses of a benzodiazepine hypnotic during the last weeks of pregnancy.

Reproduction studies in animals with Temazepam were performed in rats and rabbits. In a perinatal-postnatal study in rats, oral doses of 60 mg/kg/day resulted in increasing nursling mortality. Teratology studies in rats demonstrated increased fetal resorptions at doses of 30 and 120 mg/kg in one study and increased occurrence of rudimentary ribs, which are considered skeletal variants, in a second study at doses of 240 mg/kg or higher. In rabbits, occasional abnormalities such as exencephaly and fusion or asymmetry of ribs were reported without dose relationship. Although these abnormalities were not found in the concurrent control group, they have been reported to occur randomly in historical controls. At doses of 40 mg/kg or higher, there was an increased incidence of the 13th rib variant when compared to the incidence in concurrent and historical controls.

Temazepam is contraindicated in pregnant women. If there is a likelihood of the patient becoming pregnant while receiving Temazepam, she should be warned of the potential risk to the fetus. Patients should be instructed to discontinue the drug prior to becoming pregnant. The possibility that a woman of childbearing potential may be pregnant at the time of institution of therapy should be considered.^[4]

Patients at a high risk for abuse and dependence

Temazepam can lead to physiological tolerance, and psychological and/or physical dependence. At a particularly high risk for temazepam misuse, abuse, and dependence are:

• Patients with a history of alcohol or drug abuse or dependence
• Emotionally unstable patients
• Patients with severe personality disorders, such as Borderline Personality Disorder
• Patients with chronic pain or other physical disorders

Patients from the aforementioned groups should be monitored very closely during therapy for signs of abuse and development of dependence. Long-term therapy in these patients is not recommended.

Adverse effects

Common

CNS depression typical of hypnotic benzodiazepine are common and include, somnolence, dizziness, fatigue, ataxia, headache, lethargy, impairment of memory, impairment of motor functions, slurred speech, decreased physical performance, numbed emotions, reduced alertness, muscle weakness, blurred vision, and inattention. Euphoria was rarely reported with the use of temazepam. According to the FDA, temazepam had an incidences of euphoria of 1.5%, much more rarely reported than headaches and diarrhea. ^[4] Increased reaction time, co-ordination problems and impaired learning and memory.^[5]

• Somnolence
• Impaired motor function
  • Impaired coordination.^[5]
  • Impaired balance
• Impaired learning and memory^[5]
• Euphoria (with an incidence of 1.5% according to the FDA)^[4]
• Dizziness
• Anterograde amnesia
• Respiratory depression in higher doses
• Blurred vision (in higher doses)
• Confusion
• Lack of concentration
• Slurred speech

Less common

Hyperhidrosis, hypotension, burning eyes, changes in libido, hallucinations, faintness, horizontal nystagmus, vomiting, pruritus, gastrointestinal disturbances, nightmares, palpitation and paradoxical reactions including restlessness, aggression, violence, over stimulation and agitation have been reported, but are rare (less than 0.5%).

Before taking temazepam, one should ensure that at least 8 hours are available to dedicate to sleep. Failing to do so can increase the side effects of the drug.

Long-term use of temazepam can result in psychological and physical dependence and the appearance of benzodiazepine withdrawal symptoms when the drug is discontinued or the dose reduced. Temazepam impairs cognitive and psychomotor functions, affecting reaction time and driving skill. The use of this drug in combination with alcohol potentiates these side effects, and can lead to toxicity and death. Though rare, residual 'hangover' effects after night time administration of temazepam such as sleepiness, impaired psychomotor and cognitive functions may persist into the next day which may impair the ability of users to drive safely or may increase the risks of falls and hip fractures.^[6]

Overdose

Manifestations of acute overdosage of temazepam can be expected to reflect the increasing CNS effects of the drug and include:

• Somnolence (difficulty staying awake)
• Mental confusion
• Respiratory depression
• Hypotension
• Impaired motor functions
  • Impaired or absent reflexes
  • Impaired coordination
  • Impaired balance
  • Dizziness
• Coma
• Death

Temazepam has the highest rate of drug intoxication, including overdose, among the common benzodiazepines.^[7] Temazepam and nitrazepam were the two benzodiazepines most commonly detected in overdose-related deaths in an Australian study of drug deaths. The two benzodiazepines were found to be the sole cause of death in one third of cases.^[8] A 1993 British study found temazepam to have the highest number of deaths per million prescriptions among medications commonly prescribed in the 1980s (11.9, versus 5.9 for benzodiazepines overall, taken with or without alcohol).^[9] A 1995 Australian study of patients admitted to hospital after benzodiazepine overdose corroborated these results, and found temazepam overdose much more likely to lead to coma in comparison to other benzodiazepines (odds ratio 1.86). The authors note that several factors—such as differences in potency, receptor affinity, and rate of absorption between benzodiazepines—could explain this relatively higher toxicity.^[7]

In the United Kingdom, especially in Scotland, death due to acute temazepam intoxication and overdose is a frequent occurrence. In 1999, temazepam was implicated in about a third of all drug deaths, either alone or in combination with another CNS depressant, most often alcohol or heroin. The frequency of deaths occurring with the ingestion of temazepam alone is of major concern, mainly because a majority of drug users believe that benzodiazepines are not lethal when ingested alone, even in massive quantities. Although most benzodiazepines are considered to have a relatively high therapeutic index and overdose is a rarity, temazepam has consistently been shown to be far more lethal in overdose than other benzodiazepines. In the UK and Ireland, death due to temazepam overdose trumps all other benzodiazepine-related deaths combined. Even outside the United Kingdom, temazepam has the highest number of deaths per million prescriptions in the United States, Canada, Russia, Finland, Australia, and New Zealand.^[10]

In 2003 and 2004, temazepam was the most frequently encountered benzodiazepine in drug-related deaths according to reports from US poison control centers.^[11] In 2005, a total of 67,593 benzodiazepine exposures were reported to US poison control centers, of which 3018 (0.04%) resulted in major toxicity and 243 (0.003%) resulted in death. Temazepam was once again the most frequently encountered benzodiazepine in the vast majority of the cases which resulted in death. Temazepam was also one of two benzodiazepines most frequently encountered in the cases which resulted in major toxicity. Triazolam (Halcion) was the other.^[12]

Pharmacology

Temazepam is structurally most closely related to diazepam and oxazepam. It is a white, crystalline substance, is very slightly soluble in water and sparingly soluble in alcohol. The main pharmacological action of temazepam is to increase the effect of the neurotransmitter GABA (gamma-aminobutyric acid) at the GABA_A receptor. Temazepam is an agonist of the α₁ subtype of the GABA_A receptor. Positive modulation of the α₁ is associated with sedation, motor-impairment, ataxia, and reinforcing behavior.^[13] In rats, temazepam triggers the release of vasopressin into paraventricular nucleus of the hypothalamus and decreases the release of ACTH under stress.^[14]

The oral LD₅₀ of temazepam was 1963 mg/kg in mice, 1833 mg/kg in rats, and >2400 mg/kg in rabbits.

Pharmacokinetics

In a single and multiple dose absorption, distribution, metabolism, and excretion (ADME) study, using tritium (3H) labelled drug, temazepam was well absorbed and found to have minimal (8%) first pass metabolism. There were no active metabolites formed and the only significant metabolite present in blood was the O-conjugate. The unchanged drug was 96% bound to plasma proteins. The blood level decline of the parent drug was biphasic with the short half-life ranging from 0.4-0.6 hours and the terminal half-life from 3.5-18.4 hours (mean 8.8 hours), depending on the study population and method of determination.^[15]

Temazepam is completely metabolized through conjugation prior to excretion; in studies, 80–90% of the dose appeared in the urine. The major metabolite was the O-conjugate of temazepam (90%); the O-conjugate of N-desmethyl temazepam was a minor metabolite (7%).^[16]

Interactions

As other benzodiazepines, temazepam produces additive CNS depressant effects when co-administered with other medications which themselves produce CNS depression, such as barbiturates, alcohol, opiates, tricyclic antidepressants, non-selective MAO inhibitors, phenothiazines and other antipsychotics, skeletal muscle relaxants, antihistamines and anaesthetics. Administration of theophylline or aminophylline has been shown to reduce the sedative effects of temazepam and other benzodiazepines.

The cytochrome P450 system has not been shown to be involved in the disposition of temazepam and, unlike many benzodiazepines, pharmacokinetic interactions involving the P450 system have not been observed with temazepam. Temazepam shows no significant interaction with CYP3A4 inhibitors (e.g. itraconazole, erythromycin).^[17]

Tolerance

Chronic or excessive use of temazepam may cause drug tolerance, which can develop rapidly,^[18] so this drug is therefore not recommended for long-term use.^[4][19] In 1979 the Institute of Medicine (USA) and the National Institute on Drug Abuse stated that most hypnotics lose their sleep-inducing properties after about 3 to 14 days.^[20] Indeed, some studies have observed tolerance to temazepam after as little as one week's use.^[21] However, another study examined the short-term effects of the accumulation of temazepam over 7 days in elderly patients. Here, the authors concluded that elderly patients showed little tolerance during the accumulation of the drug.^[22] Other studies examining the short-term use of temazepam over six days and saw no evidence of tolerance.^[23][24]

In use longer than 1-2 weeks, tolerance will frequently develop towards the ability of temazepam to maintain sleep, so that the drug loses effectiveness.^[25][26] However, not all studies agree. For example, in one study that examined the drug sensitivity of people who had used temazepam for 1-20 years, the responses of these chronic users to the drug was no different from that of controls.^[27] This was in contrast to the tolerance that developed with the related benzodiazepine lorazepam, and the authors speculated that this difference may be due to the shorter half-life of temazepam, or to differences in how the two drugs were usually administered. Another study that examined the efficacy of temazepam treatment on chronic insomnia over three months saw no drug tolerance, with the authors even suggesting that the drug might become more effective over time.^[28] These studies are complicated by the possibility that tolerance may develop selectively to some, but not all, of the drug's effects.^[29] In light of such conflicting data, a recent review by Professor Malcolm Lader at King's College London has noted that for benzodiazipines in general "long-term efficacy remains controversial", but recommended they continue to be limited to short-term treatments.^[30]

Dependence

See also: benzodiazepine withdrawal syndrome

Temazepam as with other benzodiazepine drugs can lead to physical dependence, addiction and what is known as the benzodiazepine withdrawal syndrome. Withdrawal from temazepam or other benzodiazepines after regular use often leads to withdrawal symptoms which are similar to those seen during alcohol and barbiturate withdrawal. The higher the dose and the longer the drug is taken for the greater the risk of experiencing unpleasant withdrawal symptoms. Withdrawal symptoms can however occur from standard dosages and also after short term use. Benzodiazepine treatment should be discontinued as soon as possible via a slow and gradual dose reduction regime.^[31] Dependence on temazepam and other benzodiazepine hypnotics like nitrazepam, flunitrazepam, or nimetazepam often occurs due to discharging patients from hospital on benzodiazepines who were started on benzodiazepine hypnotics in hospital. It was recommended that hypnotics in hospital be limited to 5 nights use only to avoid the development of the benzodiazepine withdrawal syndrome eg withdrawal insomnia.^[32]

Tolerance to the anticonvulsant and anxiolytic effects also develops rapidly during daily administration.^[33]

Abrupt withdrawal after long term use from therapeutic doses of temazepam may result in a very severe benzodiazepine withdrawal syndrome. There are reports in the medical literature of at least six psychotic states developing after abrupt withdrawal from temazepam including delirium after abrupt withdrawal of only 30 mg of temazepam and in another case, auditory hallucinations and visual cognitive disorder developed after abrupt withdrawal from 10 mg of temazepam, 5 mg of nitrazepam and 0.5 mg of triazolam. Gradual and careful reduction of the dosage, preferably with a milder long-acting benzodiazepine such as clonazepam or diazepam, or even a milder short to intermediate acting benzodiazepine such as oxazepam or alprazolam, was recommended to prevent severe withdrawal syndromes from developing. Other hypnotic benzodiazepines, whether short, intermediate or long-acting are not recommended.^[34] Antipsychotics increase the severity of benzodiazepine withdrawal effects with an increase in the intensity and severity of convulsions.^[35]

Elderly

An extensive review of the medical literature regarding the management of insomnia and the elderly found that there is considerable evidence of the effectiveness and durability of non-drug treatments for insomnia in adults of all ages and that these interventions are underutilized. Compared with the benzodiazepines including temazepam, the nonbenzodiazepine sedative-hypnotics appeared to offer few, if any, significant clinical advantages in efficacy or tolerability in elderly persons. It was found that newer agents with novel mechanisms of action and improved safety profiles, such as the melatonin agonists, hold promise for the management of chronic insomnia in elderly people. Long-term use of sedative-hypnotics for insomnia lacks an evidence base and has traditionally been discouraged for reasons that include concerns about such potential adverse drug effects as cognitive impairment (anterograde amnesia), daytime sedation, motor incoordination, and increased risk of motor vehicle accidents and falls. In addition, the effectiveness and safety of long-term use of these agents remain to be determined. It was concluded that more research is needed to evaluate the long-term effects of treatment and the most appropriate management strategy for elderly persons with chronic insomnia.^[36]

Legal status

In the United Kingdom, temazepam is a Class C controlled drug, is available only via a special controlled drug prescription form, and possession is illegal without a prescription. Additionally, all manufacturers in the UK have replaced the gel-capsules with solid tablets. Temazepam prepared for injection is classed as a Class A drug.

In the USA, temazepam is a Schedule IV drug and is only available by prescription. Specially coded prescriptions may be required in certain States.

In Canada, temazepam is a Schedule IV controlled substance requiring a doctors prescription.

In Ireland, temazepam is a Schedule 3 controlled substance with strict restrictions.^[37]

In Norway, temazepam is a "narcotic" drug (According to the norwegian narcotics list), all benzodiazepine derivates and analogues are considered narcotic and temazepam is not available by prescription. Small amounts are punishable with a fine.

In Sweden, temazepam is a "narcotic" drug under the Narcotics Drugs Act (1968).^[38] Temazepam is banned in Sweden and possession and distribution of even small amounts is punishable by a prison sentence and a fine.

In Singapore, temazepam is a Class A-Schedule I controlled drug, along with one other benzodiazepine: Nimetazepam. The clandestine manufacture and illegal distribution of temazepam may be punishable by death. Possession of the drug without a valid prescription from a registered medical doctor is illegal and punishable by extremely long prison terms.

In Australia, temazepam is only available in tablet form and is designated a Schedule 8 control drug, requiring a prescription.

In South Africa, temazepam is a Schedule 6 drug, requiring a prescription, and restricted to 10-20 mg doses.

In Hong Kong, temazepam is regulated under Schedule 1 of Hong Kong's Chapter 134 Dangerous Drugs Ordinance. Temazepam can only be used legally by health professionals and for university research purposes. The substance can be given by pharmacists under a prescription. Anyone who supplies the substance without prescription can be fined $10000 (HKD). The penalty for trafficking or manufacturing the substance is a $5,000,000 (HKD) fine and life imprisonment. Possession of the substance for consumption without license from the Department of Health is illegal with a $1,000,000 (HKD) fine and/or 7 years of jail time.^[39]

Internationally, temazepam is a Schedule IV drug under the Convention on Psychotropic Substances. Though it is classed as a Schedule IV internationally, penalties for its possession and/or trafficking are more severe, unlike all other benzodiazepines except for flunitrazepam and nimetazepam, which are treated in the same manner as temazepam is. Temazepam and nimetazepam continue to be the most widely abused benzodiazepines internationally, and unlike other benzodiazepines, are increasingly being considered primary drugs of abuse. In Singapore, trafficking of nimetazepam and temazepam can be punishable by death.^{[40] [41]}

Abuse

The abuse of temazepam became widespread in much of Europe, East and Southeast Asia, Australia and New Zealand. It quickly superseded other benzodiazepines like diazepam (Valium) and nitrazepam (Mogadon), which were also commonly diverted to the black market. In North America, its abuse was not initially as widespread as it was elsewhere in the world since other hypnotic benzodiazepines such as triazolam and flurazepam were more commonly prescribed for insomnia. Benzodiazepines such as alprazolam and lorazepam, medications indicated for anxiety and panic disorders, were also more likely to be prescribed to patients suffering from insomnia than was temazepam.^{citation needed} In Australia, temazepam accounts for most benzodiazepine sought by forgery of prescriptions and through pharmacy burglary. Pharmacists and their staff often encounter aggressive and threatening behaviour from people seeking temazepam. There were 537 burglaries on Victoria's 1200 pharmacies from 1 January to 30 August 2001, including 'ram raids' (using stolen cars to smash through windows). Temazepam appears to be the main target in many pharmacy burglaries in Victoria. Temazepam is sought in 85% of all reported benzodiazepine forgeries in Victoria.^[42] As a result of its rampant abuse, the Australian government made a decision to restrict temazepam and put it under a much more restrictive schedule than it previously was.^[43] Since March 2004 temazepam capsules have been withdrawn from the Australian market amidst studies linking that particular form of dose to abuse, particularly by intravenous drug users.^[44]

Seized diverted pharmaceutical and illicitly manufactured temazepam tablets and/or capsules account for nearly half of all police seizures of benzodiazepines, outpacing nimetazepam, which accounts for almost a quarter of benzodiazepines seized by police in Edinburgh and Glasgow.^[45]

In the United States, temazepam is the fifth most prescribed benzodiazepine, with only alprazolam, lorazepam, clonazepam, and diazepam being more commonly prescribed in that order. Individuals abusing temazepam obtain the drug by getting prescriptions from several doctors, forging prescriptions, or buying diverted pharmaceutical products on the illicit market. Seizures of diverted temazepam in the United States rivals that of the top four most prescribed benzodiazepines, despite the fact that temazepam is considerably less prescribed.^[46]

Unprescribed temazepam is often detected in urine samples of drug misusers which suggests a high misuse potential of temazepam.^[47] Temazepam was the most commonly used and had been injected from preparations of capsules, tablets and syrup in Edinburgh.^[48] Recently, temazepam was produced as a gel-filled capsule intended to be taken orally. In the United Kingdom, temazepam is a Class C drug under the Schedule 2 of the Misuse of Drugs Act 1971. ^[49] Despite the much more stringent restrictions put on temazepam compared to most other benzodiazepines, temazepam remains to be the most sought after and abused benzodiazepine worldwide with more kilograms of diverted temazepam being seized than any other benzodiazepine. Temazepam is becoming increasingly more difficult to contain and curb its abuse. The 1990s saw a dramatic increase in temazepam abuse, especially among heroin injectors, crack cocaine smokers, methamphetamine, and dextroamphetamine users. In Europe, and especially in the United Kingdom it was at its worst. The media quickly pointed out the dangers associated with temazepam abuse, and temazepam was quickly publicized as an extremely addictive, dangerous, and destructive drug, both mentally and physically. In the United States, reports about temazepam's abuse elsewhere in the world caused concern. However, instead of placing it under Schedule III, as was proposed in the late 1990s, certain American states have made laws which require prescriptions for temazepam to be written on specially coded prescriptions, no other benzodiazepine has such requirement by law.^[50] Pharmacy burglaries and prescription forgeries in Scotland, Australia, Ireland, Finland, and several Asian countries report that temazepam is often a main target, whilst other benzodiazepines are rarely targeted.^[51][52][53]

International trend

Further information: Illicit drug trade

The misuse of temazepam remained a concern in the United Kingdom, Europe, South Africa, Russia, China, and Southeast Asia. More recently though, South America has seen a significant spike of temazepam abuse. Temazepam is believed to be the main contributing factor to crime waves in Argentina and Peru. Clandestine laboratories which illegally manufacture temazepam through chemical alteration of diazepam have contributed to the continued global consumption. North America is also becoming increasingly vulnerable to the illicit trade of temazepam, despite the fact that North America never had a serious problem with temazepam abuse as seen elsewhere in the world.^[54]

In South Africa, the continued availability of illicitly manufactured and diverted pharmaceutical products containing temazepam remained a concern. The low price and ready availability of temazepam in Northern Africa has seen a rise in their popularity. According to drug use surveys conducted in Argentina, Chile and Uruguay, the use of temazepam now ranks second after cannabis, with stimulant use levels in these countries being similar to that of cocaine.^[55][56] According to UNODC research on drug use in the East Asia and the Pacific regions, nimetazepam—a benzodiazepine previously unranked in previous studies—is now the most commonly used drug in Singapore, with temazepam being second most commonly used. In Brunei, temazepam was the most commonly used, with nitrazepam being second and nimetazepam in third. In Malaysia, more than a quarter of a million capsules of temazepam were seized in 2005. During that same year in Malaysia there were over half a million nimetazepam tablets seized.^[57] Nine temazepam seizures (which where en route to Western Europe and South America), equalling 1,430,231 capsules, between July and December 2005 were recorded in Turkey. ^[58]

In Finland, the import of drugs is an international crime and in recent years, 20–30% of those suspected of aggravated temazepam offences in Finland have been foreigners (28% in 2005). Among these, the largest groups in 2005 consisted of Estonians (32% of foreign suspects) and Russians (25%).^[59] Organised crime groups led from Estonia play an important role in acquiring temazepam and other drugs from abroad and smuggling almost all drugs to Finland. The largest groups of foreign citizens suspected of aggravated temazepam offences were Estonians and Russians, whose proportion increased significantly from the end of the 1990s up to 85% of foreign suspects. However, since 2003, their share has clearly decreased to 57% of foreign suspects and 16% of all persons suspected of aggravated temazepam offences in 2005.^[60]

In 2005, the total number of samples of suspected cases of driving while intoxicated came to 3,420. temazepam was the most common substances detected in the samples, comprising of over 82% of the cases. These findings have increased almost fivefold when compared to 2003. Temazepam is increasingly found and used either as a sole drug or as part of a polydrug regimen. ^[61]

In Japan, temazepam, triazolam, flutoprazepam, and nimetazepam are by far the most common benzodiazepines of abuse.

Illicit trafficing: manufacture and distribution

In the United Kingdom, temazepam is the most widely-abused legal, prescription drug. It's also the most commonly abused benzodiazepine in Finland, Ireland, the Netherlands, Poland, Czech Republic, Hungary, India, Russia, China, New Zealand, Australia and some parts of Southeast Asia. Surveys in many countries showed that temazepam, heroin, cocaine, MDMA, cannabis, nimetazepam, and amphetamines rank among the top drugs most frequently abused.^{[62][63][64][65][66][67][68][69][70][71][72]} Misuse of temazepam has led to hundreds of deaths and amputations, according to an unpublished survey. The study of nearly 1,000 people also found that most are unaware of the potential dangers of abusing the drug, temazepam, by injecting the capsules and tablets or swallowing large numbers of them. It discovered more than two-thirds of the randomly selected group from Edinburgh had taken some type of illegal drug in the past six months.^[73] Abuse of it has somewhat decreased since the mid-1990s when the drug was placed under a more restrictive schedule, a decision which was welcomed by many pharmacists who have been robbed by drug seekers looking for temazepam all across the country. Despite this, however, temazepam remains to be the most abused and sought after prescription drug in the UK. Temazepam still remains to be one of the most targeted of drugs in most pharmacy robberies.^[74] Illicit temazepam is also being trafficked from Eastern Europe to the United Kingdom and other Western European countries to meet the high demands for the hypnotic drug. Drug barons are manufacturing the banned capsules known as 'red jellies' and smuggling them into the UK and other western European countries via west coast ports. Intelligence gathered by police chiefs has revealed a massive increase in the availability of illicit temazepam on the streets. The new capsules were first uncovered in a police raid on a drug dealer in Greenock. Police in Strathclyde have said that the illicit temazepam that has been flooding the UK and other western European countries has caused a surge in drug-fuelled crime. Temazepam today is the most widely abused benzodiazepine worldwide, and is quickly turning into a primary drug of abuse, a fact that distinguishes it from all other benzodiazepines, which are typically used only to enhance the effects of opiates such heroin or morphine, or to ameliorate the adverse effects of cocaine or amphetamines. The use of benzodiazepines by street drug abusers is part of a polydrug abuse pattern. However, unlike other benzodiazepines, temazepam abuse has turned into an epidemic, with many of those entering treatment facilities are declaring temazepam as their main drug of abuse. Temazepam is the only benzodiazepine that is illegally manufactured and distributed by international organized crime syndicates and drug barons, though nimetazepam distribution is also criminally organized, but it is not illicitly manufactured. Primary drugs of abuse are defined as drugs with the ability to induce euphoria with psychic dependence and active drug-seeking behavior. Examples of primary drugs of abuse are cocaine, heroin, methamphetamine, and ethanol. ^[75][76]

Australia

Border problem

Temazepam based capsules and tablets are commonly detected by Customs at different ports and airports. Most are coming from countries where they are being illicitly manufactured in clandestine labs. Organized crime syndicates and drug barons in Eastern Europe and China are responsible for the illicit manufacture and distribution of temazepam. Clandestine "jellie labs" have been identified and shutdown in Russia, Ukraine, Greece, Czech Republic, Latvia and Belarus. Temazepam is also found occasionally in the baggage of air passengers. Customs detected 544 unauthorised importations of temazepam-based capsules in 2003–04. Most detections were of small or medium quantities of temazpeam (up to 200–300 tablets/capsules) brought to Australia for personal use. A number of importations, predominantly from China, involved quantities of over 1000 capsules. Most of the temazepam detected originated from the United Kingdom, Russia, China, France, and several Eastern Europe countries. The increase in illicit importation of temazepam in Australia to meet the high demands for the drug are likely due to two reasons: the fact that intravenous drug user-friendly temazepam capsules have been taken off the legal market, and because of a dramatic decrease in prescriptions for temazepam in Australia over the past five years.^[77][78] Customs detected 447 illicit importations of temazepam-based capsules in 2005–06, an increase from 341 in 2004–05, and a decrease from 544 detection in 2003–04. Quantities detected varied from 100 to 2,000 capsules per detection. Eastern European countries, China, Russia, India, United Kingdom, Sri Lanka, Philippines, Thailand, Singapore, New Zealand, Germany, France, South Africa, and even the United States, Peru, and Argentina. This is the first time that the US, Peru, Argentina, and Germany have been mentioned in Australian Illicit Drug Data Report (IDDR) for the importation of illicit temazepam.^[79][80] This may suggest a trend in the growth of an international temazepam epidemic.^[81] There were two detections of over 1,000 capsules—one from Sri Lanka and one from Peru—both of temazepam. Additionally, there were 12 detections of over 300 capsules and 10 detections of 100 to 300 capsules.^[82][83]

Street terms

Street terms for temazepam include king kong pills (formerly referred to barbiturates, now more commonly refers to temazepam), jellies, jelly, tams, terms, mazzies, temazies, temmies, beans, eggs, green eggs, wobbly eggs, knockouts, hardball, norries, oranges (common term in Australia and New Zealand), rugby balls, ruggers, terminators, red and blue, no-gos, blackout, green devils, drunk pills, brainwash, mind erasers, tem-tem's (combined with buprenorphine), mommy's big helper, vitamin T, big T, TZ, on the nod (under the influence of heroin and temazepam together), and others.^[84][85]

See also

• Benzodiazepine withdrawal syndrome
• Benzodiazepines
• Flunitrazepam
• Nitrazepam
• Nimetazepam

References