Benzodiazepines were present in a third of prescription opioid overdose deaths in 2017; alcohol in one in seven
Across 399,230 US opioid overdose deaths, 1999 to 2017, benzodiazepine co-involvement rose from 8.7 to 21.0 percent, and to 33.1 percent of prescription opioid deaths. Alcohol was involved in 14.7 percent.
Suggestive but preliminary. Not settled. how we score evidence
Caveat on this rating: Death-certificate data: co-involvement depends on what a medical examiner tested for and recorded, which varies by state and year, so both the levels and the trend are partly measurement.
The label says benzodiazepines plus opioids kill. This is the count.
Significant findings
Tori, Larochelle and Naimi (JAMA Network Open, 2020) analysed every opioid-involved poisoning death in the CDC's WONDER database from 1999 to 2017: "399 230 poisoning deaths involved opioids, of which 263 601 (66.0%) were male, and 204 560 (51.2%) were aged 35 to 54 years."
Alcohol: "Alcohol co-involvement for all opioid overdose deaths increased nonlinearly from 12.4% in 1999 to 14.7% in 2017. By opioid subtype, deaths involving heroin and synthetic opioids (eg, fentanyl; excluding methadone) had the highest alcohol co-involvement at 15.5% and 14.9%, respectively, in 2017."
Benzodiazepines: "Benzodiazepine co-involvement in all OODs increased nonlinearly from 8.7% in 1999 to 21.0% in 2017. Benzodiazepines were present in 33.1% of prescription OODs and 17.1% of synthetic OODs in 2017."
The state-level pattern: "State-level rates of binge drinking were significantly correlated with alcohol co-involvement in all OODs (r = 0.34; P = .02). State benzodiazepine prescribing rates were significantly correlated with benzodiazepine co-involvement in all OODs (r = 0.57; P < .001)."
Worth asking
Co-involvement means the drug was found at death, not that it caused the death, and death certificates undercount what was not tested for. Even so, one in three prescription opioid deaths with a benzodiazepine present is the number behind the boxed warning. If you take a benzodiazepine and any opioid is in your life, prescribed or not, the question for your prescriber is whether naloxone is in the house and whether the people around you know how to use it.
Source
Alcohol or Benzodiazepine Co-involvement With Opioid Overdose Deaths in the United States, 1999-2017 — Tori ME, Larochelle MR, Naimi TS (2020)
Top-tier peer-reviewed journal
Read the source: https://doi.org/10.1001/jamanetworkopen.2020.2361
DOI: 10.1001/jamanetworkopen.2020.2361
How this was scored
- Study design
- Cross-sectional study / survey
- Funding
- Funding not disclosed
- Published in
- Top-tier peer-reviewed journal
- Sample size
- 399,230
- Preregistered
- not recorded
- Conflicts disclosed
- Yes
- Independent of proponent
- not recorded
- Retracted
- No
Read the full scoring rubric, including what it can't tell you.
Published September 21, 2026.
Questions
How strong is the evidence behind this?
veisund rates this source "early signal". Suggestive but preliminary. Not settled. It scores 54 out of 100 on our published rubric. One caveat travels with that badge: Death-certificate data: co-involvement depends on what a medical examiner tested for and recorded, which varies by state and year, so both the levels and the trend are partly measurement. The score is calculated from recorded facts about the source — study design, funding, publication venue, sample size, preregistration — not typed in by an editor.
What is the source for this?
Alcohol or Benzodiazepine Co-involvement With Opioid Overdose Deaths in the United States, 1999-2017 — Tori ME, Larochelle MR, Naimi TS (2020). Published in: Top-tier peer-reviewed journal. DOI: 10.1001/jamanetworkopen.2020.2361. The full source is linked on this page so you can read it yourself.
Who paid for this research, and does that matter?
Study design: Cross-sectional study / survey. Funding: Funding not disclosed. Independence from the proponent is not recorded. Industry sponsorship is one of the most reliably measured biases in medicine, which is why funding carries real weight in the score rather than sitting in a footnote.
Is this medical advice?
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.