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“The shift from plant-based drugs, like heroin and cocaine, to synthetic, chemical-based drugs, like fentanyl … has resulted in the most dangerous and deadly drug crisis the United States has ever faced” – Ann Miligram (DEA Administrator) – May 2024 OverviewThe opioid crisis that continues to impact the lives of millions of people across Canada and North America has dramatically reshaped the public health landscape across the globe. For many years, treatment providers focused their efforts on supporting people dependent on opiates derived from natural sources – typically heroin from opium poppies cultivated in the Middle East or South America. The rise of synthetic opioids – and the emergence of nitazenes in particular – represent an alarming new chapter in this ongoing crisis, and pose significant challenges for treatment services, healthcare professionals, policy makers and whole communities. The use of synthetic opioids has rapidly expanded in the last decade. In 2012, synthetic opioids were involved in 6% of 41,502 overdose deaths in the US. In 2022, according to figures released by the Centers for Disease Control and Prevention (CDC), ‘fentanyl and other synthetic opioids were responsible for 70% of the 107,941 drug-related deaths’. In the UK, the emergence of nitazenes represents a significant challenge for drug treatment services. Within the last year, services have become increasingly concerned about these new substances and how best to respond to this escalating crisis. |
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The Emergence of NitazenesNitazenes are a newer group of compounds which have entered the illicit drug market in the past few years. First developed in the 1950’s as analgesics, nitazenes were never licensed for medical use due to their high potency. Some nitazenes have been found to be more potent than fentanyl, with some analogs being hundreds of times stronger than morphine. This extreme potency increases the risk of overdose, even in small quantities. In the UK, nitazenes have been found as contaminants in illicit drugs not exclusively associated with the opiate using community, including benzodiazepines such as Xanax (often purchased online), THC vape liquid and powdered cocaine. Because of this, the risk of overdose is significantly higher as the wider cohort of individuals exposed to this risk will likely be younger, with zero / low levels of opioid tolerance and with no prior involvement with treatment services. Across the UK, the National Crime Agency have revealed that there have been nearly 180 deaths linked to nitazenes, with more than a quarter of these deaths occurring in Scotland alone. |
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Whilst it could be argued that the increased prevalence and manufacture of synthetic opioids could be linked to the current heroin drought across Europe – in large part a result of the Taliban’s crackdown on opium poppy cultivation – the mass production and exportation of synthetic opioids from countries such as China has been happening for many years. Indeed, the US government has been accusing China of flooding the country with fentanyl (and its analogues) for more than a decade. The fact remains that synthetic opioids such as nitazenes and fentanyl are cheap to make, and anyone with access to the appropriate precursor chemicals, agents, catalysts and lab equipment can manufacture them. And because only small amounts of the drug are required to mimic the effects of other opioids, they can be produced, packaged and shipped in smaller packages, making them far more difficult to intercept. |
Meeting the challengeResponding to the threat of nitazenes requires a coordinated, joined-up approach that integrates enhanced monitoring, training and education; improved access to harm reduction interventions and treatment; policy reform; dedicated research and community engagement. Healthcare and drug treatment agencies must work collaboratively to implement these strategies, adapting to new challenges and utilising emerging technologies to capture key, real-time data. By being proactive and sharing data – in particular toxicology reports in the event of drug-related deaths – agencies can help minimise the risk posed by nitazenes and other synthetic opioids, and ultimately improve outcomes for the individuals and communities they support.
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Government response:Since February 2024, the UK government has banned 21 synthetic opiates in a bid to reduce the rising number of drug-related deaths. However, synthetic opioids continue to flood the drugs market and chemists will often simply ‘synthesise new drugs in order to stay one step ahead of the law’. |
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Harm Reduction Response:Thankfully, amongst service users and peer mentors, harm reduction advice about synthetic opioids is being rapidly disseminated, with those prescribed prolonged-release buprenorphine – e.g. Buvidal – at significantly less risk of accidental overdose. The widespread distribution of Naloxone must continue to be a priority for all services working with ‘at risk’ clients. Recently, the UK government announced that they would be making it easier for “police officers, social workers and probation officers” to distribute Naloxone for home use – previously, only drug and alcohol treatment services could provide Naloxone to clients to use at home. To support this initiative, it will be important that those people receiving Naloxone kits – and who ultimately will be those people administering it in the event of an overdose – should also receive appropriate training. Due to the potency of synthetic opioids, often the standard dose of Naloxone may not be sufficient to reverse the effects of an overdose, and multiple administrations may be required. This increases the amount of time needed to stabilise individuals, which could reduce the individual’s chances of survival. |
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Another harm reduction initiative that many services have adopted is the distribution of testing strips, often given to clients as part of their needle and syringe programme (NSP). Single-use tests for fentanyl, nitazenes and xylazine – a non-opioid sedative used in veterinary medicine, increasingly being found as an adulterant in illicit drugs in the UK which has been linked to deaths in the UK – are now available and can produce results in just a few minutes. Whilst no ‘rapid results’ can ever be 100% accurate – indeed even government guidance warns that “Even if a strip did detect a synthetic opioid, it would not be clear which type or at what dose and whether it would cause harm or possible overdose” – services have found these testing strips to be a valuable harm reduction tool because they help get the message out and provide a focus for discussion. |
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Looking ahead, the introduction of drug consumption rooms (DCRs) – such as the one launched in Glasgow last year – which provide a controlled environment in which individuals can use drugs under medical supervision, could prove to be an effective response in combatting drug-related deaths. However, launching such initiatives takes time, not least because England does not currently have the legal framework that allows for the operation of DCRs. Sadly, the interventions that can make an impact and ultimately save lives will take time to deliver. But this is a crisis that has been telegraphed for some time – not least in the US where the ‘chances of dying from an accidental opioid overdose are greater than those of dying in a car accident’. It is imperative that we act now – at a national level and a local level – to tackle this emerging crisis before it claims more lives. How ILLY can help?In our previous FocusOn article, we discussed how ‘utilising multiple communication methods to reach out to clients’ would help services get the message out to clients about reports of contaminated drugs. We would like to develop this idea through consultation with our ILLY Community to explore ways in which SMS messaging could be used for this purpose, and build the functionality within our systems to support this. Aside from any future system developments, ILLY users can already use the system to record harm reduction interventions that evidence the work being delivered to tackle this issue including:
As we continue to evolve our processes and tools, we also continue to engage our communities and support them to meet the challenges ahead. We want to help make a difference and support services in tackling this new crisis – but we cannot do it on our own. We would therefore welcome the opportunity to share some ideas and discuss the best way forward – we are planning a series of workshops and webinars in the upcoming months, if you would like to know more information about these then please contact us using the details below.
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