Nitazenes' Rise in the UK

The United Kingdom is facing a grim reality as drug fatality rates have soared. The years 2017 to 2021 stand out as particular markers, where the nation witnessed significant surges in drug-related deaths.

Data from public health agencies paint a stark picture of the situation. In 2017, drug poisoning deaths, including those due to overdose, reached record levels. This trend showed a worrying persistence, with the figures for 2021 reflecting a similar, if not greater, cause for concern. The preliminary data for 2023 suggests that this upward trajectory in drug fatalities has not abated.

The decision by the Taliban government in Afghanistan to ban opium cultivation in 2022 sent ripples through the global drug market, with implications for the UK. While the ban aims to curb the illicit opium trade and its impact on Afghanistan's economy and society, it could also lead to a shift towards synthetic opioids, particularly nitazenes and fentanyl, in the UK drug scene as 95% of the street heroin is coming from Afghanistan.

In the UK synthetic opioids like nitazenes have started to feature in overdose cases. This new class of synthetic opioids, largely unknown to the public, have in recent months seen a rise in both non-fatal and fatal overdoses across the country.

Nitazenes are part of the benzimidazole group of opioids, which differentiates them from other more commonly known opiates like morphine and heroin. The unique structure of nitazenes gives them a high level of potency, often surpassing that of many opioids available. Synthetic opioids are relatively easy to manufacture and can be produced cheaply in clandestine laboratories, making them an attractive option for drug dealers.

Nitazenes act on the mu-opioid receptors in the brain, which when activated, can relieve pain and induce euphoria. However, these drugs are much more efficient at activating these receptors than traditional opioids like morphine or heroin. For instance, N-desethyl isotonitazene, a type of nitazene, has been found to be effective in pain relief at doses significantly lower than fentanyl and morphine. Yet, these drugs also dangerously suppress the respiratory system, often leading to death in cases of overdose.

Developed initially in the 1950s by the Swiss company Ciba Pharmaceuticals, nitazenes were part of a search for effective and potent pain relief medications. In the mid-20th century, as medical science advanced, there was a growing need for effective pain management solutions. Ciba along with other companies, was at the forefront of researching new compounds that could offer significant pain relief. It was during this period of intense research and development that nitazenes were synthesised.

During the initial stages of development, nitazenes showed promise as effective painkillers in laboratory settings. However, as they underwent clinical trials, several challenges emerged. One significant issue was the balance between their potency as painkillers and their potential for causing side effects, including high levels of sedation and respiratory depression, which are serious risks associated with opioid use.

Due to these concerns, along with the growing awareness and regulatory scrutiny over opioid addiction, Ciba Pharmaceuticals eventually decided not to proceed with the commercial development of nitazenes. The risks associated with their use outweighed the potential benefits in a medical context, leading to their discontinuation in the pharmaceutical pipeline.

Decades later, nitazenes have resurfaced, not as pharmaceutical products, but as substances in the illegal drug market. Nitazenes can take several forms and are often mixed with heroin or sold as counterfeit prescription pills. The presence of nitazenes has been confirmed in various substances, including benzodiazepines like Xanax and opioid medications such as oxycodone. Recent seizures in Newham and Waltham Forest have confirmed the presence of these synthetics in heroin batches.

Given the stealthy nature of these drugs, there is a significant risk that individuals may consume them unwittingly, with lethal consequences. This concern is exacerbated by the infiltration of nitazenes in non-opioid drugs, expanding the danger to a broader demographic.

Isotonitazene, a member of this drug family, has been linked to rapid clusters of deaths, including 24 fatalities in 2021 and over 30 in Birmingham in mid-2023 alone. A recent study in JAMA Network Open highlighted the severe impact of nitazenes, with overdose victims often requiring multiple doses of naloxone, the overdose-reversal drug, compared to typically one dose for fentanyl overdoses.

In addition to nitazenes, there are concerns about other new synthetic opioids, like brorphine-like compounds. These are found to be slightly more potent than fentanyl.

In 2023, eleven synthetic opioids, including several nitazenes and brorphine, were classified as Class A drugs. Additionally, the government has increased funding for harm reduction services and is working to raise awareness of the dangers of synthetic opioids among drug users.

The UK government and drug sector are urged to scale up harm reduction responses and enhance surveillance and warning systems to detect and respond promptly. The adoption of harm reduction practices is essential, alongside making drug treatment more accessible, including the provision of substitute medications such as methadone and diamorphine without restrictive prerequisites.

Harm reduction facilities, like drug consumption rooms, provide a supervised environment for drug use, where overdoses can be effectively managed and reversed. These facilities, along with drug-checking services, are crucial for informing users about the contents of their drugs. Naloxone distribution needs to be widespread and not confined to drug services, reaching a wider community.

As the UK confronts the possible emerging wave of synthetic opioids, a robust and cohesive response is needed. This response should encompass a comprehensive strategy, involving coordinated efforts across various services. These collective actions are essential to effectively address and mitigate the harms of this pressing public health issue.

Release harm reduction leaflet: https://www.release.org.uk/sites/default/files/Nitazenes%20drug%20supply%20A5.pdf