First came fentanyl. Then xylazine, aka “tranq,” a veterinary sedative. Will nitazines, a dangerous new class of synthetic opioid, infiltrate the drug supply next?
“Our theory is, it’s just a matter of time,” says Brian Dawson, M.D., an addiction medicine specialist and chief medical officer for Ideal Option. “We could be looking at the very beginning of a nitazine wave.”
Nitazines, identified in Switzerland in 2019, are so new on the scene that most drug users and healthcare providers haven’t even heard of them, other than perhaps isotonitazine, known on the street as “ISO” or “Tony.”
However, authorities are on high alert, prompting Ideal Option to begin testing patients for these compounds.
The Next Wave
In recent years, authorities and toxicologists in Europe and the United States have implicated nitazines in thousands of drug seizures and hundreds of overdose deaths. In one notable case, a Florida college football player died after overdosing on three drugs, including protonitazene, a nitazine estimated to be four times as strong as fentanyl.
Other nitazines may be 10 to 40 times stronger than fentanyl, which is about 100 times more potent than morphine and 50 times more potent than heroin, according to the U.S. Drug Enforcement Administration (DEA).
Nitazine powder can be yellow, brown, or white, according to the DEA, and may been pressed into fake oxycodone or morphine pills. Distributors are cutting heroin and cocaine with nitazines to keep costs down.
If nitazine use explodes the way fentanyl did, urine drug testing will be even more critical to ensure safe and effective treatment. Nitazine patients may need substantially higher doses of Suboxone (buprenorphine) to suppress withdrawal and cravings and may have more trouble starting treatment compared to other opioid use disorder (OUD) patients.
In addition, nitazine users who overdose may need a double dose of Narcan (naloxone), the medication that can quickly reverse an opioid overdose.
“It’s taking more Narcan to reverse a fentanyl overdose than heroin or pills, and the assumption is that it’s going to take more Narcan to reverse a nitazine overdose,” says Dr. Dawson. “And even that may not be enough to save someone’s life.”
New Research
Indeed, a small study, published in JAMA Network Open, found that 9 emergency-room overdose patients who had used nitazenes required significantly more Narcan than 11 patients who’d overdosed on fentanyl alone. Two of the nitazine patients suffered heart attacks, and one died.
The signs of a nitazine overdose are familiar: small pupils and a dangerous slowing of the respiratory and central nervous systems. However, with the strongest nitazines, these symptoms can develop even quicker than with fentanyl, potentially before help arrives.
The JAMA Network open study suggests nitazines have “higher potential for overdose and death” than fentanyl, and the authors urge healthcare providers to “be aware of these opioids in the drug supply so they are adequately prepared to care for these patients.”
Testing for Nitazine
Ideal Option employs sophisticated technology, known as high resolution mass spectrometry, to screen for nitazines in urine samples.
“This technology allows us to quickly test for a broad range of drugs, which is essential given how quickly new synthetics are showing up on the street,” says Mike Gaulke, vice president of laboratory services for Ideal Option. “If there’s a new trend, we’ll find it,” Gaulke says.
This was the approach Ideal Option took with fentanyl. “Right before the covid pandemic, we were seeing fentanyl rates of about 1%,” Dr. Dawson recalls. “Then the rate started slowly creeping up before it skyrocketed.”
Today, about 36% of new Ideal Option patients test positive for fentanyl, compared to 18% for prescription pain pills and just 5% for heroin, according to data from over 4,000 recent drug samples. Xylazine, relatively new on the street, now appears in 10% of new-patient samples, about the same as cocaine. About 43% of new patients test positive for meth.
Currently, authorities suspect most people who ingest nitazines don’t know they’re using them, a situation that was common in the early days of the fentanyl crisis.
Today, many drug users, aware that even tiny amounts of fentanyl can be deadly, rely on test strips to avoid the substance. But this “precaution” won’t help detect nitazines.
“People may do fentanyl test trips on cocaine and feel like it’s safe, but if the cocaine has nitazines in it, they may die,” says Dawson.
The History of Nitazine
Though nitazines are new to the street, these compounds have actually existed since the 1950s.
Developed by a Swiss pharmaceutical company as a potential class of painkiller, nitazines interested researchers because their chemical structure differs from opioids such as morphine and fentanyl. However, nitazines were never approved for medical use in any country and were largely forgotten.
Fast-forward 70 years: After authorities began imposing stiff penalties for fentanyl trafficking, street drug manufacturers, aiming to stay ahead of the law, dug up old nitazine “recipes,” described in the pharmacological literature of the mid-20th century.
Though nitazines are not yet classified as controlled substances, the DEA has now listed several nitazine variations as “temporarily controlled substances,” allowing authorities to arrest traffickers dealing in these compounds.
Dawson predicts it’s “just a matter of time” before the cartels start ramping up production of nitazines which will pose serious challenges for patients and providers alike.