A class of synthetic opioids that are 10 times as potent as fentanyl is becoming increasingly prevalent in the United States.
The substance use disorder (SUD) industry may not be sufficiently prepared for its impacts.
Nitazenes, a class of synthetic opioids first developed in the 1950s as opioid analgesics and never approved to market, are increasingly being mixed with fentanyl and other drugs, often unknown to those consuming them. Though these drugs pose severe dangers, clinicians lack adequate knowledge of nitazenes and cannot sufficiently test for their presence.
Nitazenes currently represent a small percentage of total overdoses in the United States. The drugs’ shocking potency is what makes them “scary,” according to Dr. Daniel Brown, Midwest corporate medical director at Pinnacle Treatment Centers.
“This class of opioids has the potential to become a rising tide of multiple different analogs of similar substances that have greater potency,” Brown told Addiction Treatment Business.
Pinnacle Treatment Centers is a private equity-backed SUD provider offering services for alcohol use disorder, opioid use disorder and co-occurring conditions, among other SUDs. It has 140 locations with programs including detox, residential care, partial hospitalization (PHPs) and intensive outpatient programs (IOPs), as well as medication-assisted treatment.
While fentanyl is about 100 times more potent than morphine, nitazenes are up to 1,000 times more potent, making nitazenes about 10 times as potent as fentanyl.
The class of drugs has the same properties as other opioids, including a pain-relieving effect, euphoria and a similar duration of action.
One of the best known nitazenes is isotonitazene, an analog of one of the earliest nitazenes. The analog is known as “Iso” and “Tony,” and was identified in Europe in 2019. There have been more than 700 reports of isotonitazene by participating federal, state and local forensic drug laboratories in the United States as of March 2023, according to the Drug Enforcement Administration (DEA).
Nitazenes are becoming increasingly common in the illicit drug market. Drug users may not know that they are buying drugs mixed with nitazenes, and even if they do, they would be unlikely to know what type or how much.
The drugs have been mixed into heroin and fentanyl and marketed as common street drugs, according to the DEA. They have been pressed into counterfeit pills and sold as pharmaceuticals, including Dilaudid and oxycodone.
“The challenges to clinical care are enormous,” wrote the authors of a study published in the National Library of Medicine. “Patients in overdose-induced respiratory distress are often unresponsive and thus can provide no information to those treating them. Even if responsive or accompanied by other people, these overdose victims may not know what they have taken.”
Researchers recommend a public health campaign designed to help people who take recreational illicit drugs realize that “nitazenes are a real, albeit currently invisible, threat.”
SUD specialists are becoming increasingly aware of the drug class, but general physicians may not be as familiar, Brown said. Still, even SUD specialists may not know enough about the increasingly common class of drugs.
“Even with that awareness, we need to be able to test for it right now,” Brown said. “It could potentially be under-reported in overdoses because it’s not part of our normal panels for testing on the medical side.”
Conventional fentanyl test strips cannot test for nitazenes and specific testing equipment is rarely available.
While the full extent of nitazenes as contributors to U.S. overdose deaths is unknown, nitazenes are increasingly being reported in toxicology reports and on death certificates.
“Given their potency, raising awareness about nitazenes and implementing strategies to reduce harm through increased testing, surveillance and linkage to treatment for substance use disorders are of vital importance,” wrote the authors of a CDC report.
Nitazenes may indicate a dangerous trend of opioids becoming progressively more potent through the development of new analogs. Stronger illicit drugs require more aggressive treatment plans, including higher doses of methadone and buprenorphine.
While opioid overdose reversal drug naloxone has been effective in reversing nitazene-involved overdoses, it may require several doses.
Nitazenes’ increased potency makes it easier to smuggle, Brown said. The drugs can then be diluted to make products with similar potencies to other drugs, using much smaller quantities.
“If that trend [of smuggling and diluting] continues we could see in the next couple of years it taking over the market from fentanyl,” Brown said. “But the problem is that we’re not talking about well-trained pharmacists who are cutting these drugs. You will get batches that lead to a rash of overdoses. The potency of this is what makes that margin of error even smaller than with fentanyl.”