Before it’s too late

nitazenes - DDN article on responses to the threats of synthetic opiodsWe’ve had more than enough time to prepare for the crisis we’re facing with nitazenes and other synthetic opioids.

It’s vital we do the right things now, says Kevin Flemen.

We should be very concerned about the issue of high-potency novel opioids. While increased media coverage and the establishment of a ‘cross-government task force on synthetic opioids’ are welcome, we are yet to see anything approaching a coherent strategy for the UK. This slow progress will inevitably have fatal consequences.

Given that this crisis was foreseeable it’s unforgiveable that we are so badly prepared. Some of the interventions that people are calling for would have an impact, but will take time to deliver. In the meantime responses are needed now, at a local level.

Having started to roll out a half-day training module for drug services and other social care organisations I’ve had a little snapshot of what is and isn’t happening. This has helped refine and inform some things that are rapidly actionable, see my ten-point list opposite.

Kevin Flemen (left) and Piper
Kevin Flemen (left) and Piper

We can never be certain what the future will hold but in my opinion we are seeing a fundamental and seismic shift in the pattern of opioid use in the UK. This isn’t going to be a temporary drought with business as usual soon. We may end up with stability – one or two more popular (and hopefully less potent) synthetics becoming the substance of choice. Diluted effectively, with increased knowledge around potency, duration and routes we can reduce risk. Indeed we may end up with less risk – drugs that could be snorted rather than injected, no need to use acidifiers, less bacterial contamination?

Or conversely we could end up with a repeating cycle of enhanced risk, as compounds are replaced and changed as we saw with synthetic cannabinoids. Either way we need to prepare – and that means some systemic changes to how we engage with emergent drugs. Something that we are currently doing painfully slowly.

Kevin Flemen runs KFx which has offered training and resources on drugs and related issues since 2003. email

Subheader on DDN article looking at the effects of nitazenes and synthetic opioids

1: Pull together hyper-local focus groups – located within drug services, pulling in people who use, workers, housing, emergency services. Drill in to both fatalities and near misses. Detailed granular information, the way people are using and experiencing the drugs, how people responded to naloxone, duration of effect. Encourage people to send samples for testing.

2: Testing – in lieu of having an English testing service we must continue to impose on WEDINOS but we need to get greater random testing of samples, not just in response to ‘bad batches’. Support people and encourage people to send in samples so we get a proper picture of the distribution of novel opioids.

3: Consolidate our knowledge base – there’s a lot of information we don’t have that will inform harm reduction. How many fatalities or near misses related to smoking? We say ‘start low, go slow’ but with isotonitazene (for example) forming long-acting potent metabolites, what does this mean in practice? To what extent are the nitazenes rewarding and reinforcing redosing? Our focus groups are essential to build this knowledge.

4: Agree and standardise key messages – there’s literature going out about fentanyls that doesn’t mention naloxone, and some where there’s no mention of calling an ambulance. I’ve been in services where there are no posters, others where there’s a sea of them and the message is lost. Communication – posters, leaflets, verbal input from reception staff, key workers, groups is imperative.

5: Naloxone – There needs to be rapid and proactive examination of the pros and cons of nasal v injectable naloxone, and while the primary message has been to ‘get naloxone to people’, in some areas this has seen nasal formulations being the more acceptable option. But if the lower number of doses this affords could be a risk, it needs to be reviewed. What would the gold standard look like? We urgently need an evidence base for this – or a nasal preparation with more doses.

6: Hostel policy – there’s an ongoing clamour for drug consumption centres but with the best will in the world these will take time and significant cost to deliver. In the meantime hostel policy work developing high tolerance policies and effective in-house overdose responses can have a real impact immediately. Their effectiveness in areas where they are established is well developed and needs to be expanded without prevarication.

7: Training! Well, while you would expect this from a trainer, recent courses have highlighted some significant issues that need to be urgently addressed. This has included people excluded from OST as they’re testing negative for opiates, with clinicians unaware that some ‘brown’ heroin may contain no diamorphine and that nitazenes won’t show up on an OPI screen. There is a colossal training need – for drugs services, wider healthcare and other related services including housing, mental health and criminal justice.

8: Widening the message – as novel opioids are being found in a growing range of substances – benzos, fake Oxys and vapes, we need to widen awareness and harm reduction beyond heroin users based on evidence. Benzo users need to be a key target, many of whom may not be in touch with drug services. Given the growing prevalence of bromazolam/nitazene benzos, consideration needs to be given to refining messages (‘don’t mix’ isn’t useful when the pills are effectively ‘pre-mixed’). Messaging needs to be via channels other than drug services – chemists, mental health services, GPs – to reach people using grey-market benzos but not in touch with drugs agencies.

9: Benzo treatment – we’ve been talking about this for too long and the unwillingness to offer effective benzo substitute prescribing has been an issue for a long time. The idea of directing people to wean themselves off illicit benzos has always been less than ideal, but now that we know those benzos could contain novel opioids to offer such a message is unconscionable.

But not only do we need effective prescribing options for people using street benzos, we need to recognise that such patients may have developed opiate/benzo habits due to mixed pills and will need treatment options for both.

10: Trauma support – even with our best efforts people will die and this has a huge impact both on those endeavouring not to use and those still using, as well as people working in support services. Bereavement, grief, helplessness, survivor guilt – we need to ensure that we bake in the support all affected parties will need to cope when people die. On a recent training course we were looking at one small catchment area where the worker was describing seven people being acutely unwell or dying in December. The impact on them and the people they were supporting was colossal.

Related articles:

(Features, March 2024) Testing the Limits – the need for increased testing for synthetic opioids.

(Features, November 2023): Stayin’ Alive – A new family of synthetic opioids, known as nitazenes, have adulterated a number of illicit drugs in the UK.

(News, December 2023): Nitazenes detected in 25 Scottish drug deaths

(News, August 2023): Better utilisation of data and data sharing, including early warning systems, is needed to address the escalating drug crisis in the UK

(Partner Updates, September 2023): Release, alongside EuroNPUD and other drug treatment service colleagues in the UK, have produced harm reduction advice on nitazenes.

(News, January 2023): Fentanyl behind 80% increase in New York’s overdose deaths

(Features, June 2017): Meet the Fentanyls, a guide to the fentanyl family by Kevin Flemen.

Search the DDN archive for more on nitazenes, fentanyl and synthetic opioids.

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