Nitazenes have been a topic of conversation for well over a year in the UK, as we have had multiple instances of clusters of lives lost in short periods due to contaminated drug supplies. Treatment providers have responded to fears of a nitazene-adulterated drug supply by increasing naloxone provision, providing nitazene testing strips, warning opiate users that they risk overdose even when smoking, as well as issuing alerts when nitazenes are detected locally. Despite these adaptations, many in the sector are still in denial about the real prevalence of nitazenes in our drugs market. As a result, people with dependencies on these drugs are often met with disbelief and a service offer which is woefully inadequate.
George is a Release caller who first started using nitazenes in 2022, when he was 17. After many difficult years struggling to manage co-occurring mental health disorders and an unstable home environment, George found himself experimenting with different drugs in an attempt to relieve the worst of his mental health symptoms. One of the drugs George used were pills advertised as ‘pressed oxycodone M30s’. It didn’t take long for George to develop a dependency.
Most of the harm reduction conversations around nitazenes in the UK thus far have focused on reducing risks among people whose drugs have been contaminated with nitazenes, assuming that the user does not know about – nor desire the presence of – nitazenes. ‘The thing is,’ George explained, ‘everyone buying pressed oxies knows they really contain synthetics. “Pressed pill” is basically slang for either fentanyl or nitazenes.’ This highlights the first way in which our treatment services and harm reduction messaging are letting people down. We fail to recognise that some nitazene users are not encountering these drugs by accident – they’re seeking them out.
When George first entered treatment at his local drug service, he quickly found that there was no real understanding of nitazenes. For starters, workers were unaware that these drugs are unlikely to be detected by their drug testing equipment, and despite his daily nitazene use, George’s first urine test was negative for opiates. ‘Good news, you’re not using opiates,’ said the clinician. George was only able to begin methadone treatment at a later appointment, having learned that without smoking heroin in addition to his nitazene use he would not be prescribed.
George continued to be disbelieved as he titrated up. Different nitazenes vary in strength, but range from anywhere between ten and 2,000 times stronger than morphine. As a result, a dose of 90ml of methadone was leaving George in significant discomfort. We know from North America that people using synthetic opioids can require doses in excess of 100mg – doctors in Canada have even produced new guidance on the topic. Despite explaining this to his prescriber, and describing his withdrawal symptoms in detail, he was told that there was no way he could still be under-dosed. His prescriber’s failure to listen, and refusal to meet George’s needs, led to him managing his withdrawals by returning to nitazene use on top of his script.
Eventually George was able to be seen by a different prescriber, who agreed to a higher dose if required. Frustratingly for George, whose trust in his treatment provider was at an all-time low, even at this stage they still refused to accept that his dependence had been formed by nitazenes. His prescriber insisted on referring to the drugs he had been using as oxycodone, despite multiple tests that George conducted on his pills and on his urine using nitazene test strips. George was told that these strips were too unreliable to be considered accurate, and his trust in his treatment service was further damaged by this unwillingness to believe him. A Wedinos result would later confirm that the only active ingredient in his pills was isotonitazepyne.
Treatment providers may sometimes struggle to respond in an agile way to emerging crises. It’s understandable that drug workers, even clinicians, may not know the best way to treat a dependency on an emerging drug. However, we do know that good therapeutic relationships and patient trust are important in keeping people engaged (and alive), even when the finer details of someone’s treatment plan are a bit fuzzy.
Nitazenes have now been part of the UK drug landscape for three years, and it needs to be accepted that these drugs are sometimes used with intention, that they are increasingly prevalent, and that we must listen to people using these drugs. We must adapt our approach as a sector if we have any hope of supporting people using nitazenes in the future, as they are very likely here to stay.
Fraser Parry is drugs advocacy and support adviser at Release