A new family of synthetic opioids, known as nitazenes, have adulterated a number of illicit drugs in the UK.
It’s not clear exactly when this began, but evidence of them being present in cocaine and heroin was detected in 2021.
Nitazenes are broadly equipotent to the fentanyls – or in layman’s terms, they’re many times stronger than heroin and morphine. Unknowingly taking a drug containing nitazenes represents a severe risk of overdose. By the summer of 2023 there was sufficient evidence of them contaminating other drugs for OHID to provide a patient safety alert for all of the UK, based on an increase in both fatal and non-fatal overdoses (NFOs).
Nitazenes have been found in contaminated heroin, fake OxyContin (oxycodone) and fake Xanax (usually bromazolam rather than alprazolam), meaning the risk was extending to young people who don’t use heroin but buy what they think is OxyContin from the dark web or a few bars of Xanax from their mate. This group would have no or a very low baseline opioid tolerance to withstand the effects of a nitazene and would be unlikely to have naloxone, putting them at yet further risk. Deaths have escalated throughout 2023, most notably in the Birmingham area in July.
Still recovering from a decade of budget cuts to drug treatment and the unintended adverse impacts of the recovery agenda moving the focus away from harm reduction – and with drug-related deaths escalating every year since 2011 – treatment services were not ready for the severe overdose risk posed by nitazenes. Many of the people most at risk are no longer engaged with services, do not have or carry naloxone, use multiple drugs in combination and are also getting older.
First things first
After communicating the alert the first challenge was to engage with people at risk and offer a form of treatment they would want – whether reluctant returners or newcomers. We need to be more attractive to those people we really should be better at engaging, treating and retaining. In Dr Steve Brinksman’s words: ‘Treatment (OST) protects, you’re less likely to overdose, and if you do overdose you’re less likely to die.’
Many drug treatment services have national leads for harm reduction, and we know, trust and respect each other. We decided that because of the severe threat of overdose we should work together to provide clear advice on how to reduce the risk. A little discussion on X/Twitter with Stephen Malloy of Ethypharm and Dr Judith Yates came about one evening, sharing our concerns as the deaths and NFOs rose and rose.
The plan was simple enough – provide useful advice to people at risk. This came from a genuine place of care and concern. We would all say exactly the same things, and launch on our websites and social media feeds at the same time. The lovely Dr Yates joined in and supported our efforts, and we felt a common responsibility as those with expertise in harm reduction and overdose that we should be the people to lead our organisations and the wider sector through this storm. The unified message we released in mid-July had the advantage that we all had to agree to it before going public, reducing the likelihood of providing poor information. In hindsight we realised that although the advice itself was sound, there was too much of it, meaning it could be overwhelming – or ignored.
Up and running
The situation developed quickly and in the run up to International Overdose Awareness Day we planned an update, based on the excellent work of Lynn Jefferys of EuroNPUD. We contextualised the work to the UK, resulting in a total of six short messages released on successive days. By then our small group had expanded as more treatment services and organisations like Release wanted to support. Release kindly helped this larger flock to keep together by providing secretariat support. Given the numbers now involved, consensus on the messages was a little slower, but getting it at all is credit to everyone involved. The harms of nitazenes galvanised us.
We arrived at the idea for an individualised overdose plan because we felt too much of the advice given by staff (well-meaning as it is) doesn’t engage people as well as asking them to come up with a plan to account for the circumstances they’re in, the drugs they’re using and the resources available. Ultimately they’re the only ones who know all the detail, the where and when, and – crucially – how they could be found if they did overdose. Our intention is that by asking them to complete a plan it’s far more likely to take account of all the things unknown to us, such as where the spare key to someone’s flat is. It’s also more likely that in making a plan, that person will consider and decide to do the very things we’ve been rattling on about for years – carry naloxone, test dose, go slow and so on. Ironic, isn’t it?
We’re learning all the time about how best to respond to nitazenes – this story is about how our thinking has evolved to counter the threat, especially ‘what works’, and to ensure that the people who are exposed to it make their own plan that keeps them alive throughout it. We’re committed to continue to produce information and advice around these potent synthetic opioids that’s helpful to those using drugs, and that centres around the statement and our shared belief that ‘You are important’.
The bigger ask of people is to treat any drug as if it’s something else, something they’re not expecting to take – and be aware of the greater need for universal precautions and looking after each other.
Much as the intention was always to provide useful information to PWUD so that they could manage the risk, we knew that people reading the advice on our websites or social media accounts were more likely to be those working in the sector. It made sense to recalibrate and look at how we could influence them to influence the people they work with.
In October we evolved again with this in mind and went to HIT with the idea of keeping the messaging simple, empowering workers to have conversations with PWUD about the nitazenes threat and to discuss a plan for overdose with them. We call it a ‘Stayin’ Alive’ plan rather than an overdose plan.
HIT kindly developed some simple posters on our behalf, which could be downloaded and printed in any service, anywhere.
Download resources here: hit.org.uk/stayin-alive
In memory of the many lost, unnecessarily.
Deb Hussey is national safer lives lead at Turning Point; Jon Findlay is national harm reduction lead at Humankind; Peter Furlong is national harm reduction lead at Change Grow Live; Chris Rintoul is innovation and harm reduction lead at Cranstoun; Maddie O’Hare is deputy director of HIT
(Features, June 2017): Meet the Fentanyls, a guide to the fentanyl family by Kevin Flemen.
(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