In recent years, illicit fentanyl has been spreading rapidly through the U.S. drug supply. This dangerous and potent opioid has led to an increase in opioid-related overdoses and deaths; although fatalities have decreased in the last few years, fentanyl is still a leading contributor to the problem.

Experts have now confirmed the spread of another potentially fatal class of synthetic opioids. These are known as nitazines; while they are currently less common, they can be several times more powerful than fentanyl.

What are nitazines?

Opioids have been used as a pain relief treatment for centuries, and they have taken many forms. In the middle of the 20th century, morphine was one of the most commonly used medical opioids, but scientists were still trying to develop other opioids that either worked differently or more effectively. 

Nitazines are one of these classes of synthetic opioids. They were first developed during the 1950s to be used as analgesics, or painkillers, but the federal government never approved them for medical use. This is due to their impressive efficacy. Some nitazines—such as etonitazene, isotonitazene, and metonitazene—are approximately 1,000 to 1,500 times more potent than morphine and 10 to 40 times stronger than fentanyl. This makes their risk of overdose and addiction unreasonably high, even when used medicinally and administered under medical supervision. As such, they have rarely seen use outside of research labs. 

Unfortunately, nitazines are being found more frequently in the illicit opioid supply in the United States, and they are involved in an increasing number of overdoses. 

How did nitazines get into the opioid supply?

Much like fentanyl, nitazines are primarily used to cut opioids and other drugs in an attempt to cut costs and make a supply last longer. The drugs are made in labs around the world and then mixed into the supplies of various drugs at different sources.

The proliferation of nitazines in the U.S. opioid supply has followed the spread of fentanyl, and it started showing up in forensic tests as early as 2019. Nitazine-related overdose deaths have been reported in at least five states, primarily in the Midwest, and seizure of illicit nitazines has taken place in a handful of states across the country. 

How to identify nitazines

Because they need to be produced in specialized labs and are not widely available to the public for medical use, nitazines are considered by many to be a designer drug. As such, they can be found in many different forms. Most commonly, nitazines are found in the form of a powder. This powder may be white, or it may have a brownish hue. In many instances, it’s not easy to distinguish powdered nitazines from heroin, fentanyl, MDMA, or other powdered drugs. Nitazines can also come in pill form, often mimicking the size and shape of legitimate prescription drugs, like oxycodone. 

Much like fentanyl, nitazines are difficult to identify. Despite the best efforts of harm reduction initiatives to educate the public on opioid safety and identification and to provide ample (and often free) resources for detecting dangerous additives and cutting agents, nitazine identification remains difficult.

Unfortunately, nitazines consist of many distinct, individual drugs, and it’s not easy to verify their presence or rule it out. Fentanyl test strips, while convenient and easy to use, do not currently react to the presence of nitazines, making them useful only for detecting fentanyl.

Why are nitazines so dangerous?

Potency

The proliferation of fentanyl throughout the opioid supply drastically increased the severity of the opioid epidemic, and it has led to a concerningly high volume of fatal overdoses. Depending on the specific drug, nitazines may be just as powerful as fentanyl, or they may be several times more potent.

While nitazines are not currently as prevalent as fentanyl, their potency means that they have a high potential for addiction, overdose, or both. If the concentration of nitazines in the country’s opioid supply continues to increase, the number of nitazine-related deaths could easily match or exceed those caused by fentanyl.  

The strength of nitazines also makes it more difficult to reverse an overdose using naloxone. When administered correctly, naloxone can restore respiratory activity in a patient experiencing an overdose within just a couple of minutes, and a single dose can often keep the overdose at bay long enough for the individual’s body to process the opioids or receive emergency care while avoiding additional negative effects.

Because nitazines are so strong, naloxone may not take effect as quickly, or you may need to administer a higher dosage or additional dose of naloxone to fully reverse an overdose. During an overdose, respiratory cessation is highly dangerous, and seconds matter, so the increased potency of nitazines is a major concern. 

Difficulty of detection

Because standard field tests for drugs like fentanyl are incapable of detecting nitazines, it’s easy to feel a false sense of security when using illicit opioids. Many people are at risk of using nitazines without even knowing it, even after thoroughly testing and vetting their supply. At the moment, only lab tests can reliably detect nitazines, which makes the process largely inaccessible. Since even small amounts of nitazines can be potentially fatal, any supply may pose an undue risk of overdose.

If you know someone who uses opioids, it’s important to know the signs of potential nitazine overdose. Keep an eye out for:

• Loss of consciousness
• Shallow, slow, or erratic breathing or complete loss of respiratory function
• Slow heartbeat
• Signs of oxygen deprivation, such as blue lips and fingertips

Administering naloxone can be a valuable emergency intervention, even if it requires more doses to be effective. This should buy you some time while you call for a rescue team.

Better research, better patient care

As the opioid landscape evolves, people need access to better information, whether they’re clinicians, researchers, patients, or members of a community affected by the crisis. Ophelia’s clinicians contribute to a growing body of research that reflects the realities of modern opioid treatment. Our team is also committed to providing the gold standard of care, pairing convenient telehealth support with Suboxone® and other buprenorphine-naloxone medications (important safety information). If you have questions about opioid treatment for yourself or a loved one, you can get started for free today with a quick phone call.