Highly potent synthetic opioids known as nitazenes are emerging in Australia’s illicit drug market. This trend is raising concerns about unexpected exposure, overdose risk and how quickly health systems can identify new substances and warn the community.
The issue has received renewed attention following an ACT coronial finding involving protonitazene.
Burnet Senior Research Fellow Dr Amanda Roxburgh has more than 20 years’ experience in alcohol and other drugs research. Her particular expertise is in opioid overdose mortality and the changing nature of Australian drug markets. Her current research focuses on the factors driving fatal and non-fatal overdose in contemporary drug markets.
Dr Roxburgh explains what nitazenes are and the risks associated with them.
Nitazenes are a group of highly potent synthetic opioids. Like other opioids, they can suppress breathing and cause fatal overdose.
There are a number of different nitazene compounds, including protonitazene, and their potency varies. They were originally investigated for medical use decades ago but were not developed for therapeutic use because of safety concerns. More recently they have appeared in unregulated drug markets internationally and in Australia.
A national scoping review led by my fellow Burnet researchers Emmanuel Mammoliti, Suzanne Nielsen and I examined what is known about novel synthetic opioids in Australian drug markets. The review found their emergence in Australia remained relatively recent and limited, but availability and harms were changing rapidly.
A key concern is that people may not know they are consuming nitazenes.
Australian drug alerts and monitoring systems have detected nitazenes in substances sold as other drugs. We have seen these substances detected not only in opioids, but in drugs sold as cocaine, MDMA, ketamine and counterfeit pharmaceuticals. Burnet’s previous research has highlighted the particular risk this poses to people with little or no previous exposure to opioids.
These people could unknowingly consume a very potent opioid, which substantially increases the risk of overdose. That unpredictability means the emergence of nitazenes is not simply an issue for people who intentionally use opioids.
The ACT coronial finding has also highlighted a wider problem: how quickly emerging substances can be detected and communicated to the community.
Coronial data are an important source of information about overdose deaths, but detailed investigations and finalised cases can take considerable time.
I recently co-authored a paper specifically examining how Australia can identify nitazene-related deaths more accurately and quickly. We found that delays in national coronial data limit its usefulness for the early identification and tracking of emerging drugs and harms.
The challenge with emerging drugs is speed. If it takes months or years for information about a new substance to make its way through coronial systems, that information may come too late to prevent the next overdose.
Our research recommends bringing together information from a range of more timely sources, including forensic toxicology, emergency departments, drug surveillance programs and drug-checking services. This would allow emerging threats to be identified and communicated to the community in close to real time.
This issue closely mirrors concerns raised by the ACT Coroner, who noted there was no integrated public notification system arising from known new psychoactive substances (NPS) toxicology findings in coronial cases and that delays could reduce the usefulness of public warnings.
Drug checking services can provide a more immediate window into what is circulating in the community.
Unlike mortality data, drug checking may identify an unexpected substance before it contributes to a hospitalisation or death. It can also give people information about what a drug actually contains.
Drug checking services such as CanTEST are particularly valuable because they can tell us what is circulating in the community before those harms necessarily appear in mortality data. They also give people information about what is actually in the drugs they are considering taking. In a market where highly potent opioids can appear unexpectedly, that information can save lives.
Naloxone remains one of the most important tools available for responding to opioid overdose, including overdose involving novel synthetic opioids.
Our research has also raised the question of whether access to take-home naloxone needs to extend beyond people who knowingly use opioids, given nitazenes have been detected unexpectedly elsewhere in the drug market.
We should not assume Australia is following exactly the same trajectory as North America with synthetic opioids.
The Australian evidence to date shows novel synthetic opioids are present and harms have occurred, but their emergence remains comparatively limited. The concern is how quickly that could change and whether Australia acts early enough.
That is consistent with Burnet’s earlier work on the issue, which found that Australia already has substantial monitoring capacity but needs stronger systems to detect synthetic opioids before people are harmed.
Burnet has previously highlighted drug checking, expanded naloxone access and stronger front-line monitoring as key responses.
