We can all agree – the presence of nitazenes in the heroin supply is a problem. It’s a problem that has more than likely caused more than 400 people to lose their lives in the UK, with many more overdoses on the cards.
Their emergence should also have come as no surprise – the rise of potent synthetic alternatives to ‘traditional’ drugs has been a familiar trend ever since the early 2000s and the advent of ‘legal highs’. Very quickly, the UK decided to gift these compounds to organised crime, with tragic and predictable outcomes.
When it comes to nitazenes there seems to be a prevailing view that they can’t be managed or controlled by the people using them. This can easily morph into the belief that the only way for people who currently use heroin to ensure they don’t suffer a nitazene-related overdose is to abstain. However, there are many people with powerful reasons why they can’t or won’t stop, and they may be left feeling hopeless and at the mercy of these compounds.
At the same time, in the face of the fearsome potency of some nitazenes, services have understandably retreated to familiar ground, offering slightly tired advice like ‘don’t use alone’ or ‘look after your friends’, while rightly calling for effective but distant systemic change like the introduction of overdose prevention centres and expansion of drug testing facilities.
Of course, the introduction of evidence-based, low-threshold harm reduction should be a priority for the UK, and we should continue to promote it at every opportunity. However, there is a problem staring us in the face – currently these life-saving transformative interventions are NOT the priority for policy makers. These changes will take time and money to implement, and we’re in danger here of letting the perfect be the enemy of the good – of concentrating on future developments while doing little or nothing to intervene in the present.
As for most individual users of heroin, they’re left in a very familiar space. That is, feeling powerless waiting for these distant remedies while facing the real and present prospect of dying – at the mercy of the invisible monster in their bag of gear. We’re in urgent need of simple practical harm reduction advice that individuals can implement easily while the country waits for large evidence-based approaches to be introduced.
The idea of ‘batch cooking’ could be an example of just such a small change in the preparation of heroin (with clusters of nitazene present) that could marginally lower risk. The idea came from a chance discussion with an anaesthetist and pain specialist, someone who was no stranger to using powerful synthetic opioids on patients
The conversation turned to the nitazene threat and I asked him what techniques were used to administer a safe dose of anaesthetic. Among other things, he simply replied ‘dilution’. Dilution of a substance can of course have the benefit of both lowering the strength of a dose but also of evenly distributing the drug through a solution – clustering of nitazene within a batch of heroin has been cited as a particular threat.
For some people who use drugs, this is not a new idea. There are examples of people who prepare a number of doses of heroin in advance and then use the solution over the day or sometimes longer. Put simply, if the user were to dissolve a number of doses of heroin/nitazene mix in a larger amount of water with some added citric, the nitazene would be better distributed throughout the liquid and the dose of nitazene would be both more diluted and more evenly distributed. If the user then ‘tasted the hit’ and found it to be effective, they would have a store of ready mixed liquid solution that they could use with reduced risk.
There are a number of important issues to be thought through here – detailed in my discussion paper – but the basic concept of ‘batch cooking’ may be a useful, easy and pragmatic way for people who use heroin to lower the risk of overdose. We need to keep thinking of novel harm reduction practices like this and sharing them with people who use drugs to see if they find them practical and useful to implement, while doing all we can to ensure that any new ideas do indeed reduce risk and don’t increase harm.
Clearly, with drugs like nitazenes there comes a point where the potency of the drug is fatal regardless of harm reduction practices. But we should not stop thinking creatively about how people can survive this latest threat on a day-by-day basis.
Renato Masetti is training co-ordinator, drugs and alcohol, Health Outreach NHS
Contact him for his original paper at renato.masetti@nhs.net
WEDINOS was a network unlike any other, a monitoring system that reflected national drug markets, trends and threats, project manager Dean Acreman told the RCGP/AP conference. Through examining consumer level samples since 2013 the system had identified drugs quickly and effectively, showing that many substances contained substitutions that people had no idea they were buying. Since attracting Welsh Government support, it had become integral to harm reduction in Wales over the past ten years and had analysed more than 45,000 samples. More recently it had become a vital tool in tackling the nitazene crisis, with more than 250 samples profiled as containing nitazenes since April 2021. ‘We can turn around results very quickly,’ said Acreman. ‘Are you getting what you think you’re getting?’ he added. For example, of 37 samples found to contain nitazenes, 29 of them were submitted as oxycodone. The journey over the past few years reflected the ‘changing face of nitazenes’ as WEDINOS started to find them in heroin. ‘We put out a leaflet and gave reassurance around using naloxone,’ he said. The service had also played a key role in prison safety – HMP Parc reported spice deaths but the blank pieces of paper being sold were found to be laced with nitazenes. An information sheet for staff and easy-to-read document for prisoners swiftly followed. With an expanding list of drugs found to include nitazenes, the ongoing challenge was ‘how do we get the message out?’ he said. The UK was responsible for a third of all drug-related deaths in the EU in 2019, said Dr Caroline Copeland, director of the National Programme on Substance Use Mortality. ‘They’re glad we’ve left.’ She later added, ‘There are many different answers to why they’re so much higher in the UK – maybe some countries may not test so well. Also, Scandinavian countries have much greater investment in healthcare.’ Her national programme involves using data to understand more about the pharmacoepidemiology of drug-related deaths. Coroners voluntarily send reports from England, Wales, Northern Ireland, the Channel Islands and the Isle of Man, amounting to 60,000 reports to date. The high volume of detailed data, including demographics, meant ‘we can do an awful lot of analysis,’ she said. Data on 230 fatalities related to nitazenes between June 2023 and 2024 revealed large clusters around the Birmingham area and south coast of England. She shared concerns that the situation could be ‘even worse than we know’ as testing threw up some ‘weird things’ that could indicate that deaths could be being missed – nitazenes had been detected in post-mortem urine but not in post-mortem blood; drugs had been detected in post-mortem blood in quantities not usually associated with fatality. The service was working as fast as possible to find answers to questions that were a vital part of the picture.VITAL CLUES
The detective work on nitazenes is a vital tool in harm reduction, as DDN reports.
