Nitazenes move the needle for drug death distress

So, what exactly do we know about these new nitazenes? Rick Lines can help us here, he is the head of substance misuse at Public Health Wales and WEDINOS - which is the biggest public drug testing service in the UK…

Rick - Nitazenes are a group of substances. They're a class of high potency synthetic opioids. They were originally developed by the pharmaceutical industry in the 1950s as analgesics, pain killers, but the clinical development of nitazenes was abandoned because of concerns of adverse effects and harm related to them. So they are an illicit form of substance, and again, a high potency substitute for traditional opiates.

James - Why are synthetic opioids so dangerous to those who use them?

Rick - Well, quite simply because they are much more potent than the traditional opiates that they are used to substitute for. People might be purchasing a substance thinking it is heroin, for example, and in reality be purchasing something that has a much more potent form of synthetic opiate mixed in. So people's breathing, for example, gets incredibly, incredibly shallow. So it's usually linked, although not always, but usually linked to some form of respiratory system suppression.

James - Nitazenes refers to a number of different drugs. They're illegal, as you mentioned. Given these facts, how do you investigate or how does one go about investigating the prevalence of them in the UK drug supply?

Rick - It's very difficult. Probably the most effective way of doing it is obviously to have access to drug checking or drug testing, and we're fortunate that we have the WEDINOS programme here in Wales that is able to do some of that and there are other smaller projects in England, and they're looking to start one up in Scotland. But it's very, very difficult. We're talking about very tiny doses and we accept samples from a range of both partner agencies out in the community, from drug services, from nighttime economy venues, from prison services, from accident and emergency, from homeless hostels and shelters, etc., and we also accept anonymous submissions from the public. They can send in a sample of what they've purchased. WEDINOS works from the perspective that the only way to be a hundred percent sure of your own safety is not to take a substance, but if you are going to take a substance, it obviously increases your safety, decreases your risk of harm, to know what you're taking.

James - And as per your work, what's the scale of the nitazene problem here in the UK?

Rick - WEDINOS as a service does not test overall prevalence. It's a voluntary service, so we're only able to test what is submitted to us. In terms of nitazenes, we received our first sample of a nitazene in April of 2021, so about three years ago. Initially, for the first period of time, we mainly saw nitazenes in samples that were submitted as oxycodone. Leading up to the Christmas period, we were detecting nitazenes in quite a lot of samples that were being sent to us as benzodiazepines, counterfeit pharmaceutical products essentially that were probably being purchased from illicit online pharmacies. This was a concern because you wouldn't necessarily expect to see a synthetic opiate in a benzodiazepine product. There are different substances with different effects and it raised concerns of nitazenes encroaching outside of the opiate market into other substances. Although, keep in mind that of the substances that we have submitted to us, nitazenes are quite a small percentage, probably about 2 or 3%. But clearly we have seen an increase in the number of submissions that contain nitazenes. Now, whether that's because they're increasingly prevalent in the market or whether there is an increased awareness about nitazenes and an increased concern about nitazenes which is causing more people to send in substances, we don't know.

But first, we’re going to explore some of the proposals that could potentially make things safer for drug users. The UK’s first drug consumption room is set to open in Glasgow this summer in a bid to drive down drug deaths in Scotland. There have also been calls to allow drugs to be checked at places like nightclubs and music festivals, and health professionals would like a medication called naloxone to be more readily available in a bid to block the powerful effects of opioids.

These interventions all come under the umbrella of harm reduction strategies. The guiding principle is that, for better or worse, people are going to use drugs for a variety of reasons, so giving people the ability to make the process safer will reduce harm. Opponents of these strategies question whether this encourages illicit drug use.

Guy Jones is a senior scientist at the Loop - which supports free drug testing services. I caught up with him here in Cambridge and began by asking him about the work that he's doing to make drugs safer for those who choose to use them…

Guy - So the idea behind a drug checking service is twofold. One is, of course, to identify the drug and give information about the concentration, about the strength of that drug to help somebody to manage the amount that they consume and to mitigate the risk from that. In many cases, what we actually find is that when we tell people this is not the drug that you expect, this is a different drug with very different risks, they will simply decide that they don't want to have anything to do with this. So we offer a secure disposal service along with the drug checking service. The other aspect of a drug checking service that's extremely important is the fact that, as well as giving this information, the person using the service is able to come into contact with a drugs professional who will be an expert and has a really significant amount of knowledge about these substances, and is able to talk to the person in a non-judgmental way and simply give them information, even if they've got the right drug, about the risks that the person may not have recognised, because the level of drug education that people receive about these is often quite limited. And so by being able to give really detailed information about, okay, well, did you know that there's an interaction with this medication that you said that you take? Did you know that there's an interaction with this other drug that you're planning to consume? We can help further reduce the risk above and beyond what you can do by simply telling people, this is the name of the drug and this is the concentration that it's present at.

James - And practically, in terms of how drugs testing is carried out, do you need to take these samples to a laboratory? Can this be done quite cheaply?

Guy - So a person comes to us with their substance of concern, and they place that into a secure deposit box, and they write a little bit of information about that substance of concern onto a form. We then take it through to our laboratory, which is onsite, the same site - we've got one operating in Bristol at the moment - we run it through a number of different lab tests to identify what it is, the concentration, whether or not, especially importantly, is there anything that's unexpected that is present. That process takes between 20 and 60 minutes, depending on what the substance is. Service users then comes back, we ask them to come back after an hour, so the turnaround is really, really quick. This is quite important for a drug checking service because, if you are saying, look, we can't give you any information about this for 21 days, then the opportunity to reduce the harm associated with that may be long gone because it may have been consumed.

James - It's taken us an awfully long time to talk about, in our overall programme we're making here, the role of naloxone in abating a lot of the drug deaths from synthetic opioids. What is it and how does it work?

Guy - So Naloxone is an incredibly valuable drug and an incredibly simple drug in the way that it works. Effectively, when naloxone is injected into somebody or given as a nasal spray to somebody who is experiencing an opioid overdose, the naloxone molecules go into the brain and they kick off the opioid molecules and occupy the space where those opioid molecules want to be. This means that the effects of the opioid come to a halt and any respiratory depression that the person is experiencing, which is very often the fatal component of an opioid overdose, is ended. It's an incredibly safe drug, so you can't overdose on the opioid reversal medication, so this is a really, really valuable tool. If a volunteer sees somebody who has gone over into an overdose, they can administer naloxone, and that will reverse the effects of that overdose and cause them to start breathing again.

James - The effectiveness of naloxone makes it one of the critical components of another harm reduction strategy, alongside drugs testing, which are these safe consumption sites, things that have proven quite successful in America. Can you explain what they are, please?

Guy - The idea behind this is that it's a clinic space, which is staffed with healthcare professionals, where especially people who don't have a safe space to consume their drugs can go and consume those drugs under the supervision of a medical professional. The idea behind it is that if they run into a situation where they overdose, then they can receive immediate medical attention to address that. It also gives the advantage that it puts these people who in many cases are extremely vulnerable into regular contact with a healthcare professional. So on the day that they wake up and they're feeling good about themselves, they're feeling strong and they think, you know what? I actually am ready to make some changes on that day, they are also in contact with a healthcare professional.

James - You are mainly involved with drugs testing as we've discussed. Do you get any public money for this?

Guy - So The Loop doesn't receive any funding from the government. We're an organisation that is almost exclusively staffed by volunteers, so that helps to keep the costs down.

James - Given the popularity of these harm reduction strategies amongst many healthcare professionals, it seems like a bit of a missed opportunity to not be funding them. I'm sure I know what you're going to say as an answer to that, but I'll put it to you anyway.

Guy - It's challenging, right? I understand, totally, as a government, as politicians, you need to keep the public on side. If a person is not okay with the medical evidence and the scientific evidence behind how effective these interventions are, then they may react more emotionally and feel that it's not appropriate to help somebody who's experiencing drug addiction. Many people think that, well, they just need a tough love approach, and therefore it's better to let them suffer and hope that they reach rock bottom and then they'll just turn it around themselves. But practically speaking, while that does work for some people, it certainly doesn't work for a lot of people. The medical evidence suggests that it leads to a vastly increased cost in terms of the amount of healthcare that people need and it increases the number of deaths that are experienced by people who are brothers, sisters, children, parents of other people. These are people's loved ones. If the cost of a strategy is, well, we have to let a lot of people die to teach the other people a lesson, then that's not necessarily going to be an effective strategy.