New synthetic opioids are complicating the public health response to overdoses

synthetic opioid up to 40 times more powerful than fentanyl is scrambling the public health response to the addiction crisis in a growing number of American cities.

The Big Picture: Nitazine comes in powder, pill, and liquid form and requires time-consuming lab work to trace. It is often placed in substances that users believe are fentanyl or heroin, and are potentially fatal or can cause More severe onset of withdrawal symptoms.

• Its arrival comes as law enforcement and public health grapple with increased use of “trance” – a combination of animal painkillers and fentanyl that has caught the attention of the White House and has been found in at least 36 states plus Washington, DC.
• But most hospitals and medical examiners do not regularly test for either substance, and hospital data does not distinguish between nitazine and cases of fentanyl poisoning.
• A CDC review of overdose deaths in Tennessee concluded that an overdose associated with nitrazine may require up to four doses of naloxone, the opioid reversal drug that usually comes twice in a package.

Play status: In December, Philadelphia health officials issued a public alert after an opioid was detected in four street drug samples. Nitazine was also found in counterfeit oxycodone tablets in Australia and Scotland last month.

• The Drug Enforcement Administration declared a state of emergency for drugs mixed with heroin or fentanyl in the Washington, D.C., area last June.
• And by November, the DEA said the continued development of synthetic opioids such as nitazine is a “public health concern.”

In numbers: Tennessee saw its nitazine-related overdoses go from 10 to 42 between 2020 and 2021, according to the CDC report, which noted that the numbers are likely an undercount.

• A warning from Ohio’s attorney general last April called netazines “Frankenstein’s opiates” and reported a nearly sevenfold increase in netazine cases — from 27 to 143 — between the first quarters of 2021 and 2022.

Yes, but: Available data suggests this class of chemicals “is still very uncommon,” said Eric Dawson, vice president of clinical affairs at Millennium Health, a testing lab that monitors prescriptions and use of illegal drugs.

• Philadelphia hasn’t seen widespread use of nitazine isotopes yet, said Constance DiAngelo, chief medical examiner for the city’s health department.

Between the lines: Philadelphia plans to expand the capacity of the medical examiner’s office to identify synthetic opioids, but DiAngelo told Axios that the availability of the specialized personnel and tools needed to detect the substance remains limited.

• The fact that health departments do not receive toxicology data from hospital ERs due to privacy restrictions also limits the scope of known information.
• They can look for nitazine signals using syndromic monitoring, a system in which medical facilities share de-identified data, such as self-reported patient complaints, with health departments.
• But people are less likely to mention a drug they were unknowingly consuming to their doctor.

bottom line: New and more dangerous drugs could enter the US supply at a rapid pace, said Stephen Pasek, head of clinical data programs at Millennium Health.

• And given their strength, “they will kill a group of users before they can be tracked down.”
• HHS awarded more than $1.6 billion to states and tribal communities in September to target the opioid crisis through education, prevention, and treatment.

What we watch: While nitazine is a relatively new problem, it could add urgency to congressional debates about how to respond to the opioid crisis and fund public health efforts.