A New Drug on the Scene: Isotonitazene

As if fentanyl and its derivatives weren’t killing enough people, we another opioid to worry about. It’s isotonitazene, sometimes called “Iso” or “Nitazene” for short. it’s related to etonitazene and has similar drug effect profile.

This drug, which is not approved for medical use anywhere in the world, is a synthetic opioid with high potency. It has been identified in drug seizure analyses by the DEA on a regular basis since 2019. In 2020, the DEA issued a temporary order to schedule isotonitazene and its isomers as Schedule I controlled substances, with all the civil and criminal sanctions carried by this designation.

This drug has a high potential for addiction and causes respiratory depression in a dose-related fashion. Some reports suggest this drug may be worse at causing respiratory depression than other opioids, making it more dangerous. Its effects can be reversed by naloxone, though some sources say it might take a higher dose.

Since this drug is sold illicitly, buyers get it through unregulated sources, so the purity varies widely and inconsistently, adding to the danger of this drug.

A recent article by the Washington Post goes into more detail about how the drug and its analogues have been found in the District of Columbia’s drug supply: https://www.washingtonpost.com/local/dc-politics/new-opioids-more-powerful-than-fentanyl-are-discovered-in-dc-amid-deadly-wave-of-overdoses/2021/11/29/680afb2c-4d43-11ec-94ad-bd85017d58dc_story.html

This article says that according to experts, isotonitazene analogues are more potent than fentanyl. Deaths from analogues, mostly protonitazene, have occurred in Tennessee, Texas, New Jersey, and Iowa, among other states. Overdose deaths have also been seen in Europe and British Columbia, Canada.

There have been some reports of overdosed patients presenting to the Emergency Department with respiratory arrest, which is a common mechanism of death with opioids, but also with no heartbeat. With other opioids, respiratory depression or arrest is often accompanied by slow heart rhythm (https://www.forensicmag.com/581896-NPS-Alerts-New-Synthetic-Opioid-and-Unusual-Overdose-Symptoms/ )

This all sounds pretty bad. Several doctors in my state have seen patients who mentioned this drug among the types of opioids they are using, so I plan to start asking patients about it.  I don’t know of any drug test available commercially to detect this drug, further complicating treatment.

Out of curiosity, I Googled the drug and how to buy it, leading to a depressing array of purchase options. One website based in China offers this drug for $450 for 10 grams, or $9000 for a kilogram. Of course, they offer a selection of other controlled substances to consumers. Who knows what would be shipped if anyone bought off this website – if anything at all. And it would be illegal, and subject to schedule 1 drug penalties if discovered, lest any of my readers feel tempted to purchase off the internet.

Some news articles say the drug dealers buy isotonitazene in bulk to add to whatever illicit opioid they are selling, to make it go farther. This practice led to series of deaths in some states.

In the Sept-Oct 2021 issue of the Journal of Addiction Medicine, Shover et al published an article titled, “Emerging Characteristics of Isotonitazene-involved Overdose Deaths: A Case Control Study,” in which they compared characteristics of 40 isotonitazene deaths with overdose deaths from other opioids. They found deaths from isotonitazene more often involved other drugs and were also more often found in combination with a designer benzodiazepine called flualprazolam.

 I suspect some dealer somewhere added this second drug to a bulk supply of isotonitazene, which was then sold on the street. This emphasizes the problem of knowing what a drug bought illicitly actually contains. Potent opioids, when taken with sedatives like benzos, are known to cause overdose deaths in the unsuspecting buyer.

So what do we do about Iso? I plan to ask new patients about their use of it, or if they’ve even heard of it. We need a cheap commercially available test for the drug to get better information about the extent of the problem. And we need to educate and warn patients and providers about the drug’s presence.

And keep giving out lots of naloxone kits.