We can prepare for this drug class in the supply without reinventing the wheel.

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Marino is a medical toxicologist, addiction medicine specialist, and emergency physician.

Move over fentanyl! There’s a new boogeyman in town. At least that’s what you might be hearing from the news. And if you haven’t already heard the word “nitazenes” then you can expect to soon.

Nitazenes are a class of synthetic opioidsopens in a new tab or window, also known as the benzimidazole opioids, which have received more and more attentionopens in a new tab or window as they are being detected with increasing frequency in street drugs and overdoses. Media coverage has primarily focused on nitazenes being “more potent than fentanyl,” and a cause for concern in our ongoing overdose crisis.

Make no mistake, fentanyl continues to drive the overwhelming majority of overdose deathsopens in a new tab or window in the U.S. and the rest of North America, and so far, nitazenes have primarily been detected in drug samples with fentanyl. While detection seems to be increasing, it remains unclear what their true prevalence is in the drug supply because testing for nitazenes is limited and they are still not routinely tested for in overdose deaths. As detection capabilities are expanded, we can expect to see an increase in overdoses involving nitazenes, and we can prepare for this drug class in the supply without reinventing the wheel.

Nitazenes themselves are not entirely new. They were developed in the 1950sopens in a new tab or window as potential pain medications, but they were never approved or used medically. They are also not used in veterinary medicine. Because of this, there is limited human data on their effects, not to mention that many of the nitazenes now being detected are completely novel drugs.

However, the potency across the class is highly variableopens in a new tab or window: they can be significantly more potent than fentanyl and can have significantly longer-lasting effects. Meanwhile, other nitazenes are less potent than fentanyl. Isotonitazene — a member of the nitazene class — was first detected in drugs in the U.S.opens in a new tab or window and overdose victims in Canadaopens in a new tab or window and Europe in 2019opens in a new tab or window. Since then, 20 totalopens in a new tab or window nitazenes have been identified in street drugs with increasing frequency. They are Schedule I drugs in the U.S., meaning any possession or use is considered illegal.

In areas of North America where drug sample testing is more widely employed and available, the prevalence of nitazene-positive samples actually seems to be lowopens in a new tab or window, and they seem to have possibly decreased over time in much the same way that many fentanyl analogues (which had also previously showed up in the drug supply) were ultimately replaced once more with fentanyl. This is not necessarily reassuringopens in a new tab or window given limitations in testing, increases in fentanyl purity, and presence of other unpredictable substances like benzodiazepines and xylazineopens in a new tab or window.

In Europe, where fentanyl has not been widespread, there is more concern that nitazenes are on the riseopens in a new tab or window as they have recently been detected in multiple countries and multiple different drug products. While fentanyl doesn’t seem to be going away anytime soon in North America, Europe has the potential for nitazenes to become more widespread and cause more problems. This is because their appearance in the European drug market coincides with reduced supply of heroin, which had still been the primary street opioid there — this situation is similar to the conditionsopens in a new tab or window that led to the rise of fentanyl in North America. With action already taken against Europe’s heroin supplyopens in a new tab or window, the demand for opioids will most likely lead to replacement with synthetic alternative(s). Given the singular focus on supply-side interventions, any success at destroying the fentanyl supply should also be expected to carry similar risk for replacement with something new and something potentially worseopens in a new tab or window.

Preparing for and responding to nitazenes globally should not be as daunting as it may seem if we take heed of the lessons learned from other synthetic drugs like fentanyl — although our response to fentanyl is still lackingopens in a new tab or window in most of the basics, which is cause for concern in itself.

It is important to ensure that detection methods are available (like drug checking programs), and that people have access to nitazene test strips. Because nitazenes still respond to naloxone, this remains a crucial tool to prevent any potential overdoses from becoming potential deaths. Public awareness of these resources and education, especially since nitazenes have been detected in products sold as non-opioidsopens in a new tab or window, should be public health priorities. Overdose prevention centers can be expected to have the same potential for lifesaving benefit as they have had with fentanyl — but only if they are available. Finally, beyond just reacting and responding to a potentially toxic, rapidly changing drug supply, a more proactive and preventive measure would be a regulated, safe supply. However, this remains a hot-button, controversial topic despite evidence of benefit in the face of our worsening overdose crisis.

Politicians and policymakers have already doubled down on repeating past mistakes. We have seen them refer to these compounds in unhelpful terms like “Frankenstein opioidsopens in a new tab or window,” which does not help to inform the public, and others have sought to banopens in a new tab or window these already illegal drugs. But if there is any lesson from the nitazenes, it is an important reminder that an unregulated drug supply will continue to be inherently unpredictable and will always have the potential to be unsafe.

U.S. overdose death numbers for the past year once again broke records for the most deaths ever, and should be a reminder that our policies are not working. If we truly care about the nitazenes as a public health risk then we should treat drug use as a public health matter rather than reducing it to a moral and criminal justice issue as we have for decades.

Nitazenes may be a new threat but we already have answers, we just need to give them a chance to work.