Turning the tide on nitazenes and other dangerous drugs

Synthetic opioids have become one of the United States’ most urgent public health concerns. Last year, I warned that it is only a matter of time before the UK faces a crisis like that unfolding in America, contending that the government must recognise the evolving drug landscape and prepare for the threat posed by substances like fentanyl and nitazenes.

These drugs are highly potent and are being found more frequently in local drug supplies. Pharmacological lab testing has found that fentanyl, which can be up to 50 times stronger than heroin – itself notorious for its lethal strength – presents a significant risk. Nitazenes, which are even more powerful, can be up to 500 times stronger.

While some fentanyl originates from pharmaceutical sources, with prescription products also posing a risk of addiction and misuse, the majority of deaths in America are caused by those produced illegally. In the UK, nitazenes are so potent that they have never been approved or marketed as medicines.

Given their strength, the risk of overdose is extremely high, particularly when combined with other substances. Even minuscule quantities can be deadly. Policymakers must act to address this growing threat and work to turn the tide on nitazenes and other dangerous drugs before the situation escalates into a full-blown crisis.

Table 1: The relative potency of fentanyl and selected nitazenes in comparison to heroin

Source: The Lancet

Drug deaths in the UK continue to rise, including those related to nitazenes

The latest Office for National Statistics data on drug deaths highlights the severity of the situation, indicating further escalation. The number of deaths related to drug poisoning grew by 11% in the year to 2023, reaching 5,448 deaths. That reflects 84% rise since 2013, marking the highest level since records began in 1993. Driving this record high is cocaine, which accounted for 1,118 deaths, a 30% increase, while heroin deaths rose to 1,453, a 16% increase.

To make matters worse, the number of deaths involving more powerful opioids have also climbed. Although fentanyl-related poisonings decreased from 57 deaths in 2022 to 41 in 2023, fatalities involving nitazenes are surging. Over the same period, registered nitazene deaths increased from 38 to 52, up from just one death in 2021.

This upward trend is underscored by analysis from the Office for Health Improvement and Disparities (OHID), the government unit responsible for improving public health policy. Working with the National Crime Agency, OHID has been tracking deaths associated with synthetic opioids, reporting findings from local health and law enforcement networks, as well as coroner laboratories. This direct method reveals a more alarming picture.

As of September 2024, OHID confirmed through laboratory testing that there were 179 deaths involving one or more nitazenes in England between June 2023 and May 2024. With confirmed nitazene deaths in every region, this indicates a significant rise in the prevalence of these substances. As data is collected before deaths are formally registered, which is a delayed process, these figures are not included in the ONS data tables and precede official counts.[1]

Table 2: Deaths involving nitazenes by English region

Source: Office for Health Improvement and Disparities and National Crime Agency

There is a similar picture in Scotland, a country which continues to have the worst drug death rate in Europe. In 2023, there were 1,172 drug misuse deaths registered in total, an increase of 12% (121 deaths) compared to 2022. Although this figure represents the second lowest number in the past six years, drug misuse deaths have generally been on the rise over the last two decades. Opioids were implicated in 80% (937) of these deaths, making them the most commonly detected type of substance. Nitazene-related deaths also increased, from just one case in 2022 to 23 in 2023. No data is provided on fentanyl deaths.

The relatively low presence of fentanyl in the UK provides some cause for optimism. Despite warnings about the potential for a crisis similar to that in the United States, fentanyl has so far been kept largely at bay. This does not mean the threat has disappeared, however. The substance has already arrived on British soil, and the ground remains fertile for an escalating drugs crisis.

Meanwhile, deaths from nitazenes – substances stronger than fentanyl – appear to be on the rise. The logical explanation for this is their extreme potency, which makes them more likely to cause fatalities even in small doses. Their relative obscurity could also make them more dangerous. As a newer drug that is less well-known, users may mistakenly assume they carry fewer risks – that is, if they are even aware they are taking them, especially given they may be cut into other products.

The government has an opportunity to turn the tide on its approach to drugs

In light of these risks, policymakers must remain vigilant and avoid complacency in addressing this nascent problem. OHID says there is increased concern among government and it is working to mitigate the threat of these drugs, including working with the Synthetic Opioids Taskforce to establish a surveillance and early warning system.

However, experts believe that high levels of deep-rooted structural and social stigma are currently a barrier to drug policy innovation, with decisionmakers too hesitant to back initiatives that might be seen as condoning drug use. They believe the UK is behind the curve on the matter, effectively allowing drug deaths to continue. Parliamentarians must confront this rapidly evolving drugs market, taking proactive measures to prevent potent synthetic opioids from becoming widespread.

As I argued last year, one way of doing that is by shifting to a liberalised public health framework that prioritises the support and treatment of drug users. This should entail greater support and funding for evidence-based public health initiatives to keep users safe, such as introducing overdose prevention centres and increasing the supply of the Naloxone, a lifesaving antidote for opioid overdoses. There are other policy avenues worth exploring.

Devolve drugs powers for local health initiatives

Previous governments have largely resisted calls to promote a greater role for public health in drug policy. With the Labour Party now in office, there is a genuine opportunity to turn the tide in the fight against overdose deaths. It has a chance to intervene in the UK’s worsening situation and avoid the emergence of a full-blown opioid crisis.

Failure to act could result in a public health catastrophe with significant political repercussions. Writing in The New Yorker, Benjamin Wallace-Wells has suggested that the Democrats’ failure to address America’s opioid epidemic may have influenced the recent election results. When loved ones are dying and political leaders appear indifferent, public anger is likely to grow. The wider impacts could include increased pressures on the health system, rising economic costs, and visible signs of hardship on our streets.

Overdose deaths are highly localised, and it is in our most deprived areas that the consequences of drug use are felt most acutely. With the aim of unlocking potential across every part of the country, the Labour government has committed to devolving new powers to local areas in England. To genuinely tackle long-standing regional inequalities, improve wellbeing, and ultimately save lives, it is crucial that local leaders be granted the autonomy to implement tailored solutions, such as dedicated drug treatment in areas experiencing high levels of drug use.

Nowhere is this more evident than in Scotland, which has repeatedly called for drug laws to be devolved to Holyrood to enact the necessary measures to address its escalating crisis. If Labour were to support this, it would represent a significant departure from the previous Conservative government’s approach and reassure local regions that they are indeed serious about shifting power.

Develop a holistic drugs strategy that addresses the root causes of drug-related harm

In addition to taking public health action, the Labour government should show commitment to reducing drug harm by developing a holistic drugs strategy. While the old Johnson Conservative government published a 10-year drugs plan that incorporates some aspects of public health treatment and harm reduction, it primarily focused on controlling supply and enforcement, relying on punitive measures that are at odds with progressive, evidence-based approaches.

A holistic strategy would place greater emphasis on the full complexity of harm, bringing bring together prevention and education, harm reduction services, mental health, as well as tackling the root causes of drug use such as poverty and unemployment. A new holistic strategy addressing these issues would be more effective and more fair than the continuation of policies rooted primarily in policing.

Deploy sensible supply-side enforcement to restrict the inflow of potent drugs

There is also a role for enforcement in preventing the spread of dangerous drugs in the UK. While we do not advocate for harsher crackdowns on drug users – measures that criminalise users, discourage them from seeking support, and perpetuate harm – it is logical that reducing the availability of such substances would limit the potential for further deaths.

In the US, fentanyl deaths have recently started to decline – a remarkable development given the severity and persistence of the epidemic – and evidence suggests that changes in the drug’s availability, including law enforcement efforts to disrupt supply chains, may be behind this reversal. While theories about the decline remain inconclusive, they highlight the potential of supply reduction strategies in mitigating the risks posed by synthetic opioids.

The National Crime Agency believes that nitazenes are produced in illicit labs in China and trafficked into the UK through the Royal Mail and other courier services. While the global market for synthetic opioids remains complex, government should focus on reducing supply. Harm reduction should remain the priority and it is important to move beyond the failed ‘war on drugs’ rhetoric of the past, but it must also be recognised that availability is key to further escalation of the crisis.

It is unclear what such enforcement looks like in practice – it might include diplomatic efforts to push for bans on production in source countries, or greater border control to intercept incoming shipments – but Britain’s relationship with drugs suggests that demand is unlikely to diminish in the near future. Reducing supply should be part of any strategy to mitigate drug harm.

A new start in drug policy

The government has an opportunity to steer the country away from a looming drugs crisis. By prioritising public health, devolving powers to empower local health initiatives, and working to reduce the supply of highly potent substances, it can save lives. Failure to act risks exacerbating this potential public health emergency.

Addressing this challenge requires a fresh approach and bold action. The stakes have never been higher.

[1] Due to several factors, the data collected for this analysis does not comprehensively account for all deaths involving potent synthetic opioids, meaning these figures may be underestimates. For instance, forensic toxicology may not be commissioned if there is no suspicion of opioid involvement, and some cases may not be reported to local public health networks.

Additionally, coroner lab reporting to OHID is incomplete, having begun only in April 2024, while toxicology testing may not always detect potent synthetic opioids. OHID notes also that it is possible that not all cases in which potent synthetic opioids were detected were deaths caused by drug poisoning.