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Will Isotonitazene Be Our New Overdose Crisis Drug?

By Currents Editor posted 11-12-2022 14:34



By Peter J. Papadakos MD, FCCM, FCCP, FAARC, FNIV

The DEA Washington Division is warning local residents of a dangerous new drug emerging in the DC area that is as deadly as fentanyl.  We as neurocritical care practitioners may therefore soon find ourselves caring for patients that have overdosed on this drug and may be suffering from severe hypoxic injury and coma.

In the fall of 2019, a new synthetic opioid named isotonitazene made its debut in the US and Canada.  The drug, which is not a derivative of fentanyl but is equally as potent, is legal to export from China and was not initially banned in North America or Europe despite not being an approved pharmaceutical product anywhere in the world.  However, the DEA has now issued an emergency temporary order placing isotonitazene as a Schedule 1 drug.

Isotonitazene is a derivative of benzimidazole, an opioid analgesic.  It is 500 times more potent than morphine and has slightly more potency than fentanyl with respect to causing relaxation, euphoria and respiratory depression.  Drug dealers in the UK and Europe are mixing this with batches of heroin, a phenomenon that has potentially contributed to a number of deaths.  In March of 2020, isotonitazene was found in counterfeit dilaudid tablets sold on the streets of Canada and the US.  There are also reports that this is being mixed with other street drugs such as cocaine.  Isotonitazene is a growing public health risk and a real danger to those who misuse drugs, especially users of heroin and cocaine.  Street names of this drug including nitazene or ISO may be volunteered by patients and other involved parties.  As law enforcement increases efforts to crackdown on illicit fentanyl, do not be surprised if isotonitazene becomes the next big killer.

Another major issue for us in the emergency room and neuro ICU may be that normal toxicology screens do not identify this drug.  Luckily, though, the drug is responsive to naloxone.  It may be important for us to collect blood samples from patients responsive to naloxone but who tested negative for narcotics in our facilities and send it for analysis to help government agencies track the distribution of this drug.  I also suggest that blood samples be sent for patients who present with hypoxic brain injury with unclear causes, especially individuals at risk.


Selected Readings: 

  1. Krotulski AJ, Papson DM, Kacinko SL and Logan BK. Isotonitazene Quantitation and Metabolite Discovery in Forensic Casework.  Journal of Analytic Toxicology, 2020; 44:521-530.
  2. Baerdemaeker KSC, Dines AM, Hudson S et al. Isotonitazene, a novel psychoactive substance opioid detected in two cases following a local surge in opioid overdoses.  QJM An International Journal of Medicine, 2022; 1-5 published on-line March 3, 2022.  hcac 039

Dr. Papadakos is the Director of Critical Care Medicine at the University of Rochester in New York.
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