Isotonitazene: The Deadly Synthetic Opioid You Don't Know About

By The Fix staff 12/03/21

Initially available only on the dark web, Isotonitazene has recently gone from designer drug to a new and dangerous presence in the American drug trade.

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Hands with pill jar and tablets
Pills are the primary form in which users obtain Isotonitazene.

While many of the headlines concerning opioid addiction and overdose deaths during the COVID-19 pandemic have focused on the synthetic opioid fentanyl, another laboratory-made opioid, Isotonitazene, is slowly gaining ground in the illicit drug market. Data regarding the drug is limited to law enforcement, drug users, and black-market dealers, which has caused extreme concern among federal law enforcement. Meanwhile, overdose deaths related to Isotonitazene have been slowly climbing since mid-2020.

What Is Isotonitazene?

Isotonitazene, or ISO, is a synthetic opioid derived from etonitazene, a potent analgesic, discovered by Swiss researchers in 1957. Etonitazene was found to be both extremely powerful and highly addictive when used in studies involving both animals and human. For this reason, it has never been made commercially available for human use. Isotonitazene is a chemical analogue for etonitazene, meaning that the chemical makeup of both drugs is very similar. However, it is considered more potent that its analogue, with research suggesting that it may be 100 times more potent than morphine.

Initially available solely through dark web sources, Isotonitazene has recently gone from designer drug to a new and dangerous presence in the American drug trade. In 2020, the Drug Enforcement Administration reported that the deadly opioid began turning up in drug seizures in the spring of 2019. Since then, samples have been found in toxicology reports for hundreds of overdose victims.

Though pills are the primary form in which users obtain Isotonitazene, it can also be found in powder form. This off-white or yellow powder is cut into other drugs by black market sources to increase potency or to create a replica of existing drugs. For example, in Canada, it has been discovered in pills manufactured to resemble Dilaudid (hydromorphone).

Is ISO the New Fentanyl?

While Isotonitazene is not fueling an overdose epidemic to the same degree as fentanyl, it could certainly present a similar threat if its use continues to spread through the illicit market. For the time being, it's still new to the American illegal drug market and relatively unknown to most law enforcement agencies and traffickers. While that may impede its growth in the short term, the greater concern is that dealers may use the opioid when manufacturing other drugs, resulting in a dramatic increase in opioid deaths. Law enforcement first became aware of Isotonitazene's presence in the U.S. through overdose fatalities, with substance abusers in Illinois and Indiana dying after using cocaine that had been laced with ISO.

It's also difficult to know if ISO is on par with fentanyl because most toxicology reports don't test for its presence in overdose cases. It's possible that some overdose deaths linked to heroin or fentanyl may have actually resulted from ISO’s presence within those drugs. Toxicology lab reporting varies on a county-by-county basis, so a coordinated effort to track the spread of the drug must be prioritized by law and health officials in the immediate future.

What we do know at this point is that deaths from ISO appear to be on the rise. Statistics revealed that six people died from overdose every month during the summer of 2019. Flash-forward a year, and the number is 50 to 60 deaths per month in the summer of 2020 – a ten-fold increase over the course of a single year. Sadly, those numbers may actually be higher, as we still don't have an accurate picture of ISO overdoses due to limited test screenings.

ISO and COVID-19

Statistics regarding opioid use and overdoses during the COVID-19 pandemic have already painted a grim picture of the toll taken by the drugs. Isolation, anxiety, job loss, and financial insecurity that came with lockdown protocols only served to magnify the disastrous opioid epidemic. The mental health burdens imposed by COVID-19 have sent many former drug users back to opioids as a short-term coping strategy to reduce the strain of emotional pain and external stress. ISO only further complicates matters by adding an unknown and dangerous variable to an already untenable situation. Some users may find that their drugs of choice from the past are either too strong for them, or, as in the case with ISO, cut with a powerful opioid that could prove fatal upon ingestion.

Further adding to the concern regarding opioid use during COVID is the impact that these drugs have on lung health. Opiates depress the central nervous system, which causes slowed breathing. A person who contracts COVID and uses opioids may be more likely to develop serious complications, which could escalate to fatal levels with the introduction of ISO into their weakened system. There is no current data confirming that this is the case in regard to ISO overdose deaths, which further underscores the need for increased research.

How to Prevent Isotonitazne Overdose/Treatment

Combating the rise of ISO amidst the opioid epidemic requires increased strategies for both prevention and treatment. Adding ISO to the Drug Enforcement Agency's list of controlled substances in 2021 was an important first step. The drug is currently listed as a Schedule 1 substance alongside heroin, LSD, peyote, and marijuana, which allows for tighter regulation and stricter legal penalties for traffickers and dealers. The next logical step would be to add ISO to toxicology tests to better understand the extent of the problem in the U.S.

Continued expansion of access to the overdose reversal drug Narcan is also an effective response to rising ISO use. Increased use of the opioid antagonist to combat opioid-related overdoses has been a continued part of the public health response and it should be part of the strategy to fight ISO, as well. This is particularly important considering reports from law enforcement that several doses of Narcan may be necessary in ISO overdoses.

Finally, a more comprehensive approach to treatment is needed in response to the opioid epidemic. A medically assisted detoxification program, such as Waismann Method® Opioid Treatment Specialists, allows individuals to detox in a private room of an accredited hospital while under the supervision of a specialized medical team. Medical opioid detoxification is safer, has a greater success rate, and avoids the pain of "cold turkey" approaches to detox at non-medical facilities.

Inpatient medically-assisted detox followed by a supportive recovery care environment can greatly help individuals regain the strength, both physical and emotional, to break free of opioid addiction. By treating the underlying mental health problems – depression, anxiety, and trauma – that drive addictive behavior, individuals can get the relief that they need. Without access to effective medically assisted treatment programs, those suffering from substance misuse remain vulnerable to overdose from ISO and other synthetic opioids.

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