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A synthetic opioid linked to a rise in overdose deaths overseas has emerged on the illicit drug scene, with some experts warning it has the potential to be Australia's version of the fentanyl crisis gripping North America.
Nitazenes are a group of substances that were first developed in the 1950s but were never used clinically because of how potent and addictive they are.
The drug is stronger than fentanyl and hundreds of times more potent than heroin.
"These are lab-grown substances that mimic the effects of other opioid drugs such as heroin … but they are far, far stronger than heroin and last far longer," Uniting Medically Supervised Injecting Centre's medical director Marianne Jauncey said.
"That means the potential to be deadly is extreme."
NSW Health issued a warning about the dangers of nitazenes last month after four people were hospitalised across Sydney with severe opioid overdoses.
In April, a cluster of around 20 overdoses was reported in Nepean Blue Mountains Local Health District, where nitazenes were found in people who thought they were using heroin.
Drug alerts have been issued in almost every Australian state and the ACT since 2021 following overdoses linked to nitazenes, including drug-induced deaths.
"We know there is at least 16 or 18 deaths in Victoria that have been referred to in coronial reports, but that's actually the only formal information we have available at the moment around Australia around deaths," Dr Jauncey said.
"I'm willing to bet that there have been other deaths but we don't have those numbers yet."
Why are we seeing nitazenes now?
A significant reduction in opium production in Afghanistan may result in synthetic opioids such as nitazenes filling the gap, but they are also cheaper and easier to produce than plant-based opioids.
The chief executive of not-for-profit organisation The Loop Australia, Cameron Francis, said the prohibition model did tend to lead sellers to create more potent drugs.
"As drugs are made illegal, both in Australia and globally, that incentivises the manufacturing industry to find a new product that skirts around the laws," he said.
"It creates a drive to innovate and that means more potent forms of drugs."
Nitazenes were first detected in Europe and North America in 2019, and have been linked to an increase in the number of overdose deaths.
The National Crime Agency estimates that at least two people are dying every week from nitazenes in the United Kingdom alone.
"The UK and Europe don't have a fentanyl crisis but they now have a nitazene crisis," Dr Jauncey said.
"In Dublin CBD where they would normally have two ambulances called to an overdose every day, they had 34 ambulances called in a 24-hour period and 57 cases across one weekend."
Who's at risk?
Anyone who is taking illicit or unregulated drugs could be at risk.
Nitazenes have been found in a variety of illegal drugs and in some cases, people have unknowingly consumed them.
"Nitazenes have been detected in opioids such as heroin and oxycodone but worryingly they have also been detected in non-opioid substances such as cocaine, MDMA, and ketamine," said Brendan Clifford, from the National Centre for Clinical Research in Emerging Drugs.
"People who aren't using opioids regularly might not have access or fluency in those harm reduction interventions."
Nitazenes have also turned up in counterfeit pharmaceutical products such as benzodiazepines.
"What was concerning about that is, within that one bottle of tablets, some had the nitazene and others didn't and there were varying doses in the one bottle," Mr Francis said.
"The bottle looked real, so people could be fooled by that."
What can be done to prevent further overdoses?
Drug experts warn state and federal governments need to take preventative action now to stop future overdoses or deaths linked to nitazenes.
Unlike NSW, Queensland does not have a fully functioning early warning system, which means it is difficult to gauge how widespread the problem really is.
"So we could be seeing some nitazenes out there in the community in Queensland, [but] we're not actually putting all those pieces together in a surveillance kind of way to detect that," Mr Francis said.
"We suspect that if it's happening in NSW, something similar is occurring here, because the market is not that different."
The increased prevalence of nitazenes has prompted calls for better access to drug-checking services and wider use of naloxone, a medicine that rapidly reverses the effects of an opioid overdose or adverse reaction.
It works by blocking opioid drugs from attaching to opioid receptors in the brain.
"We need to get naloxone into the hands of every individual, every family, and every first responder so it's an essential part of everyone's first aid kit," said Emma Kill, head of Queensland Injectors Voice and Action Association.
"These days naloxone can be taken through a nasal spray so it's really easy to use."
The drug is free with no prescription under the Australian government-funded Take Home Naloxone (THN) program, but is only available from approved providers such as hospital pharmacists or alcohol and other drug treatment centres.
A spokesperson for the Department of Health and Aged Care said as of May 14, 2024, approximately 4,400 sites across Australia were registered to supply naloxone through the THN Program.
"The department is continuing to work with states and territories as well as the pharmacy sector to increase the number of access points for the THN Program," the statement said.
Department figures show more than 292,000 units of naloxone were supplied through the THN Program between July 1, 2022 and May 14, 2024.
And approximately 21,000 claims were made for a refill of naloxone between July 1, 2022 and May 14, 2024.
"We need to take our head out of the sand and embrace harm reduction, we need to put ideology aside, acknowledge the reality of drug use and embrace what works," Dr Jauncey said.
"Naxolone is one part of the solution, but there is a range of things we need to do better, including drug checking and supervised injecting facilities."
Experts say the greatest tool is education so people know the risks.
"What we understand from overdoses that have occurred is that, in some cases, people have needed to go to hospital and have an infusion where naxolone goes into their system over a period of hours," Dr Jauncey said.
"We need to be able to call emergency services and not be frightened about reaching out to first responders to make sure people stay safe in case the naxolone wears off."