- Niamh Eastwood, executive director,
- Shayla S Schlossenberg, drugs service coordinator
Drug related deaths in the UK are at crisis levels. This is largely driven by opioid related fatalities—on average 12 people a day die from opioid overdoses.123 Until now, these deaths have been occurring within a relatively stable drugs market, but that market may now be shifting with the appearance of extremely powerful synthetic opioids in the UK. These opioids are more likely to cause fatal overdoses—especially when used by people unaware of the risks they pose or who are unprepared to come across them in their drug supply.
The heroin supply in the UK and Europe largely comes from Afghanistan.4 In 2022, the Taliban declared a ban on opium production. While it is unclear whether there was a heroin shortage in the UK already or if the ban has caused a price hike, the UK supply of the drug seems to have been affected. In the past few months there have been reports from across the country of both increased non-fatal overdoses and increased fatalities.5 There are concerns that people are turning to synthetic opioids, as many of these incidents have been linked to a family of drugs known as nitazenes.
Nitazenes are a novel group of synthetic opioids that are several hundred times stronger than morphine.6 Isotonitazene is one and has been implicated in 24 deaths that happened in quick succession in 2021.7 In June and July 2023 there were over 30 deaths associated with nitazenes in Birmingham alone.8 Many people in the drugs sector are concerned that reports from across the UK of increased overdoses and fatalities are due to nitazenes entering the heroin supply chain.9 Wedinos, drug checking service for Public Health Wales, has also reported nitazenes being found in benzodiazepines including Xanax (alprazolam) and oxycodone.10
We only need to look to the United States and Canada to see what a toxic drug supply can do. The introduction of synthetic opioids there, specifically fentanyl, has been responsible for tens of thousands of deaths annually.11 We don’t know yet if nitazenes or other synthetic opioids will become the dominant opioids in the UK drug market, but if they do it could be catastrophic.
Governments and the drugs sector must act now to protect lives. We must scale up our harm reduction responses. We must also have functioning surveillance and warning systems in place in healthcare and in border agencies, such as the police, so that we can quickly identify nitazenes when they appear and make sure that information is widely available to professionals and to people who use drugs.
However, knowing about the scale of the problem isn’t enough. Harm reduction initiatives and practice must be at the core of our response, helping people to make safer decisions and use drugs more safely. Drug treatment needs to be as accessible as possible. Too often patients are refused substitute medications such as methadone because they “don’t show motivation” or because services “can’t prescribe if you aren’t using heroin.” This must stop. We need same-day prescribing of substitute medications—people should not have to wait weeks for a lifesaving medication. We need to support access to a range of substitute medications including diamorphine and expand substitute prescribing to other drugs such as benzodiazepines.
We need harm reduction facilities such as drug consumption rooms where people can bring and use their own drugs under supervision and where overdoses can be reversed. A drug consumption facility will be opening soon in Glasgow, and this is to be celebrated, but we need more facilities like this to be opened across the country.12 Drug checking services and kits must be funded and scaled up so that consumers can know what is in the drug supply. Naloxone needs to be easily accessible, not just through drug services, but in different settings that engage people at risk, including educational institutions. Given the reports of nitazenes in Xanax and codeine, this is urgent. Drug treatment services are currently the primary providers of naloxone. Online sources for naloxone and needle and syringe programmes (NSPs) should be promoted as synthetic opioid use may affect a new demographic who are not known to drug treatment services.
Peer outreach by people with lived experience is vital, not just for naloxone distribution, but also to provide harm reduction advice and distribute equipment. This needs to be supported by sustainable funding. The perspectives of peers—those receiving treatment or with experience of using drugs—must be central in the design and delivery of treatment. Only with their input will we see people wanting to access services.
A standardised monitoring system is needed with relevant data. It must be accessible to the national authorities and to people who use drugs or work in drug services at a local level. This system could promote better awareness of what is currently circulating in the drug supply, or if more naloxone is currently being used due to adulterants including synthetic opioids in the supply or unusual strength of opioids.
If we are to tackle a toxic drug supply, we need a safe supply and increased prescribing of substitute medications. People deserve to be treated with dignity, respect, and without stigma, but this can only be achieved by ending the criminalisation of people who use drugs.
Most people who die of opioid related deaths in the UK have not been in contact with treatment services for at least five years.13 When people who use drugs are treated as criminals rather than as people who are entitled to health care, then they are less likely to engage in treatment, as it can be perceived as risky and shameful. We cannot afford to maintain this status quo if we wish to tackle the current and looming crisis.
Footnotes
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Competing interests: Both authors are employees of Release, the UK’s centre of expertise on drugs and drug laws and a registered charity. Release provides legal and advocacy services to people who use drugs and those affected by the drug laws, the organisation also advocates for evidence-based policies based on principles of human rights and public health. NE is also a member of the expert reference group to the London Drugs Commission.
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Provenance and peer review: Commissioned, not externally peer reviewed.