Guidance

Guidance for local areas on planning to deal with potent synthetic opioids

Updated 1 August 2024

Applies to England

Introduction

This guidance explains how local commissioners and service providers can prepare for and respond to incidents involving potent synthetic opioids like nitazenes or fentanyl.

Illicit fentanyls and isotonitazene (strong opioids, more potent than heroin, and most likely mixed into heroin) caused spikes in drug-related deaths in England in 2017, 2021 and 2023. There is more information on synthetic opioids in annexe A.

There are signs that synthetic opioids are being seen more often in local drug markets and there are concerns that they may become much more prevalent.

Local councils and their partners should prepare for potent opioids appearing in their area, particularly in light of recent international experience. Fentanyls are still causing significant issues in the US and Canada.

Potent synthetic opioids could be sought by people who use drugs, or might be unwittingly added to street heroin. These synthetic opioids are also sometimes seen in fake opioid tablets (like oxycodone blue or yellow tablets) and even occasionally in non-opioid drugs, like cocaine, benzodiazepines and synthetic cannabinoids (SCRAs).

Local areas should:

• plan for how they will rapidly understand and assess the risk of any future threat, develop plans in partnership, and respond to the threat
• do everything they can now to review their arrangements and minimise the potential future impact of potent opioids (for example, through naloxone provision, treatment access and an effective local drug information system)

Many of the principles and activities here could be applied to incidences of other unusually potent drugs. They will also be relevant to prisons and other secure settings.

Plan and prepare for a future threat

Local areas should work through existing mechanisms for emergency preparation, response and recovery to develop a plan that can be enacted quickly in the event of an incident. This may benefit from working with or through the local resilience forum and local health resilience partnership.

The plan should enable local partners to rapidly:

• understand the scale of the threat and assess the risk
• communicate the threat
• take actions to mitigate the threat

We explain more about how local areas should do these below.

Understand the scale of the threat and assess the risk

Local areas will want to rapidly understand:

• where the problem is: particular neighbourhoods, is it widespread or in neighbouring councils
• who is affected: which users and how many
• the severity of the problem: deaths or non-fatal overdoses or other reported harm
• the timing: is the threat imminent or occurring now

Relevant information might come from:

• the local drug information system (LDIS) professional information network (PIN)
• from organisations such as the police, drug services and emergency departments, if there is no local PIN
• drug testing of service users or of drug samples seized or handed in, or of post-mortem biological samples

There are limitations to testing if the drug to be detected is not known or is in such low concentrations that it is difficult to detect. These limitations could be overcome by sophisticated and expensive testing methods, but you might not have access to these or the resources to pay for them. If you have submitted samples for this type of more reliable testing, it is vital that you follow up on the results and inform your Office for Health Improvement and Disparities (OHID) regional team about them.

Information gathered will need to be assessed, ideally first using the LDIS’s agreed scoring. This is primarily about the need to send warnings or alerts. Further risk assessment will likely be needed and could use existing local templates.

Communicate the threat

Who to communicate with

Local areas will need to communicate about the threat with:

• specialist drug treatment services
• harm reduction and outreach services
• ambulance trusts
• emergency departments
• people who use drugs

What the communications should cover

The communications should cover the following things.

What you know about the problem

What you know about the problem will be what you discover locally, as described above, or as provided by national bodies such as OHID.

Safer drug use messages

See annexe B for safer drug use messages developed for and with people who use drugs (and particularly those who inject opioids) in a time of heightened risk.

Where to go for help locally

Drug treatment is protective and people who use drugs should be encouraged to go to their local drug service for longer-term help. They should also be advised to get help quickly if they or a friend appears to be overdosing or suffering some other ill effects after taking a drug, usually by calling an ambulance or attending an emergency department.

You should target messages at the audiences most likely to be at risk and the places you are most likely to reach them. In most cases, it will be people who use drugs and are not in treatment who are at most risk, and you will need to make greater efforts to reach them.

Take actions to mitigate the threat

Assessing risk and impact will determine what measures you need to address the problem.

There should be a clear incident response plan developed locally that includes business continuity and a risk assessment. Incident response planning is likely to include reviewing existing provision and processes that could mitigate the threat, and inform the consideration of what more can be done in each area.

Actions that can mitigate the threat will include:

• making take-home naloxone available
• enhancing drug treatment access and retention
• setting up or improving the effectiveness of your LDIS
• checking the effectiveness of local drug death and non-fatal overdose review (and response) processes

We explain more about how to do these things below.

Make take-home naloxone available

Naloxone is the emergency antidote for overdoses caused by heroin and other opiates and opioids (such as methadone, morphine and fentanyl). Standard naloxone dosing should sufficiently reverse the effects of an opioid overdose – even of a potent opioid – until an ambulance arrives. Standard naloxone dosing is 400 microgram doses of injectable naloxone, or single squirts of nasal naloxone, repeated until breathing is restored.

All local councils commission drug treatment services to provide take-home naloxone. But more take-home naloxone should be made more readily available, from a wider range of outlets, to people who might need it and are not in contact with treatment. This will be especially important if potent opioids return to any area.

Outlets and routes to boost naloxone supply to people who need it most might include:

• community pharmacies
• outreach workers
• hostels and other services for homeless people
• peer-to-peer distribution

Enhance drug treatment access and retention

Make further efforts to ensure quick, attractive and easy access to treatment, especially for people who are reluctant to engage. For example, services can improve engagement and retention in treatment through:

• flexible and responsive services
• optimised pharmacological and psychosocial interventions
• contingency management (modest incentives to reinforce changes in behaviour)

Consider the range of medications that is provided locally.

Consider enhanced targeted outreach to engage particular populations, like people who have never engaged in treatment or those who have tried it before but dropped out.

Existing access and treatment statistics will be available from service providers and through the National Drug Treatment Monitoring System.

Set up or improve the effectiveness of your LDIS

The elements of an effective local drug information system are described in guidance on issuing public health alerts about drugs. You should use this guidance to set up or improve the effectiveness of your LDIS.

Check the effectiveness of local processes

There is guidance available to help you check the effectiveness of local drug death and non-fatal review (and response) processes.

Drug death review (and response) processes are described in Drug-related deaths: setting up a local review process. They include relationships with police and coroners that allow for rapid learning from post-mortem findings.

Other relevant activity to reduce drug-related deaths is described in a national inquiry report on understanding and preventing drug-related deaths and service providers’ advice on improving clinical responses.

Drug testing to reduce harm

There has been some interest in using point-of-care test strips for synthetic opioids (and for xylazine) for harm reduction purposes.

Opioid strips were previously available for fentanyls and are now available for nitazenes. Drug services are supplying these strips to people who use drugs as a way for them to check a drug sample for particular risks, before they decide whether and how to use it.

Test strips may indicate the presence of a specified drug and help someone decide not to use it, or to start with a very low dose. Test strip results can trigger useful conversations with others and encourage people to think about risks and how to mitigate them.

However, information from some of the manufacturers and suppliers makes clear the limitations of test strips. For example, it makes clear that they:

• will not detect drug concentrations below specified limits or may fail to detect a drug that is present (sometimes called a false negative)
• may not detect all variations of a drug type
• may not be used correctly
• may fail because the drug does not dissolve properly, or other substances interfere with the test
• do not indicate the presence of potentially harmful drugs other than those being tested for
• do not indicate the quantity of a detected drug

Their results can also be difficult to read, especially in low light.

So, test strips cannot indicate whether the sample tested would or would not cause harm or possible overdose.

Although test strips may have some limited role in harm reduction, it’s more important to encourage people who use drugs to:

• not use drugs alone
• have naloxone available in case of opioid overdose
• make sure that not everybody in their group is taking drugs at the same time, because someone needs to be able to call for help and administer naloxone if needed

Drug testing and screening for surveillance

Drug testing people who use drug treatment services is commonly used for therapeutic purposes (see section 2.4 of Drug misuse and dependence: UK guidelines on clinical management).

There has been some interest in screening samples of drugs or body fluids from drug users who are in and out of treatment, as a way of maintaining surveillance of the content of illicit drugs:

• locally
• regionally
• nationally
• across a multi-area service provider organisation

Information from testing strips used to test urine or drugs may provide limited information to add to other intelligence, as part of surveillance and early warning systems.

Resources

Funding

You might need additional and emergency funding to provide new or extended services, including drug testing, naloxone and treatment access.

Advice and expertise

Your OHID regional team can provide advice and expertise in preparing for, or activating, a response to an incident caused by potent synthetic opioids.

Guidance

The guidance Drug-related deaths: setting up a local review process aims to help local council commissioners set up and carry out reviews into drug-related deaths in their area.

The guidance Issuing public health alerts about drugs is for local council public health teams and their partners. It will help them to:

• assess intelligence about strong, adulterated or contaminated drugs
• issue public health alerts about these drugs

Widening the availability of naloxone explains regulations that widen the availability of naloxone.

The guidance Providing take-home naloxone for opioid overdose is for local councils and their partners. It will help them prevent deaths from heroin and other opioids by making naloxone more available.

Annexe A: potent opioids

Nitazenes

Technically known as 2-benzyl benzimidazole opioids, nitazenes is a diverse group of synthetic opioids. Examples seen in this country include:

• isotonitazene
• metonitazene
• N-pyrrolidino-etonitazene (also called etonitazepyne)
• etonitazene
• protonitazene
• N-desethyl etonitazene

Like the fentanyl analogues below, many are far more toxic on a weight-for-weight basis than heroin. Even a small amount can be enough to kill, especially without immediate naloxone or medical attention.

Fentanyl analogues

There are over 500 fentanyl analogues of widely varying potency. There is limited information available about the effects of some fentanyls, but many are more toxic on a weight-for-weight basis than heroin, some substantially so. As a result, even a small amount of a fentanyl in a heroin ‘hit’ can be enough to kill, especially without immediate naloxone or medical attention.

Brorphine-like opioids

Brorphine-like opioids are a group of piperidine benzimidazolone opioids, less common in this country than some of the other opioids, but still of possible concern.

The Advisory Council on the Misuse of Drugs reported on them alongside nitazenes in their 2022 advice on 2-benzyl benzimidazole and piperidine benzimidazolone opioids.

The ‘U’ compounds

U-47700 (7.5 times the potency of morphine) has been the most reported.

There are also U-48800, U-49900 and U-47931E (bromadoline).

Like the other synthetic opioids, they vary widely in their potency and effects.

All these have been seen as drugs on their own, rather than added to heroin.

Others

AH-7921 is only 80% of the potency of morphine and has been widely seen as a drug on its own. Because of its low potency, it is less likely to be added to or substituted for heroin.

Annexe B: messages for people who use drugs

Why you might need these messages

Local areas and their services may need to provide safer drug use messages to people who use drugs, mainly to those who inject opioids and especially at times of heightened risk. This heightened risk could be because supplies are adulterated or because people are more likely to be vulnerable, for instance at Christmas.

Developing the messages

The messages below were tested at a local drug treatment service with a small group of people who inject drugs, and then adapted based on their comments.

How to use the messages

The messages are not intended to be used in a poster because people who use drugs have told us this is not effective. Instead, local areas and services should select and adapt these messages according to their circumstances, user populations and the particular incident.

They should incorporate them in other communications and peer-to-peer messaging. And not just with drug services, but with other frontline services, such as:

• homeless hostels, shelters or outreach centres
• community pharmacies
• hospital emergency departments

Messages for people who use drugs

Drug supplies change, best test first

What’s in your drugs can change frequently and your dealer doesn’t always know what’s in them or how powerful they may be.

Best start with a small amount or inject slowly to test the effect.

Look out for your mates

If possible, use with your mates. Using alone is much more risky because there is no one to look out for you if you overdose.

Look out for the signs of overdose

An overdose won’t always look the same but some of the signs to look out for are:

• falling unconscious
• very light shallow breathing or no breathing
• loud raspy ‘snoring’ or gurgling
• blue or pale lips or fingertips

Call an ambulance

Call 999 and ask for an ambulance.

Naloxone: get it, carry it, use it

The main messages for giving someone naloxone are:

• if someone overdoses: act fast, don’t wait to see if they will recover – you could save their life
• remember, call an ambulance immediately
• check the person is breathing
• put them in the recovery position: on their side with their head resting on their arm
• give them naloxone as soon as possible

Get into drug treatment

Getting into drug treatment reduces your risk of dying from an overdose.