Spotlight on… Fentanils and other new opioids
What are new opioids?
New opioids are synthetic narcotic analgesics that have recently appeared on the drugs market, many of which are highly potent substances that can pose a life-threatening risk of poisoning. Fentanils are a particularly potent group of synthetic opioids. In some cases, these substances are used in human and veterinary medicine, in anaesthesia and for pain management. However, fentanils are also synthesised illicitly and may be sold as ‘synthetic heroin’, or mixed with heroin or other illicit drugs, and even counterfeit or fake medicines.
These substances are easy to conceal and transport because very small amounts can produce many thousands of potential street doses. This makes them both a very attractive commodity for organised crime and a severe challenge for drug control agencies. A new area of concern is the appearance of novel dosage forms, such as nasal sprays and e-liquids for vaping in electronic cigarettes, meaning that some new opioids may be relatively easy to use and possibly considered more socially acceptable than established opioids such as heroin, although the risks of inadvertent exposure may be greater.
In recent years, there has been a significant rise in the number of new synthetic opioids reported to the EU Early Warning System. In addition, a growing awareness of their potential negative impact on health has resulted in actions, which include increased restrictions in some producer countries. New opioids, not controlled under the UN conventions, can be manufactured and traded relatively freely and openly by chemical and pharmaceutical companies, often, but not exclusively, based in China.
What is happening in Europe?
Although, overall, they play a relatively small role in Europe’s drug market, there is growing concern about the availability of these substances, which is reflected in increased efforts to subject them to international control or other regulatory measures. Possibly because of this, there are signs of a reduction in the number of new fentanils reported on the European market and of a growing emergence of other new opioids, such as benzimidazole opioids. Of the ten new non-controlled synthetic opioids detected for the first time in 2020, for example, only one was a fentanil.
The availability of new opioids is particularly worrying because of their high risk of overdose due to severe respiratory depression. Fentanils and other new opioids are highly potent, may be difficult to dose and their effects may be unknown or little understood by users. For example, long-term opioid users may be at increased risk of experiencing an overdose if they lack familiarity with the effects and appropriate dosage of these new substances. In addition, where new opioids are sold as heroin, or found mixed with or as a contaminant in other drugs, the risk of accidental overdose is also increased. In those without tolerance to opioids, even very small amounts may be fatal. In a small number of European countries, and in particular Estonia, the injecting use of fentanyl and sometimes other synthetic opioids is long established and associated with a relatively high prevalence of overdose deaths. Case-based data reported to the EU Early Warning System have documented over 250 deaths in which fentanils and other new opioids have been implicated. However, from the information available, it is hard to estimate the overall true number of deaths linked to these substances. In some countries, overdose deaths linked to opioids intended for therapeutic use, including pain relief and opioid agonist treatment, also appear to be associated with a non-trivial share of drug-related mortality; again, however, data limitation does not permit accurate estimation of the extent of this problem. Overall, the assessment of current data on opioid deaths points to a pressing need to improve forensic and toxicological capacity, especially in the area of fentanils, other new opioids and opioids commonly used for therapeutic purposes.
New opioids may also present risks not only to those who use them (sometimes unknowingly), but also to others, such as postal workers, police and customs officers, families and friends of users, who may be accidentally exposed to them.
Early warning systems, including the EU Early Warning System based at the EMCDDA, play an important role in the identification of and response to harms caused by new opioids, by facilitating a rapid reaction to the threats they pose to public health (see Early Warning System on NPS). Since late 2015, the EMCDDA has conducted a number of joint investigations with Europol on new fentanils that have caused serious concerns at the European level.
Implications for current and future responses
Interventions addressing the use of fentanils and new opioids, or new psychoactive substances in general, should be based upon responses to established drug groups, but adapted appropriately to account for the nature and patterns of use of the new substances, the different user groups and contexts of use. It is important to provide education, including harm reduction, specific to new substances. This is most appropriate for target groups and individuals who are either already using drugs, or at increased risk of doing so.
Responses to acute poisoning caused by new opioids should follow the guidelines for opioid poisoning generally, including the administration of naloxone for respiratory depression. However, recent experience suggests that larger and repeated doses of naloxone may be required to reverse poisoning in some cases. Therefore, training and guidance related to the treatment of opioid poisoning and associated with naloxone programmes needs to explicitly recognise appropriate responses to poisoning related to new opioids. This should include guidance on the stocks of naloxone required to meet the needs associated with potential outbreaks of new-opioids poisoning.
Analytical and toxicological testing and risk-assessment capacities need to be enhanced and results disseminated in a timely and usable way, both to risk groups and relevant professionals. In particular, greater attention is needed to identify the role that synthetic opioids are playing in drug-related acute intoxications and deaths. People who use drugs, and those providing support to them, should be made aware of the possibility of exposure to highly potent synthetic opioids and be alerted to the fact that a rapid intervention could be necessary. There is a need to develop and evaluate further harm reduction approaches in this area. For people who may encounter new opioids in the course of their work, for example law enforcement or laboratory personnel, measures such as carrying out risk assessments, developing appropriate protocols and procedures, and providing safety equipment and training, can all help to reduce the potential risks of possible exposure.