Etonitazene identified in Toronto’s unregulated drug supply

What is the purpose of this alert?

For the first time, Toronto’s drug checking service has identified etonitazene in Toronto’s unregulated drug supply. Etonitazene has presented in one expected fentanyl sample, alongside isotonitazene and cocaine. The presence of etonitazene was not expected by those who submitted the sample to be checked.

This sample was collected in Toronto’s downtown core and was a brown powder. This sample was not known to be associated with overdose. However, the presence of etonitazene happens to coincide with an increase in overdoses, as reported by Toronto harm reduction community.

What is etonitazene?

Etonitazene is an opioid that was synthesized in the 1950s to relieve pain. While etonitazene was never clinically approved for market, it has, in recent years, presented in the unregulated drug supply, along with its analogues isotonitazene and metonitazene. Etonitazene is believed to be highly potent and more potent than its analogues: some studies suggest etonitazene could be 10 times stronger than fentanyl.

What are the potential effects of using etonitazene?

Etonitazene produces effects similar to other opioids like morphine and fentanyl, including euphoria, relaxation, sedation, slowing of heart rate and breathing. However, because of its strength, the chance of overdose from using etonitazene is increased, and greater than normal doses of naloxone may be required to arouse individuals experiencing an overdose.

When etonitazene is used in combination with other opioids or other central nervous system or respiratory depressants, like benzodiazepine-related drugs, the risk of dangerous suppression of vitals is increased (e.g., slowing down of breathing, blood pressure, heart rate). This is noteworthy since over 60% of opioid samples checked by Toronto’s drug checking service have contained more than one type of opioid or an opioid and a benzodiazepine-related drug. There is also some research that suggests etonitazene may cause increased muscle rigidity during overdose.

Etonitazene use has been reported in the United States, Russia, and Germany, and may result in death. The European Monitoring Centre for Drug and Drug Addiction recently reported the presence of isotonitazene, an analogue of etonitazene, in 23 deaths across Canada, the United States, Germany, and the United Kingdom.

Advice to reduce potential harms:

  1. Carry and be trained to use naloxone. Naloxone, also known by the brand name Narcan, is a drug that can temporarily reverse an opioid overdose. Naloxone can be picked up for free from your local harm reduction agency or pharmacy and free training is available online. Consider carrying multiple doses of naloxone.
  2. Get your drugs checked before using. In Toronto, drug checking services are offered at Moss Park Consumption and Treatment Service, Parkdale Queen West Community Health Centre (Queen West and Parkdale sites), South Riverdale Community Health Centre, and The Works at Toronto Public Health. You can also check your drugs after you have used them by submitting paraphernalia, like a cooker or a filter.
  3. Use at a supervised consumption site. Here is a list of sites that offer supervised consumption in Toronto and an interactive map of sites that offer supervised consumption across Canada.
  4. Use with someone else and take turns spotting for each other. A buddy system is safer than using alone. Stay 6 feet from your buddy if you are not from the same household to avoid passing COVID-19.
  5. If you must use alone, let someone know before you use. Call someone you know and have them stay on the phone with you while you use. Tell them your address and keep your door unlocked. If you are in Ontario, you could call the Overdose Prevention Line at 1-888-853-8542. The National Overdose Response Service is available to anyone in Canada and can be reached at 1-888-688-NORS (6677). BeSafe is an app that can be downloaded on your phone and provides another way to let someone know before you use.
  6. Do a small test dose first.
  7. Call 911 in an overdose situation. The Good Samaritan Drug Overdose Act provides legal protection from drug-related charges for carrying drugs for personal use and other simple possession offences.
  8. If your drugs did not contain what you were expecting, consider talking to the person you got your drugs from, or get your drugs from another source if possible.