Isotonitazene 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 isotonitazene in Toronto’s unregulated drug supply. Isotonitazene has now presented in 2 expected fentanyl samples, alongside fentanyl, heroin, and the benzodiazepine-related drug, etizolam. The presence of isotonitazene was not expected by those who submitted these samples to be checked.

These samples were collected in Toronto’s west end and downtown core. One of these samples was known to be associated with an overdose.

What is isotonitazene?

Isotonitazene is an opioid that was synthesized in the 1950s to relieve pain. While isotonitazene was never clinically approved for market, it has, in recent years, presented in the unregulated drug supply. Isotonitazene is believed to be highly potent: some studies conducted on animals suggest isotonitazene could be 5 times stronger than fentanyl. Isotonitazene is sometimes known as “iso.”

What are the potential effects of using isotonitazene?

Isotonitazene 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 isotonitazene is increased, and greater than normal doses of naloxone may be required to arouse individuals experiencing an overdose.

When isotonitazene 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 1 type of opioid or an opioid and a benzodiazepine-related drug.

Use of isotonitazene may result in death. The European Monitoring Centre for Drug and Drug Addiction recently reported the presence of isotonitazene 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.

View more tips to reduce the harms associated with using drugs from an unregulated supply.