Why Isotonitazene Is Not Yet the “New Fentanyl”

In the span of about a year, isotonitazene, a novel psychoactive substance (NPS), went from being practically unheard of to being implicated in a fatal overdose spike in the Midwest. While some researchers and media reports are warning about the emergence of the designer drug, one harm reductionist from the region cautions against singling it out.

The issue of “iso,” as the synthetic opioid is colloquially called, surfaced in January 2019, when a Reddit user claimed that “a reputable chinese [sic] vendor had announced” that the drug would be “coming after the new years,” presumably the Chinese New Year on February 5. Then, iso was first detected on-the-ground as early as March 2019 by a Canadian toxicology report, and subsequently in Europe that April, according EMCDA’s 2020 initial report. It turned up in the United States in August 2019, per the Center for Forensic Science Research & Education (CFSRE).

Google search interest in isotonitazene went from next to nothing to an emerging trend. (Source: Google Trends)

In January 2020, a coroner in the central Illinois city of Peoria told press that toxicology results for a person who died a month prior came back positive for isotonitazene. Since then, more fatal overdoses have involved it, Chris Schaffner, program director of Peoria’s Jolt Harm Reduction, told Filter. He estimated that about “four or five” of his center’s clients have died because of it. The city saw a 40 percent increase in overdose deaths in the first quarter of 2020 compared with the same period the prior year, breaking a previous downward trend.

“The toxicity of isotonitazene has not been extensively studied but recent association with drug user death leads professionals to believe this new synthetic opioid retains the potential to cause widespread harm and is of public health concern,” wrote CFSRE in a November 2019 Public alert about the opioid.

The CFSRE’s data suggest that detection of iso in toxicology screenings has risen steeply, from 10 initially-identified samples in August 2019 to 180 positive cases by the end of May 2020, Dr. Alex Krotulski, one of the organization’s research scientists studying iso, told Filter. Its reach may also be increasing: “Now, we are seeing greater proliferation to other states outside the Midwest, specially states in the South and East,” said Krotulski.

But CFSRE’s figures almost entirely rely on toxicology reports, not drug seizures. That’s an important distinction: Iso hasn’t yet been flagged by systematic supply reviews by law enforcement—just by a few media reports from Canada. In the Drug Enforcement Administration’s 2020 Q1 Emerging Threat Report, the federal agency didn’t report identifying iso in any of its 592 tested opioid samples. Neither did the DEA mention it in its 2019 National Drug Threat Assessment.

One expert seemed surprised by the discrepancy between iso’s presence in toxicology and seizures. “Any reason why e.g. isotonitazene is not in the list of opioids?,” tweeted toxicology professor Christophe Stove of Ghent University, regarding the DEA’s first quarter report. “Not found in seized material? First identifications do date back to 2019 (and ref material also already available in 2019).”

This could be attributed to the sources analyzed by the DEA. RAND fentanyl researcher Bryce Pardo responded to the professor’s tweet: “This is from DEA seizures/buys. It doesn’t include most exhibits from state/local law enforcement or toxicology reports.”

But even in Peoria, the center of iso’s known US appearances, its adulteration of the supply seems to be sparse. “Iso is still pretty novel” in the results of Jolt Harm Reduction’s reagent testing of drug users’ supplies, Schaffner said. Instead, the usual suspects, as well as other previously lesser-seen substances, are most prevalent. “Fentanyl is the top adulterant. Then we’re seeing cathinones coming up, particularly in stimulants. And then we see benzos. And common cutting elements like aspirin or baking soda.”

Anecdotal drug-user reports seem to signal that the already-limited presence of iso in the US is unlikely to surge anytime soon. That may be because the producer of the novel opioid has allegedly discontinued it.

“Isotonitazene is gone. The Chinese haven’t made a second batch yet, if they ever do, despite massive demand,” wrote a  Reddit user in February 2020. “Fent was a distributed, China-wide phenomenon. A lot of labs were making fentalogues. Iso analogues seem to be limited to one, maybe two, labs.”

A different Reddit user was reportedly told by their supplier that “once what they have is gone they cannot get anymore of it, as the group synthing it has already moved on to another analogue and they have 3-4 other analogues to move on to after that one,” according to a February 2020 forum comment.

The push by manufacturers to move from one NPS to the next is likely the product of US-driven prohibition. In December 2018, China President Xi Jinping agreed to US President Donald Trump’s demand for controlling all fentanyl analogues under Chinese drug policy. By April 2019, they were all banned, and by November of that year, the first Chinese fentanyl manufacturer was sentenced to death in a city 200 miles south of Beijing. With the supply-side attacks on fentanyl, manufacturers look towards NPS that remain legal.

“There’s always something novel. That’s part of the response to illicit drugs,” said Schaffner.

The dynamism of the drug supply itself is not inherently dangerous—it’s when people who use drugs are not equipped with the evidence-based, practical knowledge to keep themselves safe. That’s where harm reductionists come in. “We did quite about of education in our community” about iso, said Schaffner. “We’ve worked real hard about drug use literacy here in central Illinois. We want them to be informed and ask questions.”

“People are unsettled by it,” he said. But the presence of an unwanted substance in one’s bag is nothing novel. “They’ve come to accept it.”


Photograph of an alleged bag of isotonitazene by unknown Reddit user via Reddit

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