The emergence of nitazenes on the Irish heroin market: Lessons learned and challenges moving forward
On the 9th of November 2023, the Health Service Executive was notified of an unusually high pattern of overdoses occurring in Dublin City among people attending homeless services. This triggered an urgent review and it was quickly established that these overdoses were serious cases of respiratory depression, occurring very quickly after use and linked with a drug described as ‘strong’ heroin which required additional doses of naloxone to revive individuals.
These cases represented very early signs of a change and the emergence of a nitazene substance (N-Pyrrolidino protonitazene) on the Irish heroin market. This was the start of a 5 day overdose outbreak for the period 9th – 13th of November among people who use heroin in Dublin City, which was later followed by a second outbreak over a 6 day period in the Cork region in December.
Immediate wrap around supports were enacted, additional emergency naloxone was made available and a monitoring system was rapidly developed. A small coordination group was formed and led by the HSE and included Emergency Departments, HSE Communications, the HSE National Drug Treatment Centre Laboratory, An Garda Siochana, Forensic Science Ireland, The State Laboratory, The Department of Pharmacology and Therapeutics Trinity College Dublin, the National Ambulance Service and Dublin Fire Brigade. This group then formally became the National Red Alert Group to monitor and respond to the emergence of synthetic opioids.
Obtaining both substances and biological samples linked with overdose cases from health and law enforcement were essential for monitoring activities. Emergency Service data was chosen as the main surveillance tool to monitor outbreaks and offered updates on cases twice daily (9:00 am and 5:00pm). Through this source, we could identify the number of overdoses recorded during the outbreak periods (Dublin N=57 and Cork N=20) and when emergency call outs began to decline.
The Irish outbreaks are examples of how these substances can emerge without warning and sporadically. Countries now need to mobilise in preparation for outbreaks and have structures in place while long-term policy goals are deliberated. The Irish response will not be sustainable on a long-term basis, highlighting the need for a resourced Early Warning System and dedicated drug checking and monitoring laboratory with appropriate instrumentation and access to samples. N-Pyrrolidino protonitazene continues to present sporadically and it is not yet known what position these substances will establish on the market which could lead to policy, funding and resource challenges.
The most recent data on these substances in Ireland will be presented as well as a review of the initial outbreak periods, with input from those affected, analytical data, lessons on mobilising different stakeholder groups and developing urgent health-led risk communications, as well as national preparations underway to respond to a more diverse and challenging drug landscape.
