New potent synthetic opioid detected in Norway

Protonitazene is not used in clinical practice but sold on the illicit market. It does not show up in normal blood or urine tests, and cannot be detected with fentanyl strips or any other available drug testing kits. Even small amounts of the drug can lead to overdoses, as a result of depression of the central nervous system, respiratory depression and cardiac arrest.

Protonitazene has been associated with several drug deaths in Estonia earlier in 2022. The drug was detected in Sweden in October, before reaching Norway.  So far, the Norwegian overdose cases have been spread geographically. It is still unclear how widespread the use of the drug is, or how much is still in circulation. However, we do know that at least some of the detected cases involve ingestion via nasal spray.

Health authorities in Norway have issued warnings to users, urging them not to use drugs while alone and call for help if a serious situation occurs. Protonitazene has a delayed effect which also depends on how the drug is taken. Users are therefore advised not to take a new dose if they don’t feel the effect at once, as this increases the risk of an overdose.

Protonitazone overdoses are treated the same way as other opioid overdoses. The nasal spray Naloxone is effective, but a larger dose may be required.

Drug related deaths in Norway

Norway has had relatively high and stable numbers of overdose deaths over the past two decades. After a steep increase in the late 1990s and early 2000s, drug related deaths peaked at over 400 in 2001. In the following years one has seen a decline, and the numbers have stabilized around 260 deaths per year since 2003. One probable important reason for the decline was expanded access to substitution treatment in the early 2000s.

More than four out of five drug related deaths involve opioids. However, the drug situation has changed somewhat over the years. In the early 2000s heroin was the dominant drug, but since 2016 other opioids have been the most frequent cause of deaths. This category involves pharmaceutical pain killers like morphine, codeine and oxycodone. Synthetic opioids (for example buprenorphine, fentanyl, petidin) and methadone are also involved in a significant number of drug related deaths. In the past five years, heroin accounts for less than one in four deaths.

One of the positive effects of increased access to treatment is that people live longer. The average age of people dying from drug related deaths has increased since the early 2000, from 36 years in 2006 to 45 years in 2021. However, this also means that there is an ageing cohort of people with substance use problems, who might be at high risk of drug related deaths.

New risk groups

Recent data suggest that there are new groups who are at risk of drug overdoses. Fatalities from other opioids and synthetic opioids differ from heroin fatalities in several respects. The victims more rarely have a substance use diagnosis, they are less likely to have a criminal record, and they are more likely to have a disability pension. Many are prescribed strong opioids to treat chronic pain. There is a need for innovative overdose prevention measures targeted specifically at this group. It is also worth noting that 15 to 20 percent of drug related deaths are classified as suicide. Prevention of these deaths may require other strategies than accidental overdoses.

National strategy to combat overdoses

Norway is among the countries in Europe with the highest rates of drug related deaths. While comparisons between countries may be misleading due to significant methodological differences, there is no doubt that the number of preventable deaths is too high.

Since 2014 Norway has had a national strategy to combat drug overdoses. The strategy focuses on increased access to treatment, distribution of naloxone to reverse overdoses and reduction of high risk use, e.g. by switching from injection to smoking.

The strategy identifies several risk factors for fatal overdoses, including previous non-fatal overdoses, reduced tolerance after treatment or prison, poor physical and/or mental health, injecting use – particularly if people inject unaccompanied – and polydrug use.

Furthermore, Norway has a wide range of harm reduction services for people who use drugs, including needle and syringe programmes, low threshold health services, substitution treatment, heroin assisted treatment, and user rooms in Oslo and Bergen.

While drug use is criminalized, the police and courts no longer prosecute people with substance use problems for drug use, or possession of small amounts of drugs for personal use.

Emerging threats

Many countries have seen an increase in the use of strong opioids for chronic pain. In North America overprescription of painkillers was one of the main factors behind the ongoing opioid epidemic. 

The use of strong opioids has increased in Norway as well, although not to the same degree as in the US. This changing pattern is reflected in the increase in fatalities from other opioids, and synthetic opioids.

Another threat is the potential introduction of fentanyl and other potent synthetic opioids to the illicit drug market. Fentanyl is now the leading cause of drug related deaths in the US. Both Sweden and Estonia have experienced a significant number of fentanyl related deaths in recent years, although the numbers have decreased lately.

Strong opioids increase the risk of fatalities in an already vulnerable population. The margin of error between a normal dose and a potentially lethal dose is small. If fentanyl – or other synthetic opioids like protonitazene – gain a foothold in the market, there is reason to fear an increase in drug related deaths in the future.

Access to substitution treatment is an important strategy to reduce risk in the user population. However, police, customs and health services need to monitor developments closely and provide timely and relevant information to both users and the helping profession.

The article is written by Stig Erik Sørheim, Head of international department at Actis,

on request of PopNAD