Emerging Threat Bulletin from Gulf Coast HIDTA
Background: Isotonitazene, also known as “Iso” or “Toni,” is being increasingly identified in overdose deaths throughout the United States. This synthetic opioid was first identified in August 2019 and has been most prominent in Midwestern states. The drug is a type of benzimidazole that is structurally similar to etonitazene, a potent internationally controlled opioid. Isotonitazene reportedly has a greater potency than heroin and morphine, and it is similar in strength to fentanyl. Isotonitazene has been encountered mostly in powder (brown, yellow, or white) tablet, and liquid forms as well as nasal spray to a lesser degree. Isotonitazene has also been found concealed as counterfeit Dilaudid (hydromorphone) tablets circulating in the US. On June 18, 2020, The Acting Administrator of the DEA issued a notice of intent to publish a temporary order to schedule isotonitazene in schedule I of the Controlled Substance Act, which are drugs that are illegal and have no medical uses. The drug is also not approved for medical use by the FDA.
Source: China has been identified as a main source country for isotonitazene. The restrictions placed by the US on Chinese fentanyl analogues have opened the market to the shipping of isotonitazene. The drug has been shipped from China to European and US markets with many orders originating from Darkweb vendors. Currently, the supply of isotonitazene from China may be limited by reduced production and speed of international shipping due to the COVID-19 pandemic. Isotonitazene can be purchased in bulk at a low cost from China. Bulk quantities of the drug are often mixed with other drugs to reduce costs. Isotonitazene has been most frequently identified with flualprazolam, fentanyl, heroin, and cocaine
Overdoses: In November 2019, there were 40 to 50 isotonitazene-related deaths per month in the United States compared to about six per month from June 2019 to August 2019 according to forensic toxicology results reported by the Naval Criminal Investigative Service Multiple Threat Alert Center. Due to the shortcomings of preliminary testing, isotonitazene has not been widely identified in laboratories throughout the US. While formal epidemiological studies on isotonitazine use have yet to be performed, self-reported experiences on user websites suggest that dosage regimens for the drug can differ between and within individuals depending on tolerance of the user, other drugs being concurrently used, desired effects, purity and composition of the substance, and dosage consumed. Consumers may be at a higher risk of acute poisoning as isotonitazene is often concealed in counterfeit pharmaceuticals as seen in Figure 1. Similar to other opioids, health risks associated with isotonitazene are often respiratory depression, which in overdose could lead to apnea, respiratory arrest, and death. Additionally, the risk of an overdose from isotonitazine is increased due to the high potency of this drug often requiring several doses of Naloxone to reverse its effects.
Figure 1: Isotonitazene concealed in counterfeit pharmaceutical drugs often have an “M” on one side and the number “8” on the other side – making them almost identical to an 8 mg Dilaudid tablet. Source: International Narcotics Control Board, Global Rapid Interdiction of Dangerous Substances
Law Enforcement Encounters: As of March 5, 2020, there have been 8 NFLIS submissions of isotonitazene in the US. However, law enforcement within the Gulf Coast HIDTA AOR have not yet encountered this drug.
Public Health Encounters: While isotonitazene is on the NMS Labs Toxicology radar, 5 postmortem isotonitazene cases have been identified in the Gulf Coast HIDTA jurisdiction by NPS Discovery/CFSRE & NMS Labs as of April 2020. This information is being released to raise awareness of the unpredictability and danger of this drug. This bulletin was produced by the Gulf Coast High Intensity Drug Trafficking Area.
Questions or comments may be directed to Strategic Programs Coordinator Sabrina Perez at (571) 362-4851 or firstname.lastname@example.org. Feedback can be provided here: https://www.nhac.org/SurveySite/SurveyPage.aspx?LMSID=046df6b7-4c7e-413b-be2c-027010e25032 Sources: Chicago HIDTA DEA, National Forensic Laboratory Information System (NFLIS) European Monitoring Centre for Drugs and Drug Addiction International Narcotics Control Board, Global Rapid Interdiction of Dangerous Substances Journal of Analytical Toxicology Krotulski, Alex J, Donna M Papsun, Sherri L Kacinko, and Barry K Logan. “Isotonitazene Quantitation and Metabolite Discovery in Authentic Forensic Casework.” Journal of Analytical Toxicology, 2020. Naval Criminal Investigative Service, Multiple Threat Alert Center, Threat Division U.S. Department of Homeland Security, U.S. Customs and Border Protection 1 Specified data for Shelby County, TN, Escambia County, FL, and Santa Rosa County, FL was not available.