What is the purpose of this alert?
Toronto’s drug checking service continues to identify what we consider “ultra potent” opioids in Toronto’s unregulated drug supply, including:
- Carfentanil: A fentanyl analogue typically used by veterinarians on very large animals that is approximately 100 times stronger than fentanyl, 4,000 times stronger than heroin, and 10,000 times stronger than morphine.
- Etonitazene: An opioid synthesized in the 1950s that was never clinically approved for market and could be 10 times stronger than fentanyl.
- Isotonitazene: An opioid synthesized in the 1950s that was never clinically approved for market and could be 5 times stronger than fentanyl.
The presence of these drugs coincides with an increase in overdose deaths in Toronto, as reported by Toronto Public Health and Toronto’s harm reduction community.
Between March 1 and May 17, 2021, carfentanil was found in 4% of the expected fentanyl samples checked by Toronto’s drug checking service (11 of 274 samples). This is the most carfentanil we’ve identified in a period of less than three months since launching our service in October 2019. These samples were collected in Toronto’s east end, west end, and downtown core. Carfentanil was usually found alongside fentanyl and caffeine – and a benzodiazepine-related drug was found in over half of these samples. Three of these samples were purple in colour and one sample was known to be associated with an overdose.
Preliminary data from LifeLabs also shows a significant increase in carfentanil found in urine samples from across the province of Ontario. In both March and April 2021, LifeLabs detected carfentanil in approximately 1.5% of all urine broad spectrum drug screens, compared to 0.1% of all urine drug screens completed in August 2020.
Isotonitazene and etonitazene:
Between March 31 and May 17, 2021, isotonitazene and/or etonitazene were found in 4% of the expected fentanyl or down samples checked by Toronto’s drug checking service (6 of 171 samples). These samples were collected in Toronto’s west end and downtown core. Isotonitazene and etonitazene were found together in two samples. A benzodiazepine-related drug was found in five of these samples – fentanyl was also commonly present. Three of these samples were brown or beige in colour and three samples were known to be associated with an overdose.
What are the potential effects of using ultra potent opioids?
The use of carfentanil, isotonitazene, or etonitazene may result in extreme sedation and dangerous suppression of the respiratory system. Since these drugs are so strong, the risk of overdose is increased, and greater than normal doses of naloxone may be required to arouse individuals experiencing an overdose.
When carfentanil, isotonitazene, or etonitazene are 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 one type of opioid or an opioid and a benzodiazepine-related drug.
Advice to reduce potential harms:
- 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.
- 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.
- 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.
- 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.
- 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. 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.
- Do a small test dose first.
- 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.
- 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.