1. ‘New’ synthetic opioids in Europe: perspective from the EU EWS
Rita Jorge, PhD
Lisboa, 25 October 2017
Lisbon Addictions 2017

2. Treatment entrants citing opioids as primary drug
Quick overview
Treatment entrants citing opioids as primary drug

4. NPS identified for the first time: 2005-2017

5. Opioids identified for the first time: 2005-20174 4 4 3 9 8 1

6. ‘New’ synthetic opioid seizures 2009-2016
number of detections (cases)
amount detected (g, mL, tablets)

7. Characteristics of the ‘new’ opioids market
Manufacture:
chemical/pharma companies in China;
limited evidence of production in Europe
processing can occur in Europe (e.g. nasal sprays)
Sale:
openly on the surface web (‘research chemicals’) but also on the darknet;
in business-to-business or business-to-consumer websites;
in novel dosage forms (nasal sprays, liquids for e-cigarettes)
cost varies, but 1 kg of powder ≈ 50,000 bottles ≈ € 1 million in sales
Distribution:
typically using legitimate express mail companies
from manufacturer to consumer in as little as 2 days
often misdeclared (‘hot melt powder’)
frequently mis-sold, especially at street level
but also online
Nasal spray bottles w/ furanylfentanyl Found in a postal shipment, Norway, 2017

8. Misseling of ‘new’ synthetic opioids
as benzodiazepines
as/in heroin, amphetamine, cocaine and other fentanils
ocfentanil sold as heroin (WEDINOS, 2016)
ocfentanil sold as ‘speed’ (WEDINOS, 2015)
U-47,700 sold as diazepam
(Police Scotland, 2016)

9. Exposure to ‘new’ opioids
Who uses ‘new’ synthetic opioids and why?
Those who experiment (‘psychonauts’)
Those looking for substitutes for opioids may actively seek out new synthetic opioids
those who use heroin (including high risk opioid users)
those who self medicate with other opioids (pain, opioid withdrawal)
those avoiding drug testing
Some use the substance unknowingly
Use of ‘new’ synthetic opioids happens frequently at home, alone
Accidental
exposure!

10. Acetylfentanyl
Less potent than fentanyl; but MORE toxic (animal studies)
Detected in 9 countries
32 deaths (COD/contributing in 19, even when other substances present)
40% deaths in 1 month

11. Acryloylfentanyl Less potent than fentanyl; toxicity data not known
detected in 6 countries, nasal spray findings common
47 deaths (COD/contributing in 40, even when other substances present)
70% deaths in 3 months (June – August 2016)

12. Since then R = −CH2CH3 fentanyl −CH3 acetylfentanyl
−CH=CH2 acryloylfentanyl
− furanyl furanylfentanyl
− furanyl-H2 tetrahydrofuranylfentanyl
… carfentanil
… F-isobutyrfentanyl
Out of 33 new opioids under monitoring:
24 are fentanils (73%), of which 6 were the target of detailed investigations
From the 6 finished investigations:
At least 180 deaths identified in Europe with confirmed exposure to 1/more
Large majority of those:

13. Joint Reports launched Oct 2017
What’s next?
Joint Reports launched Oct 2017
detected in 4 countries
22 deaths (June – August 2017); COD/contributing in at least 6
USA: found in fake Percocet tablets
detected in 5 countries
6 deaths (December – June 2017); COD/contributing in at least 5
What about chronic harms?
Helander et al.,(2017) Br J Dermatol,176:1021

14. What’s next? Reducing harms, preventing overdoses
EU Early Warning System notifications, alerts, advisories, briefings
opioid substitution treatment — good evidence
naloxone: take-home programmes in 8 countries
drug consumption rooms in 6 countries
stocks and availability of the naloxone, as well as adequacy of training in how to resuscitate poisoned patients both in clinical and community settings may need to be assessed
availability of naloxone to users through community and take-home naloxone programmes?
use in a safe environment; don't use alone; don't mix with other drugs (esp., CNS depressants; take home naloxone?
skin contact, inhalation, or ingestion of fentanils poses a serious risk of poisoning to those who may come into contact with them
family and friends of users, law enforcement, emergency personnel, as well as medical and forensic laboratory personnel
extreme caution when handling materials suspected to contain fentanils
working environments and personnel should be equipped with appropriate protective equipment
antidote naloxone should be readily available to personnel in sufficient quantities; training in naloxone administration and resuscitation should also be available

15. Obrigada

16. EU Early Warning System
Backbone of the system: analytical identification of a ‘new’ substance in a confiscation or in a biological sample but it is not merely a repository of analytical data
Core function: to identify signals of serious harms and react as necessary
Push information
(informs and helps prepare at national level)
Pull information
(solicits information, investigates)
Formal notifications
Alerts, Advisories, Briefings
Joint Reports
Risk Assessments
The backbone of the information collected by the EU EWS is the analytical identification of a new substance in a confiscation (by police or customs, for example) and/or in a biological sample (in an acute intoxication or a death). But rather than being a repository of analytical data the main function of the EU EWS is to identify signals of serious harms associated with NPS and to react accordingly.