Forty years of Hepatitis C and Heroin. Here come the “Nitazenes”
The next blog in the Hep C U Later harm reduction series is a guest blog from Dr Judith Yates who has extensive experience of working within community drug and alcohol services. Here she outlines the story of heroin, hepatitis C and now, nitazenes, asking us all to consider what we can learn from the successes seen within hepatitis C elimination in tackling drug related deaths.
In 2024 we are moving into a new chapter in the story of opioid use in Europe and the UK. Changes in the drugs market mean the UK supply of illicit heroin is threatened, and the vacuum is being filled by nitazenes.
What are nitazenes, and what can be learned from our success in working towards the eradication of hepatitis C?
This is a story which began forty years ago. I became a GP in the centre of Birmingham in the 1970s, when Hepatitis C first appeared, known at that time confusingly as “Non A Non B hepatitis” or as “post transfusion hepatitis”.
In the 1980s, the first brown heroin from Afghanistan flooded into Europe and the UK and to my patients in Birmingham.
The increased number of people injecting drugs led to an increased number of my patients getting “non A non B” hepatitis. It was not until ten years later, in 1989, that the virus was given the name ‘Hepatitis C”.
Initially treatments involved interferon and ribavirin: brutal medications with lots of side effects, which although successfully clearing the virus for many people, gave treatment for Hepatitis C a very bad name. Peer support groups set themselves up around the country, helping people get tested and treated and supporting them through the treatment journey.
Things improved after 2014 with the arrival of several oral treatments which had little or no side effects, and almost 100% cure rates for some genotypes. We were all very excited. Liver specialists and peer workers stepped up to the mark and started actively searching for people to treat.
In an unusual success story, the UK is on track to “eliminate” Hepatitis C as a public health threat even earlier than the WHO target for world elimination by 2030. This has been in a large part due to the excellent efforts of peer workers who can reach out to people who have understandable fear of professionals. New cases are often among those who are farthest from ordinary health care, and affected by decades of stigma.
While the Hepatitis C story is moving in such a positive direction, sadly the number of people whose death is related to the use of heroin is still rising each year, and in 2023 everything became even more dangerous with the arrival of “nitazenes” in our local heroin supply, and the simultaneous reported shortages of heroin, leading to deaths in Birmingham.
We had four decades from the 1980s of a steady and mainly reliable supply of heroin but from April 2023, this has been threatened by a reduction in the Afghan poppy harvest. The potential vacuum is being filled by “nitazenes”.
What are nitazenes?
Nitazenes are a class of synthetic opioids first made by chemists in the 1950s. They were never used as medicines and never tested for human use. In 2019, underground chemists began to experiment with the production of “nitazenes”, as the ingredients for making fentanyl were increasingly prohibited. Nitazenes can be up to 500 times stronger than heroin and up to ten times more potent than fentanyl, and in tiny doses are very likely to cause accidental overdose and death. Nitazene powders are cheap and apparently easy to buy via the internet.
Between June and December 2023, 31 young people died in Birmingham, when tiny amounts of n-desethyl isotonitazene (a very powerful “nitazene”) were added to the bags of heroin being sold across the north of the city. These were mostly people who lived in hostels or supported housing, and were not in contact with drug treatment services. They all thought they had bought “just” heroin.
The networks of peer workers set up to work towards the elimination of Hepatitis C are powerful and trusted messengers, well placed to help explain the dangers of the rapidly changing drug markets to people who use drugs today. The people most at risk are the same people who are still most at risk of Hepatitis C infection and re-infection.
If we are to avoid the predicted increase in drug related deaths this year:
- We need rapid expansion of drug checking and testing, and better real time communication about emerging risks.
- We need increased non-judgemental drug treatment services of all kinds, with a wider offer of medications including heroin assisted treatment for those not helped by other opioids.
- Naloxone needs to be everywhere. I carry it every day.
- We need a rapid expansion of “high tolerance housing” with careful drug policies allowing people not yet able to move away from street drugs to live without fear of eviction and be helped and supported to reduce the new harms they face in 2024. No time to lose.
- International Overdose Awareness Day (IOAD) is on August 31st, when we can remember those we have lost, and think about how to prevent future deaths.