Their emergence should also have come as no surprise – the rise of potent synthetic alternatives to ‘ traditional ’ drugs has been a familiar trend ever since the early 2000s and the advent of ‘ legal highs ’. Very quickly , the UK decided to gift these compounds to organised crime , with tragic and predictable outcomes .

When it comes to nitazenes there seems to be a prevailing view that they can ’ t be managed or controlled by the people using them . This can easily morph into the belief that the only way for people who currently use heroin to ensure they don ’ t suffer a nitazene-related overdose is to abstain . However , there are many people with powerful reasons why they can ’ t or won ’ t stop , and they may be left feeling hopeless and at the mercy of these compounds .

At the same time , in the face of the fearsome potency of some nitazenes , services have understandably retreated to familiar ground , offering slightly tired advice like ‘ don ’ t use alone ’ or ‘ look after your friends ’, while rightly calling for effective but distant systemic change like

the introduction of overdose prevention centres and expansion of drug testing facilities .

Of course , the introduction of evidence-based , low-threshold harm reduction should be a priority for the UK , and we should continue to promote it at every opportunity . However , there is a problem staring us in the face – currently these life-saving transformative interventions are NOT the priority for policy makers . These changes will take time and money to implement , and we ’ re in danger here of letting the perfect be the enemy of the good – of concentrating on future developments while doing little or nothing to intervene in the present .

We ’ re in urgent need of simple practical harm reduction advice that individuals can implement easily .

As for most individual users of heroin , they ’ re left in a very familiar space . That is , feeling powerless waiting for these distant remedies while facing the real and present prospect of dying – at the mercy of the invisible monster in their bag of gear .

We ’ re in urgent need of simple practical harm reduction advice that individuals can implement easily while the country waits for large evidence-based approaches to be introduced .

The idea of ‘ batch cooking ’ could be an example of just such a small change in the preparation of heroin ( with clusters of nitazene present ) that could marginally lower risk . The idea came from a chance discussion with an anaesthetist and pain specialist , someone who was no stranger to using powerful synthetic opioids on patients

The conversation turned to the nitazene threat and I asked him what techniques were used to administer a safe dose of anaesthetic . Among other things , he simply replied ‘ dilution ’. Dilution of a substance can of course have the benefit of both lowering the strength of a dose but also of evenly distributing the drug through a solution – clustering of nitazene within a batch of heroin has been cited as a particular threat .

For some people who use drugs , this is not a new idea . There are examples of people who prepare a number of doses of heroin in advance and then use the solution over the day or sometimes longer . Put simply , if the user were to dissolve a number of doses of heroin / nitazene mix in a larger amount of water with some added citric , the nitazene would be better distributed throughout the liquid

and the dose of nitazene would be both more diluted and more evenly distributed . If the user then ‘ tasted the hit ’ and found it to be effective , they would have a store of ready mixed liquid solution that they could use with reduced risk .

There are a number of important issues to be thought through here – detailed in my discussion paper – but the basic concept of ‘ batch cooking ’ may be a useful , easy and pragmatic way for people who use heroin to lower the risk of overdose . We need to keep thinking of novel harm reduction practices like this and sharing them with people who use drugs to see if they find them practical and useful to implement , while doing all we can to ensure that any new ideas do indeed reduce risk and don ’ t increase harm .

Clearly , with drugs like nitazenes there comes a point where the potency of the drug is fatal regardless of harm reduction practices . But we should not stop thinking creatively about how people can survive this latest threat on a day-by-day basis .

Renato Masetti is training co-ordinator , drugs and alcohol , Health Outreach NHS

Contact him for his original paper at renato . masetti @ nhs . net

Zdenek Sasek | Dreamstime . com