Diagnosis and Management of Nitazene Dependence in Sydney, Australia: A Case Series.

INTRODUCTION: Nitazenes are synthetic opioids with potent μ-receptor activity. There are increasing reports of nitazene overdoses worldwide. We report on a case series of protonitazene and metonitazene dependence responding to high dose medication for the treatment of opioid dependence in both inpatient and outpatient settings.

CASE PRESENTATION: Six young adult males, five with multicultural backgrounds, presented to a public hospital in metropolitan Sydney, Australia in severe opioid withdrawal after ongoing nitazene use. Five were regularly vaping what they believed to be cannabinoids or nicotine, later toxicologically confirmed as protonitazene. One case had intentional recreational use of confirmed metonitazene. All six were commenced on opioid dependence treatment, four in the inpatient setting and two as outpatients. Four remain engaged with treatment while two were lost to follow-up.

DISCUSSION AND CONCLUSIONS: This case series describes the diagnosis and management of nitazene dependence in metropolitan Sydney, Australia. Similar to fentanyl dependence in international literature, high doses of buprenorphine were required. Complexities included unintentional nitazene exposure through vaping, initial diagnostic confusion, delay in toxicological testing and treatment retention with local alcohol and other drug services. The management of nitazene dependence was initially complex due to diagnostic, medication and patient factors. All cases were successfully managed with either methadone or buprenorphine in the New South Wales opioid dependence treatment program. This case series describes potential management strategies for future cases of nitazene withdrawal and dependence. Public and clinician awareness is important to ensure early diagnosis and successful management.