This page provides guidance for clinicians to manage opioid withdrawal and induction onto opioid dependence treatment for people with dependence on nitazenes or other high potency opioids who present with severe withdrawal. For broader advice, see Clinical guidance for withdrawal from alcohol and other drugs.
The advice guides recommended practice and provides a resource to assist decision-making, alongside clinician judgement and patient choice. The advice is based on clinical consensus, as additional research is required.
Services are encouraged to collect data on patient progress to assist refining treatment options.
This consensus guidance is only to be used in the alcohol and other drugs (AOD) specialist setting, and/or or in ongoing consultation with an AOD specialist from whom advice is obtained and updated following regular reviews.
The risk of adverse reactions including opioid overdose must be considered.
There is wide variation in the potency of different nitazenes and no robust evidence regarding the half-life of nitazenes.
The Clinical Opiate Withdrawal Scale (COWS)1 should be undertaken as part of a comprehensive assessment in all cases where nitazene withdrawal is suspected. Use the COWS at the beginning of treatment to assess response to medication and repeat as needed. When interpreting the COWS in this context, greater consideration should be given to clinical findings specific to opioid withdrawal, i.e. piloerection, lacrimation, rhinorrhoea, yawning, dilated pupils, diarrhoea, vomiting, and perspiration.
Additional sedating drugs, e.g. benzodiazepines, are best avoided unless there is a clinical need for additional supportive care and symptom relief. Short-acting benzodiazepines present fewer risks.
Options provided below are presented in order of recommended approach. See also NSW Health Interim Clinical Guidance: Outpatient Transfer from Methadone to Buprenorphine Using the Micro-dosing or Bridging Methods2.
When appropriate, discuss long term management and patient preference for medication, which may be started once the patient is stabilised.
Three options are provided.
Day 2 to 3
Discharge and continuing care
Day 1
Day 2 to 4
Preferably use subcutaneous injection morphine. However, oral morphine or morphine infusion may be appropriate depending on the clinical resources available. Alternatively, if morphine not available or allergy/contraindication, oral immediate release oxycodone may be used.
*Alternatively use IV morphine where appropriate facilities are available
There is a risk of treating a patient for nitazene/another opioid withdrawal, when the presence of nitazenes/other novel opioids this has not been confirmed.
Analysis of patient samples for nitazenes is only available through one laboratory in NSW – NSW Health Pathology Forensic & Analytical Science Service (FASS) Forensic Toxicology Lab at Lidcombe (not to be confused with FASS Drug Toxicology Unit who perform urine drug screens). Analysis of whole blood (EDTA) or urine is possible but requires at least 2 business days following receipt of sample. Therefore, clinicians are likely to need to act without confirmatory testing.
If a suspected nitazene product is provided by the patient for testing, this can be done by FASS Illicit Drug Analysis Unit and results may be available within the same day, if provided to the lab by midday.
To access testing for product or patient samples please email MOH-PRISE@health.nsw.gov.au or call 9461 7178.
There is some evidence to suggest that currently available nitazene test strips may detect certain nitazene analogues in drug samples . However, data on the sensitivity and specificity of these tests remain limited, and concerns exist regarding their usability and the potential for misinterpretation. These test strips may have a role within a clinical setting, where results contribute to a broader clinical assessment and are interpreted within the context of limited supporting evidence. At this time, there is insufficient evidence to recommend their clinical use to test biological patient samples, or consumer use to check drug samples.
A second opinion from an addiction medicine specialist is required for the treatment of patients under 18 years. This second opinion should be saved in the patient's file.
Individual exemptions from the Child and Young Person's (Care and Protection) Act 1998 are no longer required, including for children under 16 years. This is due to be updated in the OTP Guidelines 2018.
Naloxone and overdose brief intervention should be provided to the patient (family and carers) as soon as feasible, in case the patient disengages. Do not wait until discharge.
Anecdotal evidence notes that some nitazene overdose cases required more than one dose of naloxone for initial reversal or for ongoing management. There is very limited experience with intranasal naloxone for nitazene overdose, but it is expected to be effective. Standard doses of 400-800 micrograms naloxone IV/IM appear effective from a series of 9 patients involving single nitazene exposures of metonitazene, isotonitazepyne, protonitazene, protonitazepyne, etodesnitazene.3
Nitazenes can have a longer duration of action compared to other opioids, so toxicity can recur despite initial reversal with naloxone, and can pose a higher risk of respiratory depression.
Services that provide take home naloxone interventions can supply up to two units of Nyxoid® or Prenoxad® to patients per PBS-subsidised intervention. If more doses of naloxone might be needed, additional interventions should be offered to the person.
In services where the NSW Take Home Naloxone Program is not available, naloxone access can be facilitated via existing channels – on a prescriber's order or over the counter at community pharmacies. Drug & Alcohol Consultation Liaison teams may also be available to provide take home naloxone interventions.
The Ministry of Health will continue to send public health messaging and warnings.
See Safety Notice 023/24 Cases of dependence and overdose linked to nitazenes (strong opioids) in refillable vape liquids. All safety notices are available on the NSW Health Safety Alert Broadcast System (SABS).
Call the Drug and Alcohol Specialist Advisory Service (DASAS) on 1800 023 687.
They are a 24/7, free, specialist phone advisory service for all health professionals
NSW Users and AIDS Association (NUAA) is a peer-based drug user organisation that is governed, staffed and led by people with lived or living experience of drug use. NUAA has lots of good information about opioid dependence treatment and other resources.
You can learn more about different drugs, and find out what support is available to you at Your Room.
