ISO, short for Isotonitazene, is a deadly opioid that first started circulating the streets in the United States in 2019, and since August of last year, the drug has taken the lives of at least 19 Americans.  A derivative of etonitazene, ISO is a synthetic drug to treat chronic pain.“But because it was really strong and had side effects, it really never gained medical use,” Dr. Roueen Rafeyan, the chief medical officer of the Gateway Foundation and an assistant professor of psychiatry at Northwestern University. “ISO is a white or yellow powder [that] can be mixed with other substances.  It’s a manufactured opioid...similar to fentanyl but estimated to be even more potent.  In humans, it is probably sixty times stronger than morphine.”In June, the Drug Enforcement Administration (DEA) first categorized ISO as a “schedule I” drug, indicating the synthetic has “no currently accepted medical use and a high potential for abuse.”  Although it has been around for decades, it has only recently become a major public health concern in the U.S.

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“[It] went under the radar,” said Dr. Harshal Kirane, the medical director of Wellbridge Addiction Treatment and Research. “One of the primary reasons ISO in particular has resurfaced now is that China banned fentanyl and all of its derivatives in 2019.”  Because of the ban, drug manufacturers started producing alternatives and these were shipped overseas.“As the new kid on the block, ISO was also able to evade regulation,” said Dr. Rebecca Trotzky-Sirr, an assistant professor of clinical emergency medicine at University of Southern California.“Routine tests don’t pick it up, and while 19 people were identified as dying of ISO overdoses, this is probably and underestimate,” Rafeyan added.  Of the linked fatalities, he said, “Known cocaine users [bought] cocaine, used it, overdosed and died, and they thought that it was maybe laced with fentanyl, but actually the cases are turning out to be ISO.”  The drug was only discovered after autopsies were performed on the bodies to determine cause of death.Trotzky-Sirr explained, “Amid the coronavirus pandemic, we see that people are going to different suppliers for their drugs and there’s just more unknown.”  Overall, Kirane said, “ISO represents the next step in this ongoing cycle of more readily available, more potent synthetic opioids.”Gateway Foundation, the largest non-profit substance use treatment center in the U.S. is currently developing a urine test to detect the drug well before deadly overdoses occur.  Rafeyan emphasized the importance of rapid testing in order for patients to receive life-saving treatment.  “There are some reports that actually Narcan does work for [ISO], but you need higher doses and repeated dosing,” he said. “Testing for ISO will avoid situations where a patient who has used ISO is given a standard amount of Naloxone and it doesn’t work, and the providers and doctors start thinking maybe this is something else, missing an opportunity to save a life.  It is really important for everyone to be aware of [ISO] -- the health care community, as well as the general population.”

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Deadly opioid ‘ISO’ implicated in at least 19 overdoses in US after China bans fentanylA Synthetic Opioid More Powerful than Fentantyl has Emerged