A record number of Americans died from drug overdoses last year. According to the Centers for Disease Control and Prevention, in the 12-month period ending in September 2020, drug-related casualties surged nearly 30 percent to reach 87,000.

Health experts attribute the rise in casualties to increased drug use during the Covid-19 pandemic, as more Americans suffered through long periods of stress and isolation. But they are also warning of a troubling trend that has emerged: the popularity of a new synthetic form of highly addictive opioids. 

Last August, the U.S. Drug Enforcement Agency (D.E.A.) issued a warning about Isotonitazene, or ‘iso’ as the opioid is commonly called, and temporarily categorized it as a ‘Schedule I’ substance — meaning that it has high potential for abuse and has no accepted medical application.

“The availability of synthetic opioids in the illicit drug market continues to pose an imminent hazard to the public safety,” the D.E.A. said in its announcement. “As the United States continues to experience an unprecedented epidemic of opioid misuse and abuse, the presence of new synthetic opioids with no approved medical use exacerbates the epidemic. The trafficking and abuse of new synthetic opioids are deadly new trends.”

According to the D.E.A., the majority of the iso that is seized in the U.S. is manufactured in China — a similar trend to fentanyl, another synthetic opioid that has wreaked havoc on communities all across the United States. Right now, iso is just one small part of the broader opioid crisis — fentanyl still claims more lives — but health professionals say its emergence highlights some of the challenges the authorities face in breaking the opioid trade,  namely the fact that Chinese manufacturers evade regulations by exporting new forms of synthetic opioids to the American market. 

Before Covid-19 sent the nation into lockdown, there were some signs the U.S. was finally making progress fighting the opioid epidemic. In 2019, for example, under growing pressure from the U.S., China banned the production of fentanyl — the infamous prescription painkiller that is mostly manufactured in China and whose potency has contributed significantly to overdoses in the United States. 

With the arrival of iso, however, it appears Chinese chemical and drug manufacturers — many of whom still illicitly produce and trade in fentanyl — have discovered a new way to tap into the huge demand for opioids among Americans. Iso is not explicitly illegal in China and has similar potency to fentanyl, though experts have yet to gather precise data on the new drug. 

“The entire trend for drug overdose has been increasing exponentially for the past 40 years. In 2018, there was a decline in overdose deaths. That got some people excited. The former administration declared victory over the opioid epidemic,” says Hawre Jalal, a researcher at the University of Pittsburgh who focuses on mathematically modeling the opioid epidemic. “But 2020 is going hyperexponential again.”

While fentanyl is still the synthetic opioid that accounts for the most drug overdoses in the U.S., experts say the arrival of iso illustrates the “whack-a-mole” nature of the opioid epidemic: crack down on one and others emerge. 

“Over the last 12 years, there has been an explosion of new drugs appearing on the market,” says Michael Evans-Brown, a specialist in early warning and risk assessment for emerging drugs at the European Monitoring Centre for Drugs and Drug Addiction, an EU agency. “So it is very likely controlling this type of substance will lead to a new class of drugs. Chemists will look in the literature, and so long as there is a demand, you will probably have this endless cycle.”

While iso has been around since the 1950s, the D.E.A. says that drug seizures and biological samples show that the drug is being identified more frequently in the U.S. since China’s fentanyl ban. The synthetic opioid, which belongs to the class of drugs called benzimidazoles, has claimed at least 19 American lives from August 2019 to January 2020, but the true number could be much higher.

Because it is a newer drug, iso can pose more of a risk for users. Not only is it strong — leading to more overdoses — but because it is new, standard drug tests often don’t catch it in patients’ systems, making treatment more difficult. 

“The danger is higher because it is not detected in routine drug testing,” says Roueen Rafeyan, the chief medical officer at the Gateway Foundation, a non-profit focused on addiction treatment. “If a patient presents at an E.R. with a drug overdose, iso is more potent so it needs more naloxone [which is used to treat opioid overdoses]. But they don’t know it is iso. So then they lose the opportunity to save the life.”

Over the last 12 years, there has been an explosion of new drugs appearing on the market. So it is very likely controlling this type of substance will lead to a new class of drugs.

Michael Evans-Brown, a specialist in early warning and risk assessment for emerging drugs at the European Monitoring Centre for Drugs and Drug Addiction, an EU agency.

Because iso is still technically legal in China, drug sellers can openly sell iso online with little fear of punishment. Indeed, a simple Google search reveals numerous sites peddling the drug, all from Chinese manufacturers. 

“Vendors feel bold about this because, so long as the substances are legal in China, they are not violating domestic law,” says Nicole Cook, an analyst at C4ADS, a Washington, D.C.-based think tank that recently published a report on illicit synthetic drug networks. “There is just little domestic risk.”

Chinese manufacturers of opioids run the gamut in terms of size and type of operation. “There are mom-and-pop operations. Some are making legitimate pharmaceuticals in the daytime and then using the same equipment to make the illicit stuff at night,” says Ben Westhoff, the author of Fentanyl, Inc., which tracked the path of the illicit drug from China to the U.S.. “Some of them are operating within the letter of the law. They are even getting government subsidies.” 

There are also various routes to the United States. Some experts say that due to harsher crackdowns on opioids in the U.S., most of the illegal shipments are first being sent to Mexico, and then distributed in the U.S. with the help of cartels and traffickers. Others say that even with stricter regulation, there are still significant shipments that come to the U.S. through the postal service. 

“Parts of the U.S. government say that everything is going through Mexico and the direct trade [through the mail] has dried up,” says Louise Shelley, a George Mason University professor who researches drug supply chains. “I believe that is wrong. The shipping routes have changed, and they are going through intermediary points. The absence of cases does not mean it is not happening.” 

Given the challenges of targeting supply — even if China stops being the world’s major supplier, experts predict that other countries, like India, will assume the mantle — many addiction experts argue that more attention needs to be placed on demand. “You have to start where it ends,” says Steven Dudley, the co-founder of InSight Crime, a think tank focused on organized crime in the Americas. “And you have to target the overprescription of opioids, which started this epidemic. You are not going to stop this by tracking down the fentanyl.”

Politically, however, it is easier to ascribe responsibility elsewhere. “We frequently look for a boogeyman,” says Dudley, “and if we don’t pin the blame on China, we will blame Mexico.”

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