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Nitazenes are potent synthetic opioids, never licensed for human use due to profound central nervous system and respiratory depression. Developed in the 1950s, they re-emerged in illicit drug supplies in 2019.1 2 Geopolitical events constraining European heroin supply are expected to drive demand for replacements.3 Nitazenes may require higher and repeated naloxone dosing for reversal and have been increasingly identified in postmortem reports, thus representing a public health concern.4 5 Scottish drug-related deaths are the highest in Europe.6 A Surveillance Study of Illicit Substance Toxicity (ASSIST) commenced in 2022 to provide ED surveillance data on illicit drug-related morbidity and mortality, compare clinical characteristics to toxicological analysis and identify emerging trends.