Previously a stark example of the harms of synthetic opioids, Estonia successfully implemented a range of harm-reduction programmes that reversed its bleak opioid public health crisis.
A recent European study taking stock of the Estonian response to the rise drug-related deaths since the turn of the century demonstrates how harm reduction is an essential part of any public health programme.
Produced within the wider Synthetic Opioids prevalence, use and overdose in Europe (SO-PREP) European project, which aims to produce evidence-based recommendations to prepare for a potential synthetic opioid crisis, their Estonian report described how synthetic opioids entered the country, and how the national Health Institute responded.
The Estonian synthetic challenge
Estonia is a particularly distinct example of a market where synthetic opioids have been more prevalent than conventional opioids. Disruptions in the supply of Afghan heroin to Europe at the start of the 21st century led to the widespread adoption of novel psychoactive substances, particularly fentanyl. Within a year of fentanyl’s introduction, it had overtaken heroin as the most commonly consumed opioid in the Estonian market. As a synthetic opioid, fentanyl is estimated to be 100 times stronger than morphine, with a dose as small as 3mg being enough to kill an adult. As a result, Estonia had the highest mortality rate due to drug overdoses in Europe between 2007 and 2017.
With drug overdose deaths peaking in 2012, there was a need for radical change to prevent this crisis from spiralling any further. Although people who used fentanyl naturally moved away from injecting the drug to smoking it, policy action was needed to take control of the drug harm narrative and reshape the future of the nation.
The Estonian National Institute for Health Development (NIHD) launched their overdose prevention programme in 2013. Most notably, this programme rapidly introduced the opioid agonist naloxone (a drug capable of reversing opioid overdoses) in the country, distributing it not just to people who inject drugs, but their families, friends, health care providers and any organisation that routinely came into contact with vulnerable population. Aljona Kurbatova, Head of Drug Abuse and Infectious Diseases at the NIHD told TalkingDrugs that the “the launch of the government funded national take-home naloxone program in 2013 was considered to be one of the most important steps in resolving the fentanyl crisis”. The number of overdose deaths dropped just as the distribution of naloxone increased across the country.
Not only did the naloxone programme provide an emergency solution to reverse overdoses, it integrated people who use drugs into the health solution. Aljona highlighted how people who used drugs felt more empowered when carrying naloxone as it gives them the opportunity to save others: “Saving someone’s life has increased their [people who use drugs] self-esteem and sense of self-worth”.
The SÜTIK diversion programme
Police diversion programmes have also been important to provide an alternative to punishment and support for individuals where needed. SÜTIK, a social support service aimed at improving the quality of life of people who use drugs, was adapted from an American programme and deployed by law enforcement and health officials in 2018. Police officers can refer people who have committed a drug-related offence to a support ‘peer’ as an alternative to punishment. This peer, who is employed by SÜTIK will then support clients by listening to them and encouraging the client towards less risky behaviours. Short- and long-term goals are set with both parties for at least 12 months, with the peer signposting the client to relevant social and economic services to facilitate their recovery.
SÜTIK’s peers that have gone through similar drug use experiences and can listen and counsel individuals, signposting them to social services if needed. Such support services, beyond helping people access psychological, harm reduction and social services, help build a non-judgemental and trusting relationship with individuals that have often been disenfranchised from the wider society.
What does the future hold?
Harm reduction has demonstrated its efficacy in reducing overdose deaths. However, more can be done to consolidate these improvements. Mart Kalvet, a member of the NGO LUNEST (the Estonian Association of Psychotropic Substance Users) said they are further advocating for the creation of drug consumption rooms across the country, as a way to bring harm reduction services together in a physical space. They also advocate for the abolition of penalties for drug possession, which is proven to improve health outcomes for people who use drugs.
For the NIHD, Aljona mentioned that a new Estonian drug policy would be released this year, which would emphasise the need for people-centred solutions and advocates, and move towards the eradication of stigmatising language from public discourse. The response of the general public has generally been positive towards harm reduction projects because of their efficacy in reducing overdoses. Increasingly, problematic drug use is being viewed as a mental health issue rather than a criminal behaviour.
Although there is always more progress required to normalise drug use and improve access to harm reduction services, the Estonian example of how to reverse such a dire public health crisis is commendable, and should be examined as a case study by the UK, the US and other jurisdictions experiencing an opioid overdose crisis.