Since 2017, the Baltic nations of Latvia, Lithuania and Estonia have acted as the canaries in the mine for Europe’s drug market, providing early warnings of new synthetic opioids. This remains true today: recent reports from civil society organisations and the European Drugs Agency (EUDA) highlight that the impact of the latest wave of synthetic opioids is being predominantly felt there.
Historic synthetic opioids in the region
As Europe’s front line for drugs coming from Asia, people using opioids in the Baltics have had to adjust significantly to geopolitical changes in heroin supply. The first Taliban ban on opium production in 2001 caused a massive shortage across the region and leading to drops in product purity: estimates show that heroin purity in Latvia dropped by 10-20% by the fall of 2001.
Fentanyl, most likely produced in Russia, quickly filled the demand. It became a common opioid of choice in the area – particularly among Estonia’s Russian-speaking population. Even when heroin purity returned to normal levels, fentanyl remained the drug of choice for most people using opioids in Estonia (and to a lesser degree in Latvia and Lithuania). This persistence was due to the fact that much larger and costlier quantities of heroin were needed to match fentanyl’s effects.
However, its strength, combined with a lack of access to naloxone and proper support services, led to a concerning increase in fentanyl-related deaths, particularly in Estonia. Overdose deaths reached an all time high of 160 in 2012, pushing the government to implement several measures aimed at reducing drug harms: law enforcement cracked down on fentanyl trafficking, and harm reduction services stepped up their work to support people who use drugs across the country. Other programmes, like take-home naloxone and SÜTIK – a diversion programme connecting people who use drugs with support peers – were increased to help people stay safe and access support.
A new wave of synthetic opioid threats
Today, the threat of synthetic opioids flooding European markets is back – this time in the form of nitazenes, a new family of synthetic opioids that are reportedly stronger than fentanyl and increasingly found across various non-opioid drug supplies.
Once again, the Baltic region served as an early warning. Estonian media has reported on nitazenes seizures into the country, originating from China, Greece and Sweden. Mart Kalvet, a founding member of LUNEST, the Estonian harm reduction association that delivered SÜTIK, told TalkingDrugs that Estonia may have been the first country where nitazenes – specifically isotonitazene – were found in Europe after being detected by police in April 2019. Kalvet highlighted that the Estonian state’s effective crackdown on fentanyl, but comparatively few efforts to address the demand for strong opioids, may have generated the perfect conditions for a new class of synthetic opioids to enter Europe. Since 2019, nitazenes’ prevalence and harms have only grown. In 2022, 39% of Estonian and 3% of Latvian drug-related deaths were associated with nitazenes; by 2023, this grew to 48% and 29%, respectively. In Lithuania, nitazenes are the second most dominant synthetic opioid after carfentanil, detected in about 39% of all drug-related deaths in 2023.
The European threat assessment of synthetic opioids, published just this month by the EUDA, underscores how the region is a key entry-point for these drugs into the continent: 96% of all seized nitazenes in Europe in 2023 happened in the region. The majority of these nitazenes originate from China, shipped in through the mail or trafficked through Latvian groups that are connected with Russian organised crime.
Drug-induced mortality rates per million among adults (15-64) in Latvia, Lithuania and Estonia. Source: EUDA
What to do about this wave of drugs
While Estonia has previously established a good response to fentanyl’s harms, its response to nitazenes has been somewhat subdued. The other Baltic nations are even less-equipped to deal with synthetic opioid harms: Latvia and Lithuania have some of the lowest Opioid Substitution Therapy (OST) access rates in the continent. High levels of stigma and administrative barriers to access mean that treatment retention levels are low, particularly in rural areas.
A serious barrier to reducing opioid-related deaths is the general lack of access to naloxone. Estonia is the only of the three countries with a formal take-home naloxone programme. In Latvia, no national drug strategy seems to be in place, with the previous one having expired in 2017. Parliamentary discussions around a plan to reduce “drug abuse” in 2022 identified the need for take-home naloxone programmes to reduce drug deaths; however, naloxone is currently only available in pharmacies through prescriptions. A take-home programme has not been yet implemented due to “lack of budgetary resources”.
Lithuania does have a national drug strategy in place since 2022, which runs until 2035. Its text recognises that naloxone access is key to reducing drug overdoses, but notes that only 200 people are prescribed it per year. Take-home naloxone programmes have been trialled multiple times with limited success as prescriptions remain limited to people in drug treatment or their family members. Some Lithuanian police forces carry naloxone, but the threat of arrest after recovery remains as drug use remains illegal in the country.
While no public drug checking happens across the Baltics, Estonia and Lithuania have community-level testing made available by civil society organisations. For people using opioids who don’t access their services, they have no idea what they’re consuming or its potency until it’s too late.
Kalvet believes that harm reduction services need to be scaled up, and that includes following through on promises made. In June 2021, Estonia published its National Drug Strategy 2030, produced in collaboration with health, law enforcement agencies and civil society organisations, including LUNEST. An ambitious document, it pushes for a supportive rather than punitive approach to drug use, calling for prevention, treatment, harm reduction and supply-side control. This includes opening drug consumption rooms and drug checking services.
Regional coordination is needed
The different approaches to dealing with drug harms across the Baltics highlights the critical importance for collaboration and sharing best practices within the region. The EUDA’s threat assessment calls not only for collaboration between law enforcement agencies on intelligence sharing on organised crime, but also on sharing public health interventions to reduce drug harms. Key to this is establishing subnational and national OST and sterile injecting equipment distribution targets. Harm reduction needs to be scaled up and move beyond urban centres; this can be provided through state treatment services or civil society.
The Baltic nation-states are like a European weathervane, giving the continent an insight on what is on the opioid market horizon. Responding to their early detection and putting public health emergency measures in place will be key to reduce fatalities. As Estonia has shown, it’s possible to reduce the drug supply’s deadliness through harm prevention and community support. Europe must learn from these past experiences before heroin markets are completely transformed.
