Where Heroin Falls, Fentanyl Rises in Estonia

Fentanyl use has risen dramatically since 2002

While heroin use in Europe is seemingly on the decline, there has been a dangerous uptick in synthetic opioid use, most notably in Estonia where the abuse of fentanyl has given the country the notoriety of European Union's drug-death capital.

The 2014 report by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) revealed that across Europe as a whole, heroin use appears to have stabilized or be on the decline. For example, data showed a drop in heroin-related treatment entry, alongside downward trends in overdose deaths, and drug acquired HIV infection -- all which are historically symptomatic of heroin injection.

While these are certainly positive developments, a concurrent upward trend in the use of synthetic opioids is being seen in some countries, notably Estonia where fentanyl use is on the rise.

Fentanyl, as the EMCDDA describes it, is “a narcotic analgesic with a potency at least 80 times that of morphine.” Within the illicit market it is colloquially referred to as "China white," or more morbidly "Flat-line," due to its notorious ability to induce fatal overdoses. The situation across Europe is, of course, not uniform; many EU member states hold little or no data to suggest illicit fentanyl use has become a problem. In Estonia, however, fentanyl has become the opiate user's "drug of choice," with the number of people being treated for the drug surpassing that of even heroin.

Many place the date of Fentanyl's arrival in Estonia as 2002, when the country was experiencing a dearth of heroin. Exploiting further this void left by heroin, fenatanyl is relatively easy to procure, cheaper, and much stronger than other opiates, making it far harder for opiate dependent users to discontinue. Furthermore, as Time magazine reported last year, the drug is comparatively easier to smuggle; uncut it is barely detectable.

The devastating effect this arrival has had in Estonia is hard to ignore, with drug-induced deaths reaching a staggering rate of 191 per 1 million inhabitants, according to the EMCDDA report, many of which are attributed to fentanyl. This compares to the European Union average of just 17 deaths per 1 million people. Fentanyl must be cut with whey powder or glucose in order for it to be safer for human consumption, giving it a purity of around 5-10 percent. But, the Estonian Forensic Science Institute has found in recent years that amateur chemists are getting these levels wrong, with fentanyl reaching up to 14 percent purity, an extremely dangerous rate.

Many users of fentanyl in Estonia come from marginalized ethnic Russian communities, reported The Christian Science Monitor in October. Kristina Joost, a social worker with a needle exchange program in the capital, Tallinn, explained that Russian-speaking Estonians face greater stresses as a result of their lower socio-economic standing, and aim to relieve this stress with fentanyl. “The bigger the stress” she says, “the harder the drug”. The problem has been compounded by the fact that fentanyl abuse is still a relatively new phenomenon, leaving social workers unprepared. As Joost stated in a separate interview, "In the last 20 years we had to learn everything about this problem, and we are still fighting the fire."

Improving the health and social conditions for fentanyl users in Estonia is paramount to tackling the problem. The EMCDDA's 2012 report placed a high priority on opioid substitution treatment (OST) for those suffering from dependency. There are also calls to raise the profile of the problem, alongside introducing harm reduction tactics such as ensuring the availability of naloxone to users and their families, and educating them in overdose prevention. With regards to law enforcement, the EMCDDA advise the need for greater knowledge of production sites and trafficking routes, combined with discussion and cooperation with producer-countries outside of the EU such as Russia and Belarus.

Katri-Abel-Ollo, analyst at the Estonian Drug Monitoring Centre has warned that while this is for now a predominantly Estonian problem, the drug is so lethal that Europe cannot afford to be unprepared. Indeed, as the recent EMCDDA report has shown, figures from Finland, Sweden and Germany reveal fentanyl use is rising in those countries. A gradual decline in heroin use in Europe is welcome, but only if governments can mitigate the uptake of far more harmful synthetic opioids filling the gap.