Opioids in Estonia
Country snapshot - Viljam Borissenko
Has opioid related harm increased or decreased in your country in recent years?
Viljam Borissenko: If we look at overdose deaths, then Estonia opioid-related harm is decreased, last year, in 2020, drug-related overdoses was lowest since 2000, 20 persons lost their lives. The highest overdose death rate was in 2012 when the overdose death rate was 170 persons (https://aastaraamat.prokuratuur.ee/prokuratuuri-aastaraamat-2020/tugevatoimelised-uimastid). That’s one of the main indicators, which shows opioid harm in Estonia.
What has been valuable or effective intervention in your country?
There is a complex of interventions, which has brought down opioid-related harm in Estonia. One of them is effective police work. In the year 2017 Estonian police arrested some main producers and distributors of fentanyl. As a result, the market dried down. Even just recently, on August 5th 2021 prosecutor's office published, that police have arrested a man, who held high-risk carfentanyl with a quantity for 40 000 people.
Another effective intervention is needle exchange and naloxone education. Since 2016, Naloxone has been available in Estonia. From 2015 to 2019 close to 4000 sets of Naloxone have been distributed. In most cities in Estonia, there are harm reduction services, also regular needle exchange buses driving around regularly.
A program has been running in Estonia since 2015, which allows prisoners to be released to halfway houses and to adapt to society in a safe environment. At the same time number of prisoners are dropping, at the end of 2020 the number was 2348, so 102 less than at the beginning of the year. Another reason is that substance users are sent to drug treatment programs instead of prisons.
How would you rate the current political commitment to deal with these problems?
In my opinion, during the last two years, not much is done at the political level. The last drug prevention plan „White book“ ended in the year 2018. But now it seems like there are some improvements. Now drug prevention committee just recently released a drug prevention policy till the year 2030, the new „White book“. There committee has targeted challenges in Estonia and goals for the next decade. One highest goal is, that in the year 2030 nobody would die because of a drug overdose. Also, this Document describes approaches in different areas: treatment, police work, medicine, social work, communication with society etc. Co-operation between those fields is also very important.
What are the main measures/decisions/interventions that you see missing at the moment in your country?
One of the aspects which are missing in my opinion: In the course of developing a new policy, the government and other experts could gather around the table also some representatives of non-governmental organizations, which have worked in this field for decades and have valuable experience. At the same time, there could be more support for co-cooperation between the official social system and NGO-s in Estonia. The National Institute of Health Development could do the research among NGO work in streets and residential programs, to get a proper picture of results etc.
Another approach that is missing in Estonia is counselling based treatment. We have some meeting based programs, but they are not successful, partly because not educated staff and low expectations. Better quality groups are on self-financing and some people can not afford it.
National definitions usually refer to acute deaths directly related to drug consumption ("overdoses", "poisonings" or "drug-induced"). Note that, in a few countries, the figures might include also a limited number of cases of deaths indirectly related to drug use (e.g. accidents with positive toxicology). Note in addition that in some countries, statistics published at national level may differ from those presented here, owing to differences of case definition used at national level.
These are absolute numbers, and not all drug deaths are caused by opioids, though a majority are. In 2019 the number of overdose deaths with opiates was 19 (overall overdose deaths - 27).
Available data indicate that the majority of people who inject drugs (PWID) in Estonia primarily use opioids, mainly fentanyl. In 2015, there were an estimated 8 600 PWID aged 15-44 years in the country. Studies among PWID report that amphetamine use also remains common in the eastern parts of the country.
Data from specialised treatment centres in Estonia also indicate that opioids (mainly illicit fentanyl or 3-methylfentanyl) were the most commonly reported primary substances for first-time clients entering treatment in 2016. Nearly 70 % of all treatment clients whose primary substance of use was an opioid reported injecting as their main route of administration. Overall, females account for approximately one out of five treatment clients, but the proportion of females among treatment clients varies by the type of programme and type of illicit drug used.
Drug-induced deaths and mortality
In 2017, 110 drug-induced deaths were reported. Toxicological results attributed the vast majority of these deaths to overdoses of synthetic opioids, mainly fentanyl (in 28 cases fentanyls only) and other fentanyls, such as carfentanyl (reported in 15 cases). The mean age at drug-induced death has increased in recent years, although even in 2017 one fifth of victims were younger than 25 years. Compared with 2016, overdose death cases are more widely spread throughout the country.
The drug-induced mortality rate among adults aged 15-64 years was 130 deaths per million in 2017, considerably higher than the European average of 22 deaths per million.
In 2017, most clients who entered treatment in Estonia were treated in outpatient settings. Among clients entering treatment, 9
out of 10 reported opioids as the primary drug of use (mostly fentanyl, but also methadone or heroin). Most of those who
entered treatment received OST, with methadone being the most commonly prescribed OST medication in Estonia. Although
the coverage of OST is not known, it is assumed to be relatively low.
Domestic production of amphetamine and gamma-hydroxybutyrate (GHB) as well as cannabis cultivation has been reported
in Estonia, but production sites are usually on a small scale. Importantly, an illicit production site for fentanyl was dismantled in
Estonia in 2016. Criminal networks and organisations continue to play a role, but in recent years, sales of drugs via the
internet, particularly the darknet, are reported to have increased substantially. Shipments of synthetic opioids, such as
fentanyl and its derivatives, are increasingly trafficked into the country via postal services. Herbal cannabis, GHB,
methamphetamine and fentanyl are the main substances present on the Estonian drug market.
While fentanyl is reported to enter the country from Russia, the new fentanyl derivatives mainly originate in China. Given the
high potency of some of these substances, they are usually trafficked in small amounts, making them difficult to detect. In
2017, a record amount of fentanyl and its derivatives was seized, up to 10 times more than in previous years.
Estonian law enforcement agencies put their efforts into reducing the availability of illicit drugs among minors, including
distribution via darknet markets, tackling large-scale trafficking and limiting the distribution of illicit synthetic opioids.
Opioids in Estonia - Additional reading
Associated Press: Estonia won its war on fentanyl, then things got worse
In March 2020 The Associated Press wrote an article about the opioid crises in Estonia opening the complicated story of fentanyl use. Estonia has been fighting an opioid crisis for nearly two decades, with an overdose mortality rate nearly six times higher than the European average. Despite the fact that the police won the opioid battle, the market has turned ever further towards synthetic drugs.
"Once fentanyl landed in Estonia, heroin disappeared. Even after poppies started growing again in Afghanistan and Estonian police choked off fentanyl supply in 2017, heroin didn’t come back. Instead, users turned to cocktails of other kinds of synthetic drugs, including amphetamines, alpha-PVP, a dangerous stimulant also known as flakka, and prescription drugs, harm reduction workers, users, public health officials and police told The Associated Press."
Fentanyl is at least 30 times more potent than heroin, making it difficult for users to go back to heroin after being accustomed to synthetics' potency.
According to the article, Estonia won its war against fentanyl in 2017 when a covert laboratory concealed under a staircase in a brick home outside of Tallinn was discovered after a major law enforcement surveillance operation. That year, it was one of two big police busts that essentially cut off opioid supplies. In 2017, police confiscated nearly 10 kilograms of fentanyl, up from 314 grams the previous year. Following the busts, the number of overdose deaths dropped dramatically.
Users did not resort to using heroin after fentanyl was removed from the market, according to local experts. Instead, they started injecting a mix of prescription drugs like amphetamines, opioids like isotonitazene and tramadol, benzodiazepine sleeping pills, and cathinones.
“A person who uses fentanyl compared to a person who uses alpha-PVP is still more in control,” said Aljona Kurbatova, head of the drug abuse prevention center at Estonia’s National Institute for Health Development. “They are mostly a danger to themselves, but with alpha-PVP, people don’t really control how they act.”
Methadone treatment center in Estonia's capital Tallinn
White Paper on Estonian Drug Reduction Policy 2014–2018
Based on the annual reports and reviews of the White Paper, the report on the results of the focus group discussions, relevant publications and studies, and the information received from experts, the Ministry of the Interior, in cooperation with researchers from the Institute for Health Development, prepared this final evaluation report (2019). The report highlights the major changes and developments during the implementation of the White Paper and identified bottlenecks and development needs as a basis for drawing up the policy instrument for the next period.
From the end of 2013, the naloxone program for the prevention of drug overdose deaths has been introduced for opioid patients and their families. Since 2015, the program has been used for people released from prison who have used opioids before imprisonment. In Estonia, naloxone is used in three dosage forms - solution for injection in an ampoule, solution for injection in a pre-filled syringe and, since November 2017, as a nasal spray. Naloxone is a prescription drug that can only be prescribed by doctors, only a few of whom are currently involved in the provision of services to drug users in Estonia.
Experts believe that the number of opioid substitution treatment sites is sufficient, but due to their uneven regional distribution, these sites are not accessible to many people in need. Since 2015, prisoners released from prison with experience in opioid use will have access to a naloxone program, during which released prisoners will receive the necessary first aid and naloxone training and will be provided with naloxone as a medicine. The availability of the naloxone program in prison varies.
One of the future targets is to guarantee substitution treatment at the place of residence and, where necessary, integrated with the treatment of communicable diseases.