Estonia’s fentanyl battle: time to scale-up overdose prevention strategy?

As a joint project between London and Estonia, we present the remarkable history and unique challenges Estonia faces because of the dominance of fentanyl in the opioid market. The presentation will detail the geopolitical and historical reasons fentanyl emerged in Estonia, and the legislative battles addiction services now face in preventing overdose deaths, made more urgent by the emergence of new and potent fentanyl analogues. These include laws that mandate naloxone must be prescribed by a doctor, rather than distributed freely. We also discuss the role police interventions play in the fentanyl supply in Estonia. The presentation is scientifically grounded on our ongoing study into naloxone use in Estonia and London (due to be completed April 2019).

Background: Due to heroin supply problems during the Afghanistan war and Estonia’s close ties with Russia, Fentanyl became and remains the predominant opioid available for recreational use in Estonia, making it unique in Europe. Peaks in opioid overdose death rates coincide with Fentanyl’s introduction in 2002, and with fentanyl analogues entering the market in 2009 and 2012. However, the opioid reversal agent, naloxone must be prescribed by a doctor, limiting its potential to protect opioid users from overdose deaths and leaving the community at risk to further changes in the opioid market.

Aim: To assess overdose witness rates, training with and experience using naloxone, confidence administering naloxone in opioid users and their networks in Estonian cities, Tallinn and Narva.

Methods: quantitative questionnaires from 150 opioid users, their family and friends, and staff at addiction services in Tallinn were compared with 215 of the same questionnaires delivered in South London.

Preliminary results: Service users (n=54 Estonia, n=134 London) were mostly male (67.3% Tallinn, 81.3% London). Lifetime overdose rates in Estonia were 72.7% vs 41.4% in London and injecting drug use was 98.2% in Estonia vs 60.9% in London. Initiation into drug use was almost 8 years earlier in Estonia at 16 years vs London’s 24.9 years. Almost all Estonian service users had witnessed an overdose (92.7% vs 74.2% London). 66.1% of Estonian service users had been trained in naloxone use vs 58.7% in London. Despite only 60.0% of service users having naloxone, 32.7% service users in Estonia had reversed an overdose (Vs 13.6% London, where 74.8% have naloxone).

Conclusions: There is a high-risk opioid using community in Tallinn and Narva, who witness more overdoses and deploy more naloxone despite naloxone being less available compared to a similar population in London.