The Fentanyl Crisis in Estonia – Part One – Fentanyl

This pair of articles is based on, and inspired by, a July 7 New York Times article by Azam Ahmed, an international correspondent for the New York Times. It focuses on the fentanyl overdose crisis that assailed the country of Estonia, beginning in 2002 and lasted for 15 years. This was years before drugs poisoned with fentanyl started to claim lives in the USA and Canada. This first article describes a brief history of fentanyl, a synthetic opioid that is far more potent than heroin.

Fentanyl was first synthesized by Dr. Paul Janssen in 1960. While the origin of fentanyl occurred for laudable reasons, there is no doubt it has become the scourge of the 21^st century, given its lethality and world-wide use.

Janssen first synthesized fentanyl in his quest for a better anaesthetic to be used during surgery.  Open heart surgery, and other major surgeries had been developed since 1952 and the anesthetics used had a variety of drawbacks including inducing severe low blood pressure (hypotension) and an irregular heartbeat (arrythmia). In some cases, they even proved lethal to the patient.

Fentanyl as an anaesthetic had some important advantages. It induced better anaesthesia and had fewer side effects. It also had an extremely rapid anaesthetic effect. However, it was soon discovered to be 100-300 time as potent as morphine. Often, after surgery it would reduce the patient’s breathing and occasional deaths occurred because of this.

While similar to the effect that morphine had on breathing, its increased potency made this a more serious problem. Indeed, overdoses due to fentanyl occur because breathing stops completely and the user suffocates.

Fentanyl came to more international attention through its use in 2002. In Moscow, Chechen rebels took about 900 people (audience and performers alike) in a theatre at a evening performance. Their goal was to get Russia to remove its troops from Chechnya.

The hostage-taking was stopped when Russian forces piped a noxious gas into the theatre which resulted in the deaths of all the hostake-takers (although its possible two of them escaped) and 132 hostages. The 700 or so surviving hostages were poisoned by the gas and suffered permanent debilitating injuries. These included light to medium severity disabilities according to the Russian classification system in use at the time.

Subsequent analysis of victim’s clothing and urine revealed that the gas contained fentanyl derivatives. Clearly, the lethality of fentanyl had been amply demonstrated. After the “rescue” doctors were unable to treat the hostages who survived because the Russian government refused to disclose the contents of the gas that was used.

No doubt this was because the Russian Federation was a member-state of the Chemical Weapons Convention. This convention included this statement: “never and under no circumstances to carry out any activities prohibited to member-states of this Convention to develop, to accumulate, to stockpile and to use chemical weapons that can cause death, temporary incapacitation, or permanent harm to humans or animals.”

Had doctors known that fentanyl had been used, victims could have been treated with naloxone which was developed in 1961 and approved in 1971 by the Federal Drug Administration in the United States for the treatment of opioid overdoses.

In the same year, possibly due to its proximity to Russia, fentanyl appeared on the streets of Estonia and their fentanyl crisis began, fifteen years earlier than fentanyl overdoses began to increase in the USA. However, the use of fentanyl as a desired opioid more likely began because of the Taliban in Afghanistan.

At the time the Taliban had banned the cultivation of opium poppies in Afghanistan which had produced a shortage of heroin. In Estonia, that gap was filled by fentanyl and the overdose crisis ensued.

In Estonia, as the drug took hold, overdoses rapidly reached the highest level in all of Europe. Estonia made major efforts to deal with the fentanyl crisis. It was able to pass new laws, shut down labs and provide help for addicts. The help included measures like:

Law Enforcement Assisted Diversion

Essentially this is like the decriminalization program Portugal instituted, as described in chapter 14 of my book.  The program allowed police, instead of charging offenders, to refer them to health services and counselling.

Supply Disruption

Authorities were successful in discovering and shutting down drug labs and in arresting involved individuals.

Harm Reduction Services

Users were issued take-home naloxone kits, and needle exchanges to reduce the risk of using drugs.

Resocialization

Recovering users were able to live in drug-free environments and given vocational training to allow them to work. This increased their chances of gaining a livelihood without resorting to drugs.

Incidentally, this is very similar to the proposal in the second edition of my book that recovering addicts would do best if they were able to live in half-way houses run by the same rehabilitation centres where they received their initial treatment.

Given that the prime consideration is not to send them home, where they would be exposed to all the drug cues that elicit major cravings (see my blog article: Rehab as a Revolving Door), some alternative to this must be found. A half-way house run by the staff of the rehab center would allow recovering individuals to maintain some familiarity with the staff, while at the same time eliminating the harmful cues they would be exposed to at home.

After instituting these measures, by 2018 Estonia saw a 70% reduction in overdoses. This is a very impressive result and one countries like Canada and the USA should strive to emulate. As one might expect, authorities in Estonia concluded that they had solved their drug problem.

However, the introduction of newly synthesized street opioid drugs produced even more serious problems. These new drugs were much more deadly than fentanyl. What’s more, they were harder to treat and their effects are even more addictive and more difficult to quit. Part 2 describes the problems produced by these drugs.