Over the last two decades, Estonia has witnessed one of the biggest problems with opioid use in Europe and the highest overdose death mortality rate. Based on the risk behaviour and infectious disease prevalence studies among people who inject drugs since 2005, it can be seen that the main opioid injected between 2005-2017 was fentanyl. Estonia is one of the few countries in the world where the drug market has been dominated by illicitly produced fentanyl – a synthetic opioid that is 50 to 100 times more potent than morphine – as well as other fentanyl-analogues such as carfentanil, which can be even more potent. Fentanyl appeared on the Estonian drug market in 2002 due to a temporary shortage of heroin caused by the war in Afghanistan, leading to several waves of overdose deaths among users. At first the situation was expected to be temporary with heroin soon returning to the market. During the following decade, however, fentanyl and 3-methylfentanyl started to dominate the opioid market. Due to fentanyl’s higher potency, switching back to weaker opioids is difficult and heroin disappeared from the Estonian drug market.

The use of SOs (synthetic opioids) has predominantly occurred among communities in the capital area as well as in the northeast region of the country - regions most affected in the end of 1990s and 2000s by socio-economic problems. As the problem was new throughout the world, there were no recommendations or practices from other countries that Estonia could have adapted at the time and the lack of timely and sufficient action led to an unacceptable loss of human lives. It took years for the seriousness of the situation to reach the political level. Clearly defining the SO problem on the state level allowed different parties to be more efficient in achieving shared aims. Significant progress has been made in areas such as group-based scheduling of drugs, take-home naloxone provision and other harm reduction services. As a result of successful police surveillance work, the main SO supply chains were severely disrupted in 2017.

These developments have led to a substantial decrease in overdose-related deaths. However, the decreased availability of SOs has not led to a significant increase in the uptake of OAT, rather motivating the demand for and emergence on the drug market of new alternative substances. New emerging substances can cause unknown harms to people who use drugs and have also required drug services to adapt to the new market situation, which is resource-demanding and costly. Until 2021 the fentanyl market is still disrupted and has not recovered to its previous extent. However, other types of SOs (e.g., isotonitazene and other 2-benzylbenzimidazole group opioids) have started to emerge. Without drug checking services, having an up-to-date overview of the drug market has proven to be difficult. In conclusion, Estonia was unprepared for the emergence of synthetic opioids in 2002 and it took nearly 15 years to mitigate the situation. In recent years, the number of deaths related to synthetic opioids has been increasing in some European countries and it is important to learn from the Estonian experience. The project SO-PREP aims to strengthen European countries' preparedness and response to the threat and potential harm from synthetic opioids.

[See also, Youtube video - Nordic Reform Conference 2021: Aljona Kurbatova, Head of the Center for Drug and Infectious Disease Prevention at the National Institute for Health Development in Estonia. (28 minutes)]