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What Canada can learn from tiny Estonia's huge fentanyl problem

Fentanyl pills are shown in an undated police handout photo.

HO/THE CANADIAN PRESS

Jaan Vaart remembers the summer that fentanyl hit Estonia.

Already addicted to heroin, Mr. Vaart recalls being only vaguely aware that his dealer was giving him something new. He was more concerned about getting his fix.

If the high from fentanyl felt familiar, the difference between this new drug and heroin soon became clear.

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"I overdosed two times that week," he says, "and a third time later that month."

He knew from friends and from what he saw in the news that people were dying, and he wanted to stop. Instead, he grew more hooked. Soon he was using it up to six times a day. He dropped out of school and became isolated from his old friends and family. To feed his addiction, he turned to crime. Eventually, he ended up in prison.

Of all the former Soviet republics, Estonia might seem the least likely for Mr. Vaart's story to have taken place. The tiny country, perched on the Baltic Sea next door to Russia and looking across to Finland, is a beacon of success in a region of political and economic instability.

It is among the world's most wired countries and is recognized as one of Europe's most important incubators for high-tech startups. A member of the euro currency zone since 2011, it is consistently ranked as one of the European Union's fastest growing economies.

But it also outperforms in a far darker measurement: Estonia has the European Union's biggest fentanyl-abuse problem.

Unlike Canada, where the deadly scope of the fentanyl crisis is only now coming into focus, Estonia has been dealing with the problem for more than a decade. The country's response – which was slow off the mark and only became focused specifically on fentanyl after the crisis drew the world's attention – could offer a cautionary tale for Canada, where a Globe and Mail investigation has found governments of all levels have been similarly slow to act.

Though there are differences between the two countries' experiences, the bottom line is the same: Without intervention, fentanyl kills people at an alarming rate.

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After communism

The problem began in the late 1990s as hard times came to large swaths of Russia and its former satellites after the fall of communism. Although Estonia as a whole was charting a promising course, some areas of the country – such as the northeast – were hit hard by the collapse of its industrial base.

It was an environment ripe for drug dealers to exploit. By 1999, between 15,000 and 20,000 people in the country of 1.3 million were hardened heroin addicts, fed by a reliable supply from the poppy fields of Afghanistan. Most were male, and most were under 25.

The following year, when the Taliban imposed a ban on opium, the supply to the former Soviet republics was cut off. To fill the void, dealers began production and street distribution of synthetic opioids. "China White" and "White Persian" – street names for fentanyl and its molecularly similar cousin 3-methylfentanyl – were pushed to users who could no longer get heroin.

Almost immediately, there was an epidemic of overdose fatalities.

In 2002, 105 fatal overdoses from illicit drugs were reported – 90 per cent caused by fentanyl. Over the next 10 years, the toll topped more than 1,000, again almost all from fentanyl or 3-methyfentanyl, giving the country the highest overdose death rate per capita in the European Union. In 2012, when 170 deaths were reported, it became among the highest fatal overdose rates in the world.

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Estonia is not the only European country to have been struck with a fentanyl crisis, but it is a "special case": According to a 2015 report from the European Monitoring Centre for Drugs and Drug Addiction, fentanyl use there has become what the centre calls "endemic" – a permanent situation with no end point.

But why have users in Estonia not returned to heroin, when the supply channel from Afghanistan has been restored for at least 10 years?

"It's what they call the million-dollar question," says Aljona Kurbatova, head of the Infectious Diseases and Drug Abuse Prevention Department at Estonia's National Institute for Health Development.

She believes the situation is likely supply-related – orchestrated by the traffickers.

"The dealers realize it's easier to traffic and package fentanyl than heroin … and so they strictly control the market in favour of fentanyl," she says. "Even though drug users themselves say they would prefer heroin, it's simply not allowed [by dealers] in Estonian markets."

Others are not convinced the market explains everything. Katri Abel-Ollo, an analyst at the Estonian Drug Monitoring Centre, suggests that some fentanyl users in Estonia may have developed an addiction that does not easily allow a return to an alternative drug.

"One intravenous drug user told me that after fentanyl, heroin was like pure water to him," Ms. Abel-Ollo says. "They have no interest in buying heroin any more because they need much stronger doses after fentanyl use."

A lost decade

Almost all fentanyl users in Estonia inject it, though a small group of users inhale it. So in addition to the overdose deaths, the country's widespread intravenous drug use presents other stubborn challenges.

Estonia has the European Union's highest HIV infection rate, with more than 1 per cent of the population HIV-positive – seven times the rate of neighbouring Finland. Hepatitis C, a sometimes-fatal infection of the liver passed along easily through the reuse of dirty needles, is also rampant. One study in Tallinn found 94 per cent of fentanyl users were hepatitis C-positive.

The initial public-health response in Estonia was not to fight fentanyl abuse specifically, but to combat the exploding injection-drug problem in general. A needle-exchange program first appeared in 1997, and the first methadone drug-substitution program arrived in 1999. But these were small-scale efforts, and the services were only available in certain regions, Ms. Kurbatova says.

Only in 2004 did harm-reduction services become widely available – with a large amount of funding over four years from the Global Fund, a public-private partnership that serves as the world's largest financier of programs to combat AIDS, tuberculosis and malaria. In addition, there was funding for more widespread non-pharmacological treatment, such as cognitive behaviour therapy.

A more focused response specific to fentanyl did not arrive until 2012, when the number of overdose deaths brought media attention from around the globe. Police cracked down on fentanyl, and naxolone, an antidote for overdoses, was introduced the following year.

The efforts have brought some success. The rate of new HIV cases has fallen to about 300 a year, from about 1,500 in 2003. In recent years, there have been fewer overdose deaths – unofficial estimates from 2015 suggest only 84 fatalities – but the rate remains the highest per capita in Europe.

But Ms. Kurbatova laments the country's slow response.

"We lost a decade," she says. "In the 1990s, when drug injection began, we decided to neglect the problem. Had we introduced evidence-based policy that had been tested by many countries around the world – like substitution treatment and efficient HIV testing – we would have saved a lot of people that we lost."

Looking forward, she says, more needs to be done for fentanyl users, who, in the most recent 2009 estimate, numbered 6,000.

"Naloxone is a good short-term fix, but it is not enough in itself. It prevents a death, but then what? An overdose is a moment in a user's life when he rethinks about the value of his life and his behaviour. And then you need to be able to motivate, to offer possibilities of treatment," Ms. Kurbatova says.

She also thinks Estonia needs to be prepared to experiment with new treatment strategies. "We don't know whether heroin-assisted replacement would work in the context of fentanyl, but with our situation, it needs to at least be considered," she says. This would involve the government itself issuing controlled levels of heroin to users, a concept that has been shown to improve lives for unregulated heroin users in other parts of Europe, including the United Kingdom and Switzerland.

For many, any government action may come too late, as some fear there's a far more ominous reason for the slowing deaths.

"Another possible explanation is that a generation of drug users are simply dying out," says Gleb Denissov, who, as head of the Estonian Death Registry, has had a front-row seat to the crisis over the past decade. "And this group is not being replaced by new users."

Statistics suggest this as a compelling explanation. One study showed that between 2005 and 2009, the percentage of people between the ages of 15 and 44 who use injected drugs decreased from 2.5 per cent to 0.9 per cent in Estonia. It's a possible indication that news users may be decreasing.

Even more telling is that the average age of overdose deaths has shifted over a decade – in lockstep with the aging of the epidemic itself. Whereas in 2002, the average age of overdose victims was 24, in 2014 that age had increased to 33. It is perhaps not just that fewer users are dying; it's that there are fewer around to die.

If this explanation is accurate, it offers some hope. It suggests that programming is working to prevent people from becoming fentanyl addicts, and that an end to the fentanyl crisis is possible.

But it also suggests that there is a block of the population that has been consumed by the drug, a lost generation that cannot escape fentanyl and is dying out over time.

Jaan Vaart is lucky he's not among them. His life changed a few months after he was released from prison. He overdosed one more time, while at a job he had. He woke up to paramedics trying to resuscitate him, and he took off. The ridiculousness of the scene – literally running from the people who had just saved his life – made him realize how low he had sunk.

He joined Narcotics Anonymous. After some setbacks, it stuck, and it has for the past 12 years.

Now 41, he is an addictions counsellor sharing his experiences with people who are trying to find a way to leave fentanyl.

But he is also concerned about the generation ahead.

"If I would say one thing about the future of drugs in Estonia it's that even if naloxone has solved a bit of the problem of overdosing, it has not solved the problem in the long run," he says.

"The dealers, they have other drugs. I'm sure they introduced more than a 100 different types in Estonia last year. It's not about the drugs. You need to deal with social factors, the psychological factors, the spiritual factors that lead people to drugs."

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