Repressive drug policies fuel overdoses in Estonia – An interview with Mart Kalvet

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Repressive drug policies fuel overdoses in Estonia – An interview with Mart Kalvet

22 November 2017
Peter Sarosi

Estonia is a country hit hard by the opioid overdose epidemic. People struggling with overdoses in other countries can learn a lot from the Estonian example about what works and what does not work in preventing deaths and suffering. We interviewed Mart Kalvet, an activist representing LUNEST, the Estonian organisation of people who use drugs.

Drugreporter: Tallinn is often called the overdose capital of Europe. Why do so many people in Estonia die of overdose?

Mart Kalvet: People in Estonia, especially in Tallinn, surrounding areas, and in the Ida-Viru County, where the concentration of Russian-speaking people and/or people without citizenship is greater, die of overdoses at a greater rate because they use street opioids, often in combination with other substances – both legal, like alcohol and prescription medicines (clonazepam, diphenhydramine, etc.), as well as illegal, like amphetamines. Most of the people who die of overdoses are injecting drug users. The primary cause of death is almost always listed as fentanyls, because fentanyls are pretty much the only street opioids available in Estonia. There is no one clear explanation as to why that is. The “original” fentanyl — 50 to 100 times more potent than morphine — had made occasional appearances on the market before the start of the current overdose epidemic, but didn’t catch on as the main drug of choice of opioid users before the year 2002. The combination of a long drought in Afghanistan, the post-9/11 US military action in the region, and scrupulous work by Estonian anti-narcotics agencies may have been seminal in crashing the heroin market and facilitating the emergence of suppliers of synthetic black market opioids in Estonia, but these factors don’t really explain why heroin never returned to Estonia, and why there’s no fentanyl problem to speak of (yet!) in the surrounding countries.

How many people use opioids in Estonia?

Although exact numbers of users of illicit drugs – especially injecting opioid users – have never been known, it is estimated that the population using injectable drugs in Estonia was almost halved after 2002 — if you were an opioid user at that time, you either quit heroin, because it was no longer available, or switched to fentanyl. A lot of the fentanyl users I’ve talked to claim that for them, heroin (which actually tries to make a reappearance on the market now and then, but has thus far failed to make a lasting comeback) has the same effect as injecting clear water. Toxicologists claim that, for fentanyl users, achieving the desired effect takes four or more times more heroin than for an average heroin user, which might mean that the opioid users here couldn’t afford to substitute fentanyls for heroin even if they wanted to.

Another aspect that probably affects the overdose rate is the fact that fentanyl has actually not been widely available in the Estonian black market for some time. Successful busts of great amounts of regular fentanyl by the police in the 2000s made it possible for trimethylfentanyl to emerge as the market leader. In recent years, a similar pattern has repeated — despite the recent blanket ban on all possible fentanyl-type drugs and their precursors, novel fentanyl analogues like furanylfentanyl, acrylfentanyl, carfentanil, ocfentanil etc. appeared on the wider marker… but not before the drug police had managed to infiltrate and take down a large network of trimethylfentanyl suppliers. There appears to be a disconcerting correlation between successful police action and spikes in overdose deaths. Correlation, of course, does not imply causation, and the amounts confiscated represent only a tiny percentage of the amount of drugs consumed daily in the country, but since similar trends are evident everywhere where attempts to solve the problems around the black market of drugs with brute force have been made, the unwanted consequences of enforcement of drug laws should not be overlooked.

Do the authorities acknowledge this?

I must stress that this is not the official position of Estonian state bodies. The police claim that the correlation is spurious, as according to their sources, the novel analogues had appeared even before the crackdowns. A coordinator of substitution therapy at a methadone centre who’s been active in the field of addiction treatment and harm reduction since the 1990s, told me that every time, before newer, more potent and deadlier drugs appeared on the Estonian market, there would be massive dumping campaigns conducted by organised crime groups who were giving away the new analogues for free for a couple of weeks, until their clientele had been properly hooked. Inquiries among former and active injecting drug users do not confirm such accounts — no-one I know has ever heard of drugs being given away for free — but as far as I know, the question of why these specific drugs have overtaken the market in these specific periods of time in Estonia, or why overdoses spike in the same years that police confiscate record amounts, has never been properly studied. Until that happens, hearsay, speculation, and anecdotal evidence are all we have to rely on.

What harm reduction measures are accessible for drug users to prevent overdoses?

We have harm reduction centres that distribute clean needles and syringes, as well as other gear, but the quality of their work is not uniform, and a lower level of quality appears to be in direct correlation with the overall attitudes of the personnel of these centres towards their clients — people don’t want to go to exchange needles or get methadone from a facility where they’re treated like human garbage. Until now, there have been no mechanisms in place for clients to express either their dissatisfaction with the services, or proposals for making them more efficient.

The official position of the coordinators of Estonia’s methadone program — as well as pretty much everyone involved with the field of drug policy in an official capacity — is that all interventions have to be evidence-based. Unfortunately, there’s no evidence of the level of efficacy of methadone-based substitution treatment for users of fentanyl and fentanyl analogues. That’s understandable, as Estonia is the only place in the world where fentanyls are the drug of choice for the overwhelming majority of street opioid users. Alas, the methadone program’s international evidence base rests on treating only heroin addiction. That may be the reason why a significant percentage of people receiving methadone also inject additionally — and are sometimes kicked out of the programs when caught. Most of the methadone patients for whom the therapy appears to be giving the best results seem to be people who started using opioids in the 1990s or early 2000s, when fentanyls were not yet the dominant opioids on the market, i.e. people who started their opioid use with poppy extract or heroin. The official bodies have noticed this, and we’ve been told by several official sources that a plan to expand the substitution treatment program with state-funded buprenorphine is currently being considered, so hopefully things will be changing in a better direction.

Naloxone is available in Estonia at five harm reduction centres in Tallinn and the Ida-Viru County. People who want to get it — drug users, their family members, and people with an otherwise heightened probability of witnessing an overdose — have to take a half-hour training course. Unfortunately, awareness of the effects of naloxone, its role in reviving overdose victims, and its availability among injecting drug users is relatively low. I have heard several accounts from people who were stopped and frisked, and after finding a naloxone kit on their person, taken to the police station for medical tests, and later fined and/or arrested. The police don’t hang around needle exchange facilities anymore, trying to arrest clients, but carrying a syringe, either used or clean, on your person is still considered probable cause for drug-testing by the police, which undermines the efforts of harm reduction workers. We’ve recently been told by representatives of the state police and border guard board that such practices are now heavily discouraged, which, if true, would definitely be an important step in the right direction… but I’d like to see that written into law as well.

Click here to read the full interview.

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