The fentanyl epidemic in Estonia: factors in its evolution and opportunities for a comprehensive public health response, a scoping review

Anneli Uusküla, Ave Talu, Sigrid Vorbjov, Maris Salekešin, Jürgen Rannap, Liis Lemsalu, Don Des Jarlais

Research output: Contribution to journalShort surveypeer-review


Background: The spread of illicitly manufactured fentanyl has the potential to greatly increase the fatal overdoses in many places in the world. The purpose of this paper is to analyse the evolution of fentanyl use epidemic in Estonia. Methods: this scoping review is based on extensive review and synthesis of broad range of literature: research reports, newspaper, magazine, coverage of illicit fentanyl use; policy documents, position papers, reports released by government agencies, and surveillance data. Results: For an over a decade up to 2017, Estonia has had the highest overdose death mortality in Europe. The use of (injected) fentanyl is a major contributor to the Estonian overdose death epidemic. Shutting down a major producer and distributor of illicit fentanyl has been extremely effective in curbing the number of overdose deaths. Unfortunately, this supply-side intervention came ten years into the epidemic, and might be difficult to replicate in settings with decentralized production. In areas faced by fentanyl we would recommend large-scale implementation of opiate substitution treatment and naloxone distribution, syringe service programs to provide for safer injecting and link to other services (high frequencies of fentanyl injection create high risk for HIV and HCV transmission), and programs, such as “Break the Cycle,” to reduce initiation into injecting drug use. Further, the means of responding to emerging substances should match the world in which different substances can be rapidly introduced, and where people who use drugs can change preferences based on market availability. Conclusion: Addressing illicitly manufactured fentanyl may serve as a public health learning experience for developing early detection and rapid response programs in rapidly changing drug use environments.

Original languageEnglish (US)
Article number102757
JournalInternational Journal of Drug Policy
StatePublished - Jul 2020


  • Estonia
  • Fentanyl
  • HIV
  • drug death
  • illicitly produced fentanyl
  • overdose

ASJC Scopus subject areas

  • Medicine (miscellaneous)
  • Health Policy


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