What is the current Synthetic opioid situation in Europe? How can countries be better prepared and equipped for a continued rise in synthetic opioid prevalence, use, and incidents?

1. opioid
preparedness
webinar
Webinar on Synthetic
Opioid Preparedness
What is the current SO
situation in Europe? How can
countries be better prepared
and equipped for a continued
rise in synthetic opioid
prevalence, use, and
incidents?
Welcome to SO-PREP webinar on
13.6.2022 13:00-15:30
1

2. Webinar Program
▪ Welcome words | Elina Kotovirta [Ministry of Social Affairs and Health Finland] 13:00 5 min
▪ Introduction | Chair Tuukka Tammi [Finnish Institute for Health and Welfare] 13:05 5 min
▪ Presentation of the SO-PREP Project & Current SO situation in Europe | John-Peter Kools
[Trimbos institute, The Netherlands] 13:15 10 min + Q & A 5 min
▪ Experiences and lessons learned from the synthetic opioid crisis is Estonia | Aljona Kurbatova
[The National Institute for Health Development, Estonia] 13:50 20 min + Discussion + Q & A 10 min
Break 5 min
▪ Roundtable online group discussion: Are the Nordic countries prepared? | Members of the
Nordic Drug-Related Deaths Expert Group 14:30 45 min
▪ Tools (toolbox) and strategies for SO preparedness in Europe | Tuukka Tammi & Aljona Kurbatova
14:55 20 min + Discussion + Q & A 10 min
▪ Wrap-up & closing remarks I John-Peter Kools 15:25 I 5 min
2

3. Synthetic Opioids prevalence, use and overdose in Europe
Webinar on
Synthetic Opioids preparedness
Nordic region
June 13 2022

4. Overview
1. Background of the issue of Synthetic Opioids
2. Project SO-PREP, approach and results
- Research
- Preparatory toolkit,
3. Conclusions and discussion

5. Synthetic opioids and global trends
Key developments in the drug markets in the past decade:
• Increase in synthetic substances
• Increased role of the Internet/ online markets
• Changes in consumer groups, consumer motives (e.g recreational,
self-help, medical, problematic/dependency)
• Plus the ‘Corona years’: travel restrictions, trade disruptions, mental
health issues and impact on substance use?
• -> Very volatile drug markets

6. Synthetic opioids
• Synthetic opioids
+/+ Pain relieve
-/- High risk of physical dependence and overdose
More potent/toxic and unpredictable than heroin

7. High potency of Synthetic Opioids

8. Complexity of Synthetic Opioids
- increasing number of novel substances
- diversity of users: marginalized, psychonauts, nightlife, self
medication
- adulteration : e.g. heroin/benzodiazepines laced with fentanyl.
- various markets: diversion from medical circuit, prescription
online market, illegaly manufactured
- supply and demand driven: initatially supply driven
(e.g. US/Canada/EE) but later on demand-driven?
Major risks:
• Self-medication for pain relief, tranquilizer
• Synthetic opioids become a business model for organised crime groups

9. European project SO-PREP
Is Europe well prepared for the rise of Synthetic Opioids?
1. What is the current situation?
2. Are countries able to monitor changes?
3. Are there services, interventions in place to respond to SO

10. European project SO-PREP
European Commission supported project, 2020 – June 2022
• Partnership of 3 National Focal Points, 2 Universities and a European
network
• Conducted in Finland, Estonia, Germany, Netherlands, Germany
2 elements:
• Research on the situation in Europe + lessons learned from other
countries (USA, Canada, Estonia)
• Development of a preparatory toolkit

11. SO-PREP Research on the current situation
Combining 3 different datasets:
1. Analyzing the EMCDDA workbooks 2018 and 2019 (primary source of
data), conductd in 2021
2. The EMCDDA Reitox National Focal Points survey, Questionaire in 2020
3. Civil society information (Correlation European Harm Reduction
Network), Questionaire in 2020

12. Research findings
• Increases in the seizures of SOs have been reported over the last years in Europe,
in particular in the Nordic and Baltic countries.
• Trends of the prevalence of SO use in the majority of the countries with available
data, in specific in the Nordic and Baltic, showed an increase of availability and
use.
• Overdose and overdose mortality involving opioids and SOs do not show major
increases in recent years in Europe.
• Although rises in treatment of problematic use of prescription opioids and OST
medications are reported by some countries across Europe, the average number
of people entering treatment for SOs in recent years was found to be stable.
(Except FI, EE)

13. European Drug Report 2021
• Synthetic Opioids: 67 new substances detected between
2009-2020, 10 of them in 2020.
• Increases in seizures of SO substances (fentanyl-type and non-
fentanyls) and SO precursors
• More complex patterns of use and a growing importance of
synthetic substances
• Despite pandemic impact (and uncertainties) a growing
concern
“Everything is increasingly available, is more potent and mixed with
everything.”

14. Increasing prevalence and concerns in Europe (II)
“The question isn’t if SO will hit European markets, it is more a
matter of when.”
Interviewed expert from Canada

15. Conclusion of the research
Europe is, unlike the North America, not in an epidemic phase
of SO prevalence and use;
however, given the increasing trends of availability, use and
harms of SOs in some European countries in particular in Baltic
and Nordic region in recent years, it is important to remain
highly vigilant and to become better prepared.

16. Vigilance is required and better preparedness is recommended
Protective factors:
• Synthetic opioid market supply seems no main target for organised crime
• Environmental factors:
- ‘welfare state’, less inequalities
- drug policy & services: PWUD have access to pubic health services
Recommendations:
• More pro-active responeses recommended
• Address supply of SO:
- Over-prescription and over-use of opioid pain medication
- Vigilant on business model for organised crime
• Address demand of SO:
- Invest in opioid treatment (= protective and response measure)
- expansion and coverage of harm reduction services

17. Thank you for your attention!
jkools@trimbos.nl

18. Experiences and lessons learned
from the synthetic opioid crisis in
Estonia | Aljona Kurbatova [The
National Institute for Health Development,
Estonia]

19. Synthetic Opioids prevalence, use and overdose in Europe
The fentanyl crisis in Estonia:
“It was so much easier when
it was just heroin.”
Aljona Kurbatova
National Institute for Health
Development

20. Overview
Presentation topics:
✓ The rise and fall of fentanyls in Estonia
✓ Challenges encountered
✓ What can we learn from this experience?
Report available:
https://so-prep-project.eu/publications/

21. The rise and fall of fentanyls in Estonia
Fentanyl emerges on the Estonian drug
market:
✓ 2002 due to heroin shortage caused by the war in
Afghanistan
✓ lack of timely action
✓ sharp increase in overdose-related deaths
Fentanyl establishes itself on the drug
market:
✓ under suitable conditions substances can rapidly take over
the market
✓ switching back from fentanyl to heroin is difficult
Figure 1. Illegal drugs causing most poisoning deaths in
Estonia 2000-2009. Source: Tuusov et al., 2013

22. High potency of Synthetic Opioids

23. Challenges
✓Drug services unprepared
✓People who use drugs unaware
✓Diversity of user populations and markets
✓Rigidity of national responses

24. The rise and fall of fentanyls in Estonia
Steep increase of overdose-related deaths
followed by significant decrease:
✓ 2002 vs 2004 vs 2009 vs 2012 vs 2016
✓ Group-based scheduling of substances implemented in 2016
✓ Limited availability of fentanyl since 2017
✓ Large, organized criminal organizations disrupted in 2017-2018
✓ Roll-out of the take-home naloxone program since 2013
✓ Expansion of other harm reduction services
Figure 2: Drug-related deaths and naloxone provision in
Estonia. Source: Causes of Death Registry, NIHD
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Naloxone
provision
Drug-related
deaths
Drug-related deaths Naloxone provision (cumulative)

25. Challenges
Challenges in the time of limited
availability:
✓ No reduction in demand
✓ No substantial increase in OAT uptake
✓ Strong motivation to find alternative
substances
✓ α-PVP emergence on the market
✓ Rapidly changing drug markets create
challenges for drug services
“It was so much easier
when it was just heroin.”
… some time later…
“It was so much easier
when it was fentanyl.”

26. Challenges

27. Lessons
Lack on
knowledge
Being
unprepared
Wishful
thinking
Loss of
life

28. Lessons
✓ Importance of rapid warning systems
✓ Importance of PWUD provided information
✓ Rapid dissemination of information
✓ Drug checking services
✓ Proactive and targeted approaches
✓ Adjusting OAT and take-home naloxone programs
✓ Destigmatization of people who use drugs and decriminalization of drug use
✓ Preparedness, preparedness, preparedness

29. … learned or not?
Signs of emergence of nitazenes on illegal drug market
- are benzimidazole opioids new “fentanyl”?

30. https://so-prep-project.eu
Thank you for your attention!
E-mail: nneo@tai.ee

31. BREAK

32. Roundtable online group discussion
Are the Nordic countries prepared?

33. Finnish Institute for Health and Welfare
Forensic toxicology and the EWS
Early signals and preliminary trends
Pirkko Kriikku, PhD, Forensic toxicologist
13th June 2022

34. Port-mortem
toxicology:
Case U-47700
13th June 2022
pirkko.kriikku@thl.fi - FINLAND 34
2015
May 2017
March 2017
2017
2016
Dec 2016
Sept 2016
Oct 2016
April 2016
March 2016
U-47,700
added to screening
March 2015
First mention of U-47,700 in a
Finnish discussion forum
Nov 2016
U-47,700 scheduled as a
narcotic in Finland
Nov
2016
July 2016
Feb 2016
Oct 2015
Forensic toxicology
issued a warning to
the general public

35. Clinical forensic toxicology
• Clinical drug screens and DUID
analyses
• Often large number of samples
• Good source of information when
evaluating NPS trends
13th June 2022
pirkko.kriikku@thl.fi - FINLAND 35
(In 2022 so far 3 death cases)

36. Finnish national EWS network
13th June
2022
pirkko.kriikku@thl.fi - FINLAND 36
Seizures
Finnish
national
EWS
Customs
laboratory
Police laboratory
(RTL)
Clinical forensic
toxicology
Post-mortem
toxicology
Finnish
medicines
agency (FIMEA)
Poisons
information
centre
Hospital
emergencies
Serious adverse effects
emergencies
deaths
NOPSA-
verkosto
EMCDDA EWS

37. Future challenges for the Finnish EWS
• Alerts and information to those who use drugs
• Twitter, website, app?
• Organized by the labs together?
13th June 2022
pirkko.kriikku@thl.fi - FINLAND 37
Future SO-prep challenges for Finland
• Need for a flexible legislative base that enables pilot studies
• Laboratories / analytical side fairly well prepared but the
treatment sector?

38. pirkko.kriikku@thl.fi - FINLAND 38

39. SE national preparedness related to synthetic
opioids
Joakim Strandberg, Head of Unit for Drug Prevention
The Public Health Agency of Sweden

40. • Opioids is involved in
many deaths
• Less new SO discovered
(compared to 2017 at
least)
• The most common
substances in drug related
deaths (2012-2020)
Current situation
Overdose Suicide Unclear cause
Heroin Zopiclone Methadone
Buprenorphine Propiomazin Alimemazin
Methadone Oxycodone Oxycodone
Alprazolam Alimemazin Tramadol
Amphetamine Paracetamol Buprenorphine

41. • Reporting urgent events and sharing of additional information
• Requires registration and log-in
A national warning system on narcotics (VSN)

42. • National collaboration and co-ordination
– Smooth and reliable processes (in place since beginning of 2000)
– Internet monitoring (several authorities)
– Collecting evidence (including scientific)
• Laws and regulations
– Act on destruction – an administrative regulation
– Goods dangerous to health
– Narcotics
Work related to new substances

43. • Widely available to drug users
• Number of regions with naloxone programs increased from 13 to 20
between 2019 and 2020 (21 regions in total in SE)
• Additional inquiry to support increased availability of naloxone
– contributing to a systematic work to provide naloxone
– propose initiatives to make naloxone available to more people who need it.
• There is also an ongoing investigation led by the Swedish Medical
Products Agency on the possibilities for OTC (over the counter)
classification for naloxone
Naloxone

44. • Just published; a new report (in Swedish) to the SE government
on drug related deaths (see link sent from Mimmi)
Conclusions
• Need for improved statistics
• Targeted measures to various groups
• Both similarities and differences among those who die, e.g.
Drug related (death) statistics

45. • More… or less?
• Addressing mental health problems and comorbidity
– Suicide prevention
• Increased availability to treatment
– Drug consumption rooms?
– Needle and syringe exchange programs
• Addressing risk factors for drug use
Is Sweden prepared for a rise in synthetic
opioids?

46. End
joakim.strandberg@folkhalsomyndigheten.se

47. Synthetic opioids
in Denmark
Christian Tjagvad
PhD, PostDoc Senior consultant MD
SERAF Gladsaxe Substance Use Disorder
University of Oslo Treatment Center
Denmark
SO-PREP webinar 13.06.2022

48. Prevalence in prescribed opioids among women and
men in Norway, Denmark and Sweden, 2006-17
Muller et al., Scand J Pain 2019

49. Prevalence in prescribed opioids among people in Denmark, 2014-
2020
Sorensen et al., European Journal of Clinical Pharmacology, 2020

50. Main drug of use for people enrolling in treatment for drug use
disorder in Denmark, 2011-2020
The Danish Health Authority, The drug situation in Denmark 2021

51. Number of non-fatal acute drug poisonings leading to hospitalization in
Denmark, 2010-2020
The Danish Health Authority, The drug situation in Denmark 2021

52. Cause of overdose death by opioids in Denmark
Simonsen et al., Forensic Science International, 2020

53. Cause of overdose death by opioids in Denmark
Simonsen et al., Forensic Science International, 2020

54. Thank you

55. Strengthening synthetic opioids health systems’
preparedness to respond to the potential increases in
prevalence and use of synthetic opioids
Tools for SO preparedness in
Europe:
Toolkit with seven
implementation guides
Tuukka Tammi, 13 June 2022, Helsinki
tuukka.tammi@thl.fi
SYNTHETIC OPIOID PREPAREDNESS
55

56. Field-Tested Toolkit for Better Preparedness
• Toolkit = seven implementation guides (reports), seven policy briefs,
seven fact sheets
• The aim of theis to provide the service developers and providers
health care providers, governments and other stakeholders for
enhancing their preparedness to monitor and respond to emerging
threats of synthetic opioids
• The Toolkit will include recommendations and guidance on the
implementation of selected measures to respond to synthetic opioids,
including how to fast-track the implementation
• These recommendations are based on good practices and experiences
from countries across Europe and North America.
56

57. Seven Key Responses
e-Health
Opioid agonist treatment
Naloxone programs Drug consumption rooms

58. What aspects of a key response
need to be adapted/changed to
work for synthetic opioids?
SEVEN KEY RESPONSES HOW THEY CAN BE APPLIED TO
SYNTHETIC OPIOIDS
https://so-prep-project.eu

59. Main challenges posed by synthetic opioids
✓Adverse health effects
✓The growing complexity of the synthetic opioid market
✓Potency and unpredictability
✓Scarce scientific evidence

60. Main topics
✓Evidence of effectiveness for synthetic opioids
✓Differences on addressing opioids vs synthetic opioids
✓Adapting responses to address synthetic opioids
✓Operational challenges
✓Policy considerations/Recommendations

61. Challenges
✓Lack of research – practice informed vs evidence based
✓Lack of expertise
✓Legal barriers
✓Costs of adaptation and lack of funding
✓Stigmatization of people who use drugs

62. Examples: Online monitoring
Keyword selection and search strategy
✓ Already existing lists of SO-related keywords can be used and expanded. For example, the EMCDDA
list of SOs or van der Gouwe, et al. that identified almost 60 terms of new SOs that were used to
crawl (sub)forums.
✓ Internet users may use jargon, synonyms or (deliberately) misspelled words, so many (misspelled)
variations of words should be included in keyword selection as well as such terms as “U47700”,
“u44770” or “pinky” for U-47700 or “carfentanyl” for carfentanil .
Examples of online monitoring relating to the supply of SOs
✓ I-TREND’s SASF
✓ PsyIT’s SASF2
✓ Monitoring Telegram by Blankers, et al.

63. Examples: Drug Consumption Rooms
Provision of services
✓ DCRs are currently equipped to respond to the use synthetic opioids by providing a supervised,
hygienic, safe space for drug use, promoting education and information about substances and safer
use practices.
✓ Increased alertness is for the appearance of new substances or combinations.
✓ Integrating DCR, drug checking and naloxone provision.
Building safer use skills
✓ Training DCRs’ staff on different types of SOs, their effects and risks, and strategies for early
detection and management of a SOs overdose.
✓ Training DCRs’ visitors on different types of SOs, their effects and risks, and safer use strategies.
✓ Precision scales available at DCRs can help visitors better control the amount of substance they
use.

64. Examples: Naloxone
Administration and dosage
✓ Multiple sequential doses of naloxone are needed for clinical reversal of new SOs and currently
recommended doses of naloxone may be inadequate.
✓ Unlimited supply of naloxone should be provided (e.g. prepacked naloxone kits usually include
limited supply).
Targeted distribution of naloxone
✓ Prioritisation of naloxone distribution to people who use drugs other than opioids, as other drugs
can be laced with synthetic opioids.
✓ Expanding programs to include more potential bystanders.

65. Contact details and social media
65
#soprep
https://so-prep-
project.eu/
jkools@trimbos.nl
aljona.kurbatova@tai.ee
tuukka.tammi@thl.fi
inari.viskari@thl.fi