Last year, 100 people in Estonia died from drug overdoses. The year before, the figure was 113, according to the Health Board's causes of death registry. Of the 100 deaths, 42 were linked to synthetic opioids from the nitazene group.

Drug-related deaths in Estonia began to rise in 2019. While the numbers had previously been stable, there was a sharp increase in 2022. At the same time, one of the main goals of Estonia's drug policy is that no one should die from a drug overdose. This prompted the Ministry of Justice to commission a thorough analysis to understand what kind of people are dying from overdoses and what factors increase the risk.

Gerly Tamm, a postdoctoral researcher in experimental psychopathology at Ghent University and one of the study's authors, noted that since just a few years ago there were only around 30 to 40 such deaths annually, getting closer to zero is entirely possible. "But right now, nearly 100 people die every year. That number is far too high," she said. As of the end of August, 57 people in Estonia had died from overdoses.

The threefold increase in overdose deaths is linked to the widespread availability of nitazenes, a group of potent synthetic opioids. Like fentanyl, nitazenes cause a quick and powerful high, but there is one key difference: nitazenes do not respond as effectively to life-saving treatments as fentanyl does.

Nitazenes are spreading mainly in the Baltic states and are much less common elsewhere in Europe. Artur Kamnerov, head of the narcotics and organized crime division at the North Prefecture, explained that the rise of nitazenes is largely due to the disappearance of certain other substances, such as fentanyl, from the market. This shortage has fueled demand among addicts for new and accessible synthetic opioids.

"To our knowledge, nitazenes are also spreading in Latvia and the United States. In other European countries, their presence is smaller, because other substances like heroin and fentanyl are still available," Kamnerov said.

Last spring, the prescription drug naloxone was added to patrol officers' equipment. Naloxone can save lives in cases of synthetic opioid overdoses, including those caused by nitazenes. No statistics are collected on how many lives police have saved using naloxone.

"We have trained our patrol officers to use naloxone and it is now part of our daily equipment. Naloxone has certainly helped save lives from opioid overdoses," Kamnerov said.

Who is the average user?

A recently completed analysis shows that the profiles of drug overdose victims are highly diverse. According to Gerly Tamm, the study revealed that overdose deaths cannot be directly predicted based on socio-demographic factors such as education or employment. Gender and age proved to be more significant.

"Statistically, most overdose deaths are among men over the age of 30, often Russian-speaking and living in Harju County. But when we dig deeper into the data, we see a very heterogeneous picture: among the dead are both young people and those in their 90s, men and women and people with varying levels of education. The average is an illusion," Tamm stressed.

The study confirmed that while more men die from overdoses, women face a higher individual risk. "If a woman uses drugs, her risk of dying is greater," Tamm said. One specific feature in Estonia, compared with Finland, is the age distribution: in Finland, overdose deaths are more common among people under 25, while in Estonia they occur more often among users over 30.

"This doesn't mean younger people aren't using drugs. Previous studies have shown that they do, but death tends to occur at a slightly older age. We don't know exactly why that is and the reasons are likely very individual," the researcher explained.

Tamm added that while the average user can currently be described through quantitative statistics, more qualitative studies are needed to understand why people start using drugs and why they continue.

"In Estonia, there is little qualitative knowledge on this subject, which makes it difficult to say what prevention methods would work. What we do know from previous studies is that public awareness is essential — people need to know what they are taking and what happens when certain substances are used together. How it affects behavior, the mind and the body," she said.

What are the effects of different substances?

One major concern in Estonia is that people often don't know how different drugs work or what happens when multiple substances are taken together. According to Gerly Tamm, there is a clear need for more education in this area. She noted that strange beliefs about drug use are widespread and many people don't even know the actual effects of certain substances.

One example is nicotine. "When you ask people what nicotine or smoking does to the body, they often say it's a relaxing, calming substance and that they smoke to feel calmer. But in fact, nicotine is a stimulant. People don't know this even about such a widely used substance — let alone about other drugs with complicated names," she explained.

That is why Tamm sees public education as crucial — people need a broader understanding of what stimulants and depressants are. "If someone is going to use them anyway, they should at least understand the effect each substance has. For example, if a person takes a sedative and a sleeping pill together, they should be aware that their heart may stop because both drugs slow down cardiac function. This kind of risk, which comes from not knowing, can be reduced," she said.

Many overdose deaths are linked to the combined use of prescription drugs and illegal substances. "Often people don't even know what they're taking. There have been cases where someone thought they were using heroin, but it was actually the synthetic opioid nitazene," Tamm said.

According to Artur Kamnerov, new synthetic opioids are becoming increasingly potent, leaving users with less and less margin for error when dosing. From the police perspective, prevention means trying to detect new substances as early as possible and blocking their spread by intercepting distributors.

"It's a real challenge because more and more encrypted social media groups are popping up, where buying and selling drugs is extremely easy. Unfortunately, inflation hasn't affected the black market, meaning users are unlikely to stop buying due to lack of money. For instance, the price of cannabis hasn't changed in the past ten years," Kamnerov said.

The problem is also that no substance is pure or safe. "Drugs never come with an instruction manual, so the correct dose is found by trial and error. If a new substance is stronger than earlier ones — like fentanyl and nitazenes — it's nearly impossible to dose it in a way that won't cause serious harm or death," she said.

Gerly Tamm said several countries now offer drug-checking services. That means a person can go to a testing center and find out what substance they actually have; another option is to test it at home. "If someone uses drugs, at least they then know what they're taking. Some fatal cases happen because people think they're using heroin, but it's actually a nitazene, a synthetic opioid," she said.

Right time and place

One of the report's findings was that many of those who died had previously been in prison or in drug treatment centers. "This doesn't mean the treatment was bad. Rather, it indicates that these people had severe addictions. The problem lies in the transition. After leaving prison or treatment, there is no systematic referral to services. People have to seek help on their own, but often they don't reach the right place at the right time," explained Gerly Tamm.

According to her, the system doesn't need to be rebuilt from scratch, but cooperation between services should be improved. For example, family doctors, psychiatrists and social workers could have access to a shared data system and be able to refer patients to the next specialist.

Tamm said family doctors in Estonia could also play a bigger role in monitoring medication use among older patients. "People often don't remember how many pills they've already taken. This can cause an overdose. Family doctors, together with psychologists, could teach ways to keep track of medication use," she said.

One of the most surprising findings for Tamm was that among drug overdose deaths were people over 90. This, she explained, is partly due to methodology — specifically, how drugs are defined. "A narcotic is a legal term: the law defines which substances are considered illegal drugs. But that list also includes medications that in medical terms are completely ordinary drugs. We often see overdose deaths where an illegal drug was used together with a legal one, like a prescription medicine. The terminology is confusing, which is why older people sometimes end up categorized in drug overdose death statistics. But if we think about what a drug overdose really means — an overdose from psychoactive substances — then yes, it fits. Still, it doesn't match the classic profile of a drug death that we're used to," she explained.

Tamm said the study is unique in Estonia and even globally. "It wasn't a traditional academic study but rather applied research. From a scientific standpoint, it was also special because we combined data from different registries: the health information system, Ministry of Justice records and others. All the data was linked using personal identification codes. That is rarely done, because it is complicated and raises data protection issues," she said.

This approach made it possible to view the profiles of people who died from overdoses from multiple angles — health, criminal records, education and more.

Between 2021 and 2024, a total of 332 people died from overdoses, 262 of them men. Artur Kamnerov, head of the narcotics and organized crime division at the North Prefecture, said there is currently a slight increase in drug-related crimes. Misdemeanors, however, have fallen by nearly half compared with previous years. Most drug-related crimes involve handling large quantities of narcotics, while most misdemeanors are tied to drug use.

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