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Estonia stems fentanyl crisis but has few answers for US

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Tallinn (AFP)

Sitting in the back of a mobile clinic, in front of racks of anti-overdose treatments and clean needles, Jaan Vaart recalls when fentanyl first appeared in Estonia in 2001.

"I overdosed four times in a month. A lot of people died," Vaart tells AFP. "That was June or July, I remember."

The yellowish powder is 50 times stronger than heroin, meaning just a few grains can be enough to kill.

"You go unconscious, you stop breathing, you're going blue," Vaart says. "People are using and then pass away, boom."

Against the odds, Vaart survived.

The opioid that is behind the deadly overdose crisis in the United States has also taken a heavy toll in tiny Estonia.

Of the more than 1,600 overdose deaths in Estonia since 2001, the vast majority were caused by fentanyl, according to the European Monitoring Centre for Drugs and Drug Addiction.

The highly addictive drug took a particular hold during a shortage of heroin in the country.

The Baltic nation of just 1.3 million people had until recently the highest proportion of fatal overdoses in the European Union.

But official statistics show that opioid-related deaths plunged to 39 in 2018, the lowest in 15 years and less than a quarter of the peak of 170 in 2012.

It is one of the world's rare good-news stories in the desperate fight against fentanyl.

The success has begun attracting attention, especially in the US, where the government said fentanyl and other synthetic opioids killed 32,000 people in 2018.

However, experts warn that Estonia's small size may make replicating its turnaround elsewhere impossible.

- Life-saving antidote -

Having survived six years of close calls as an addict, Vaart began rehab in 2004 after the realisation that his luck was running out.

"It was prison, death or homelessness. Then I decided to make a change," he recalls.

But overcoming dependency was only the first step.

"I was 26 when I stopped and it was, 'What next? Go back to mother? My classmates were businessmen, doctors, and where am I? I'm nothing.'"

Nowadays, though, Vaart plays a key role in Estonia's anti-fentanyl drive, coordinating the health ministry's network of rehabilitation and needle-exchange centres for the capital, Tallinn.

Today the mobile clinic -- an inconspicuous blue van from the outside, but a clean, brightly lit ambulance inside -- has parked at a run-down housing estate in the Mustamae suburb.

Vaart and his colleagues meet users, offering them clean needles, food, drugs advice or just someone to talk to.

Crucially, the team also hands out the drug naloxone, a nasal spray that can save the life of someone in the throes of a fentanyl overdose.

Officials launched Estonia's take-home naloxone programme in 2013, the year after drug deaths peaked.

Since then, staff have taught around 2,000 people how to administer the treatment.

"The drug users are using it, and also the family members, service providers, and we've trained the police," Katri Abel-Ollo, the leading fentanyl expert at Estonia's Institute for Health Development, told AFP.

- Police breakthroughs -

The biggest strides in the war on fentanyl came in 2017, when police shut down a major laboratory one year after they nabbed members of a gang smuggling in the drug over the Russian border.

"The main middlemen and people who brought fentanyl to the Estonian market have been caught and brought to justice," Rait Pikaro, head of the organised crime division in Estonia's North Prefecture, told AFP.

"Since then we’ve seen a significant change on the market and overdose deaths are four to five times lower than before."

Abel-Ollo says that fentanyl has not disappeared completely from the Estonian market -- new fentanyl derivatives from China still appear, and sales of drugs via the internet are on the increase.

But the quantities trafficked into the country are significantly smaller than before.

- An unrepeatable success? -

Estonia's success has caught the attention of countries seeking strategies to stem their own opioid epidemics.

"The United States and Canada delegations have been here and they have tried to learn, but Estonia is so small," Abel-Ollo said.

"It's quite difficult to teach them to tackle this problem."

State prosecutor Vahur Verte believes the key is Estonia's small size and effective databases to share information on criminals.

"Everyone knows everyone, so it's easy for the different authorities to come together around the same table and speak honestly," he told AFP.

And whereas in Estonia, fentanyl spread among illegal drug users, the US opioid crisis grew out of people becoming addicted to fentanyl-based painkillers prescribed by doctors.

- Law of nature -

Estonia's success in slashing fentanyl deaths coincided with better economic times that have seen its jobless rate fall to around five percent from nearly 20 percent in 2010 when the impact of the financial crisis drove despair.

But the social problems that fuelled the addiction epidemic, like the poverty and unemployment that are prevalent in Estonia's marginalised Russian minority, have not gone away.

"It's the law of nature that something should replace fentanyl," Abel-Ollo said.

"So far it has been prescription medication and also cathinones," -- cheap, mind-altering amphetamines.

These are "bad for the mental health of our drug users. But at least they're not as lethal as fentanyl."

In his mobile clinic, Vaart believes the key to helping people kick drugs is deceptively simple.

"Sometimes it's a reminder of where I was, and that experience helps us to look through that addiction, to see there is a little boy or little girl who just needs some safety."

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