Opioid problems are changing in Europe with worrying signals that synthetic opioids may play a more significant role in the future

Abstract

Heroin has been the opioid most associate with harm in Europe; however, this may be changing. Recently there are signals that synthetic opioids could play a more important role in the future creating a need to be better prepared to respond to any significant changes in patterns of opioid consumption. Opioids remain a leading cause of drug-related mortality in the European Union (EU), but the health burden is lower than that observed in North America. In 2021, there were 6166 overdose deaths reported in the EU [1]. An estimated adult mortality rate of 18.3 per million. In comparison, in 2021 the age-adjusted rate of overdose deaths in the United States was 324 per million [2, 3]. This difference is striking and arguably reflects differences in both patterns of use and public health provision. In North America, a growing public health emergency has been linked to an increase in the use of synthetic opioids among a population in which service contact is often limited [4]. Illicitly manufactured fentanyl has displaced heroin and prescription opioids to become the main driver of an epidemic in opioid-induced deaths. In the EU, things look different. Heroin has been the main opioid of concern since an ‘epidemic’ in the use of this drug during the 1990s and 2000s. Today, the information available suggests that the heroin-using population is overall an aging one with little evidence of significant new initiation. This is also a population characterised by high levels of service contact by international standards. If the current situation in Europe remains stable, simply because of natural aging we might expect that opioid-related problems will diminish over the next decade. There is some evidence that this is beginning to happen. Although heroin remains important in public health terms, it is not as central as it once was. Treatment demands have declined and other non-opioid drugs now represent a larger share of new presentations. Injecting use has also become less common and is now only reported by ~20% of new attendees. In other indicators, such as data from emergency presentations, other drugs, notably stimulants, now appear more prominently [5]. Opioids remain associated with around three quarters of drug-related deaths and heroin remains in absolute numbers at EU level the drug associated with the greatest share of opioid deaths. However, only in a minority of countries is it now the most common opioid detected. When detected, it is usually in combination with other substances. This is not new as polypharmacy has always been observed in heroin mortality data. What is new, however, is the more significant contribution that synthetic opioids and cheap ‘street benzodiazepines’ appear to be now playing as a driver of trends in mortality in Europe. There are other signals that synthetic opioid use is occurring within the EU and causing harm. There appears to be an increase in the prescribing of opioid-containing pain medicines in some countries and these are also beginning to feature more in indicators of harm [6, 7]. Fentanyl(s) both diverted from therapeutic use and manufactured illicitly has become an established problem in the Baltic countries and there is evidence (e.g. from syringe residues) of use in marginalised groups of elsewhere. In 2021, ~140 deaths associated with fentanyl were reported in the EU. However, a significant share of these was associated with fentanyl diverted from medical use. Since 2009, a total of 78 new uncontrolled opioids have been identified on the European market. These include 13 highly potent benzimidazole (nitazene) opioids [8]. The appearance of this group is likely to have been potentiated by of a number of national and international actions aimed at reducing the availability of fentanils. Nitazene opioids have been available in some Baltic countries from around 2019, but their availability appears to have increased since 2022 and they are now contributing to a rapid escalation in the numbers of opioid related deaths. Outbreaks of deaths associated with these substances have also been noted in other countries recently, including the United Kingdom [9]. New opioids have also been found in fake benzodiazepine or opioid analgesic medicines and in mixtures with bromazolam, a new benzodiazepine, and xylazine, a veterinary anaesthetic and sedative [10]. Most heroin in Europe is produced from poppy grown in Afghanistan. Price and purity data suggest that heroin availability has remained relatively stable in recent years. Information from satellite monitoring and other sources suggests that actions by the Taliban have caused a dramatic reduction in poppy cultivation in 2023 [11]. If sustained, this could lead to a shortage of heroin in Europe from late 2024. A previous short-lived heroin shortage led to changes in opioid consumption patterns in some countries that persisted even when heroin availability increased [12]. It is too early to speculate if a shortage will occur, but should this be the case, it could increase the demand for synthetic opioids in the short term, which may persist into the future even if heroin availability returns. Currently very little synthetic opioid production is thought to occur in Europe, but seizures of laboratories and precursors have been recently observed. Europe is also a centre for synthetic drug production with links existing with groups producing synthetic opioids for the North America market [13]. There is, therefore, very little to suggest that synthetic opioid production could not be rapidly scaled up if market conditions were supportive. In conclusion, although it is difficult to draw direct parallels between Europe and North America [14] the American experience does provide an example of how changes in opioid use can occur rapidly with important implications for public health. Speculating on the future is difficult, but an assessment of the current European situation would suggest that changes in the availability and use of synthetic opioids pose a credible future threat to public health, especially if some of the new forms available prove to be attractive to a wider group of consumers. It would be prudent to increase our preparedness to detect and respond rapidly to any significant changes in opioid consumption especially if there is evidence of greater use among younger age cohorts. In the short term, a potential heroin shortage may require us to increase treatment provision, a worst-case scenario, however, is that in the longer term, we may also need to respond to new challenges posed by the increased availability and use of potent synthetic opioids. Paul N. Griffiths: Formal analysis (equal); writing—original draft (lead); writing—review and editing (equal). Thomas Seyler: Data curation (equal); writing—original draft (supporting); writing—review and editing (equal). Joanna M. De Morais: Investigation (equal); writing—original draft (supporting); writing—review and editing (equal). Jane E. Mounteney: Formal analysis (equal); writing—original draft (supporting); writing—review and editing (equal). Roumen S. Sedefov: Formal analysis (equal); writing—original draft (supporting); writing—review and editing (equal). The authors wish to acknowledge the contribution to this article made through the work of the Reitox network of national focal points. None. Data available on request from the authors.

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