Not Just the United States

In 2025, synthetic opioids claimed almost 38,084 American lives, cementing the United States as the epicenter of the world’s fentanyl crisis. Yet, the United States was not the first nation to face the dangers of fentanyl and illegally made synthetic opioids. Nearly a decade before fentanyl and its analogs infiltrated the US drug supply, the small Baltic country of Estonia was the first nation to fully experience the devastating repercussions of fentanyl. Today, Scotland confronts a similar crisis, where synthetic opioids are gaining an increasing presence in the drug market. The experiences of both Estonia and Scotland demonstrate how rapidly illicit drug markets evolve and how governments have sought to react to such a critical security threat.

Estonia, the Original Overdose Capital of Europe

In 2000, a shift in the global drug business took place far away from Western countries: The Taliban banned the cultivation of opium poppy in Afghanistan. This disrupted the production of opiates such as morphine, codeine, and heroin. A global decline in heroin supply followed. As heroin became scarcer, illicitly manufactured fentanyl (IMF), emerged as a substitute in some drug markets. The arrival of fentanyl into Estonia occurred swiftly, between 2001 and 2003. Initially viewed by the rest of the world as a temporary substitution until heroin supplies recovered, illicitly manufactured fentanyl, instead, became firmly established within the Estonian drug market. Due to its extreme potency, low cost, and the absence of international precedents to aid Estonia’s response to the incursion of such a deadly drug, the decade-long fentanyl epidemic began.

Estonia’s Response: A Slew of Measures

Between the years 2010 and 2017, 70% to 80% of overdose deaths in the country were directly related to fentanyl usage. As overdose fatalities increased and injected fentanyl became more widespread, the fentanyl epidemic began to be identified as a public health crisis. It consequently received increased attention from the Estonian government and harm reduction services. Harm reduction measures expanded considerably over the following years. In 2013, the naloxone take-home program launched, later extending intranasal naloxone to prison medical departments and driving increased distribution by healthcare providers. By the end of 2016, methadone maintenance treatment, part of a broader ramp-up in Opioid Substitution Treatment (OST), became available at 8 institutions. In 2017, law enforcement agencies dismantled clandestine laboratories and seized 9.7kg of fentanyl, disrupting organized criminal networks and the Estonian fentanyl market through key arrests. By 2018, the Needle and Syringe Program (NSP) had scaled up to nine organizations providing free HIV testing, drug counseling, and sterile needles and syringes. This was attained through the efforts of outreach workers and a mobile syringe-exchange van. Antiretroviral Treatment (ART), free through Estonia’s healthcare system, reached over 70% of people who inject drugs in the same year. In addition, SÜTIK, a police diversion program initiated in 2018, acts as an alternative to criminal punishment and provides resources and peer support to drug users. The combined efforts of law enforcement, governmental agencies, and harm reduction services contributed to a significant decline in overdose deaths, which fell to 39 in 2018.

Scotland – The Once “Sick Man of Europe”

Scotland is confronting many of the same challenges Estonia once faced. The infiltration of synthetic opioids into Scotland’s drug supply is an emerging problem related to both polydrug use and the contamination of drugs such as heroin and benzodiazepines. Like Estonia, Scotland has a long history with heroin use. However, unlike Estonia, its heroin market was largely unaffected by the Taliban’s 2000 ban on opium poppy cultivation. It was a second ban, issued in April 2022 by Taliban supreme leader Haibatullah Akhundzada, that impacted Scotland’s drug market. Supply disruptions encouraged greater polydrug use and pushed many users to obtain benzodiazepines and methadone through the black market, increasing the risk of contamination. Nitazenes and fentanyl analogs have since been detected with increasing frequency in Scotland’s drug supply. In 2024, opioids and opiates, such as heroin and methadone, were implicated in 80 percent of drug-related deaths, with nitazenes linked to 76 of those fatalities.

The Scottish Government’s Responses

Unlike Estonia, Scotland’s drug market has not been completely overtaken by fentanyl or other synthetic opioids. Their main area of concern is contamination. Scotland’s longstanding history of prescription drug misuse has compounded this risk. The illegal diversion of prescribed benzodiazepines and methadone, followed by tighter prescribing practices, pushed many users towards the illicit market, where the likelihood of contamination is significantly higher. In response, the Scottish government has expanded both public health and law enforcement measures. The Drug Deaths Taskforce, established in 2019, provides independent expert advice to inform policies and services aimed at reducing drug-related deaths. This was followed by the launch of the National Mission on Drug Deaths in 2021, which increased investment to make high-quality treatment and recovery more accessible.

Scotland’s Harm Reduction and Law Enforcement

Scotland became the first country to introduce a National Naloxone Program, and under the new Mission Plan, emergency service personnel and police officers routinely carry naloxone. Additional measures, similar to Estonia, include Needle and Syringe Programs (NSPs), Opioid Substitution Therapy (OST), and participation in the RADAR early warning system, which monitors emerging threats such as fentanyl and nitazenes. Scotland has also opened its first safer drug consumption facility, providing a clean, supervised environment where people can consume drugs while reducing the risk of a fatal overdose. Law enforcement services, such as the Serious Organized Crime Taskforce, have worked alongside these public health initiatives. As harm reduction services work to provide access to quality treatment and care, law enforcement have worked in coordination with government agencies to disrupt criminal networks responsible for supplying contaminated drugs.

Shared Experiences

Although separated by both geography and time, Estonia and Scotland have experienced the detrimental effects of synthetic opioids. Scotland, almost parallel to Estonia, gained an understanding of how synthetic opioids can easily infiltrate drug supply. As the drug market continues to evolve, both Estonia and Scotland demonstrate that synthetic opioids can emerge under different circumstances. Still, they produce very similar consequences. Through the combined efforts of law enforcement and harm reduction services, the experiences of Scotland and Estonia provide examples of how countries can respond to the unpredictable nature of synthetic opioids.