The same fundamental drivers but differently expressed: what can we learn from comparing the recent experiences with synthetic opioids in the US and Europe?

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Pardo et al.’s analysis makes a powerful argument for why synthetic opioids have become a major health problem in the United States that also represents a threat to other regions. They highlight the market advantages that highly potent synthetic opioids deliver to suppliers with respect to profits and risk mitigation and argue persuasively for the need for innovative responses. Reflecting from a European perspective, we would endorse the central tenets of this argument, but also point out that there are more general lessons to be learnt from comparing how these same drivers have also impacted on European countries, drawing upon our experience of implementing some of the innovative measures they call for.

While modern drug markets appear more innovative, digitally enabled and globally connected than ever before, they are still adaptive to local demand conditions. In Europe, the trends in long-term opioid use are stable, or even declining, and overdose deaths far lower; the age-adjusted death rate for the United States is more than nine times that found in the European Union (EU). Fentanyls are a concern in Europe, but overall play a more minor role, with patterns of use and supply also differing. Importantly fentanyl overdoses often occur in temporally and geographically limited clusters, and in terms of interventions this means that greater investment is needed in outbreak investigation; rapid risk communication; and forensic and toxicological analysis. These complement the innovative interventions highlighted by Pardoe et al. which already exist, to some extent, in Europe. We would, however, also place special emphasis here on the well-established benefits of adequate access to substitution treatment for opioid overdose prevention.

We would argue that the factors driving the growth in fentanyl availability in the United States can be seen in Europe with respect to the availability of synthetic substances more generally. In addition to synthetic opioids, synthetic cannabinoids, cathinones and benzodiazepines are easy to source, cheap to buy and now appear to be playing a more important role in overdose deaths among marginalized groups. Synthetic drug production within Europe also appears to be growing dramatically, benefitting from innovation in production methods which exploit new routes of synthesis from a wider group of potential source chemicals. This is leading to the greater availability of drugs such as methamphetamine, and the recognition that Europe can now be considered internationally a producer region for some synthetic substances.

A second lesson from the both the US and European experience in this area is the speed at which new drug use patterns can emerge and the rapid ability of the drug market to respond to threats. As international attention has been drawn to the risks posed by fentanyls, control measures have been increased. It is interesting to note in this context that of the eight new synthetic opioids identified in Europe in 2019, only three were fentanyl derivatives. Similarly, the measures proposed by Pardo et al. to disrupt on-line drug markets have been tried in Europe, with some initial success. However, we are also now seeing adaptions including the use of applications and encrypted services that have the potential to make both monitoring and disrupting on-line drug sales even more challenging.

In conclusion, potent synthetic substances that can be easily and cheaply sourced or produced near to consumers bring clear benefits to those involved in drug supply. In our view, the take-home messages from the analysis provided by Pardoe et al. are not, therefore, restricted to fentanyl alone. Rather, this paper represents an important case study on how synthetics substances of all types are likely to play a greater role in future drug problems; that drug markets are becoming more innovative and dynamic and that this is challenging our current response models; that the drivers in this are now global but will be expressed differently in different localities; and, crucially, we are going to need to be more proactive and innovative in our responses including, but not limited to, the interventions highlighted as potentially useful in this paper. Finally, to add further support to the contention that this is an increasingly global and dynamic issue, we note recent concerns that synthetic drug production in Afghanistan, a country traditionally associated with the production of heroin, is rapidly growing and may even have the potential to surpass in value the production of opioids in the longer term. It may therefore be that the main criticism we would make of this paper is that the term ‘opioid’ in its title could be considered surplus!