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Nordisk Alkohol Nark
Nordisk Alkohol Nark
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Nordisk Alkohol- & Narkotikatidskrift : NAT
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SAGE Publications Sage UK: London, England

10.1177/14550725241253362
10.1177_14550725241253362
Commentary
North America's fentanyl death crisis: Selected lessons for Europe's future?
https://orcid.org/0000-0002-2186-4030
Fischer Benedikt Faculty of Health Sciences, Centre for Applied Research in Mental Health & Addiction, 1763 Simon Fraser University , Vancouver, British Columbia, Canada; Research & Graduate Studies, University of the Fraser Valley, Abbotsford, BC, Canada; Department of Psychiatry, 7938 University of Toronto , Toronto, Canada; Department of Psychiatry, Federal University of Sao Paulo, São Paulo, Brazil; School of Population Health, University of Auckland, Auckland, New Zealand

Jutras-Aswad Didier Research Centre, Centre Hospitalier de l’Université de Montréal, Montreal, Canada; Department of Psychiatry & Addictology, 5622 Université de Montréal , Montreal, Canada

Le Foll Bernard Department of Pharmacology & Toxicology, 7938 University of Toronto , Toronto, Ontario, Canada; Department of Family & Community Medicine, 7938 University of Toronto , Toronto, Ontario, Canada; Dalla Lana School of Public Health, 7938 University of Toronto , Toronto, Ontario, Canada; Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Center for Addiction & Mental Health, Toronto, Ontario, Canada; Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada

Robinson Tessa Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, 3710 McMaster University , Hamilton, Ontario, Canada

Benedikt Fischer, Faculty of Health Sciences, Simon Fraser University, 515W Hastings St., Vancouver, BC V6B5K3, Canada. Email: bfischer@sfu.ca
22 5 2024
8 2024
41 4 464468
20 3 2024
23 4 2024
© The Author(s) 2024
2024
SAGE Publications Ltd, or Nordic Centre for Welfare and Social Issues, unless otherwise noted. Manuscript content on this site is licensed under Creative Commons Licenses
https://creativecommons.org/licenses/by-nc/4.0/ This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage).
drugs
Europe
fatality
fentanyl
interventions
North America
overdose
policy
public health
toxicity
typesetterts19
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pmcFor the past decade, North America ([NA]; i.e., Canada and the United States) has been experiencing an unprecedented public health crisis from drug-related toxicity deaths (DTDs) (Ciccarone, 2021; Fischer, 2023). After 2000, this crisis has claimed in excess of 1 million lives; this death toll is similar to that from the COVID-19 pandemic, but involves mostly younger ages, thus incurring a comparably higher burden of disease. In 2022, there were 109,680 (rate: 32.4/100,000) DTDs in the United States and 7525 (21.2/100,000) DTDs in Canada, representing the leading cause of death for many age groups (Ciccarone, 2021; Fischer, 2023). Importantly, the vast majority of recent DTDs in both countries have been caused by illicit, synthetic opioid (fentanyl/fentanyl-analogues [F/FA]) products. F/FA substances are highly potent and toxic, commonly mixed or contaminated with other drugs, resulting in extremely high risk for overdose fatalities (Cheema et al., 2020; Hayashi et al., 2021).

The European Union's (EU) recent DTD levels are substantially lower in magnitude (i.e., 6166 or 1.38/100,000 in 2021) compared with NA's exceptionally high DTD toll (EMCDDA, 2023). While there has been recurring speculation whether a similar F-/FA-related crisis may unfold in the EU, there is conflicting evidence towards the possibility of such a scenario. On the one hand, recent epidemiological data show that approximately three-quarters (74%) of DTDs in Europe were opioid-related. Although a minority of EU countries report that most of these DTDs were heroin-related, these deaths feature increasing involvement of both (pharmaceutical and non-pharmaceutical) opioids, including a small (<3%) – but mostly prescription-related – proportion of fentanyl-related DTDs recorded mostly in Germany and Northern Europe (EMCDDA, 2023). On the other hand, Europe overall has not experienced the markedly oscillatory patterns in prescription opioid dispensing that occurred in and contributed to vast supply reductions for medical and non-medical opioid use in NA, and therefore presumably facilitated the onset and rapid proliferation of F/FA availability (Fischer & Robinson, 2024; Manchikanti et al., 2022). At the same time, the availability of heroin in Europe depends on imports from volatile global, illicit drug markets – a source that may quickly change or dry up, and so lead to supply gaps that may facilitate the proliferation of widespread F/FA availability and use.

The arguably quintessential lesson from NA's persistent F/FA crisis is that, despite extensive expansions of standard and implementation of new intervention strategies, these efforts have overall not effectively succeeded in reducing the related DTD toll (BCCDC, 2024; Fischer, 2023; Irvine et al., 2019). For example, in the province of British Columbia (BC), Canada's epicenter of the DTD crisis, a widely diversified menu of opiate agonist treatment (OAT; e.g., including different medication and/or administration options) has been made available. While up to approximately 25% of the population at risk for overdose are estimated to be OAT-engaged, especially long-term retention is low and/or co-use of other (opioid and non-opioid, including F/FA) drugs is common (Krebs et al., 2021; Piske et al., 2020). For targeted prevention, approximately 50 government-sanctioned (and more unofficial) supervised consumption/overdose prevention service sites (SCS/OPS) have been established. While illicit substance use at these facilities is considered DTD-protective, the existing SCS/OPS contingent cover only a marginal proportion of overall drug consumption episodes on the population level; moreover, most SCS/OPS do not accommodate non-injection (e.g., inhalation) use, the most common mode of use implicated in recent DTDs, therefore further limiting utilisation and protective impacts (Panagiotoglou, 2022; Parent et al., 2021). Similarly, point-of-care and take-away versions of “drug checking” services (e.g., for F/FA content) are available; however, their utilisation is considered sporadic, and effects on risk behaviors unclear (Ti et al., 2020; Tilhou et al., 2023). Finally, naloxone (antidote-based overdose reversal) is widely disseminated and frequently applied; yet, its mode of action is only reactive to overdose, and its applied efficacy is increasingly compromised by both common solitary/isolated drug consumption and increasing F/FA potency and/or contamination with other drugs (Fischer et al., 2024; Lei et al., 2022; Pergolizzi Jr et al., 2021).

In consequence, while each of the interventions described provides substantive elements of protection, this, on the overall population level, has been insufficient to curtail BC's excessive and persistent DTD toll. These adverse circumstances raise fundamentally important questions as to the appropriateness, but especially inherent limitations of the intervention strategies presently available and relied on for a DTD-related public health crisis (EMCDDA, 2023; Fischer, 2023; Irvine et al., 2019). These questions are hypothetically while equally pertinent for Europe, where a reasonably good availability and coverage of related interventions, in conjunction with elaborate 'early warning' systems exist; however, in case of an acute F/FA-related crisis as recently experienced in NA, these may prove to be similarly insufficient to effectively address and halt the to-be-expected DTD toll.

A recent Canada-based innovation to reduce F/FA-related DTDs have been “safer opioid supply” (SOS) programs where, to date, a small proportion of at-risk users are provided with pharmaceutical-grade opioids (e.g., morphine, hydromorphone, fentanyl) to reduce illicit/toxic F/FA exposure and related overdose (Fischer & Robinson, 2023; Ledlie et al., 2024). While the SOS concept is controversial and concerns exist regarding possible diversion, initial results have shown notable improvements for drug use, overdose risk and health outcomes among participants, and so warrant further evaluation and evidence-informed ramp-up.

In conclusion, the odds of a F/FA-driven DTD crisis in Europe similar to NA's are hard to gauge. If it unfolds, the armory of existing intervention strategies, based on experiences described, may be expected to be insufficient, underscoring the need for anticipatory strategic preparedness and advanced intervention development and establishment.

Data availability: All data in this manuscript are accessible in the public domain (e.g., in the form of journal articles, reports, websites).

The authors declared the following potential conflict of interest with respect to the research, authorship, and/or publication of this article: Dr. Fischer and Dr. Jutras-Aswad have held research grants and contracts in the areas of substance use, health, policy from public funding and government organisations (i.e., public-only sources) in the last 5 years; Dr. Fischer was temporarily employed by Health Canada (2021–2022). Dr. Jutras-Aswad has received study materials from Cardiol Therapeutics and Exka for clinical trials. Dr. LeFoll has obtained research support (i.e., research funding/in-kind supports or expert consultancy) from Pfizer, Inc. (GRAND Awards & medications), Indivior (clinical trial funding & consultancy), Aurora Cannabis Enterprises Inc., Bioprojet Pharma, Brainsway (Transcranial magnetic stimulation [TMS] study), Canopy Growth Corporation (research grants), Alcohol Countermeasure Systems (ACS), Alkermes, Universal Ibogaine, and Shinogi. Mrs. Robinson has no competing interests.

Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Jutras-Aswad acknowledges a clinical scientist career award from Fonds de Recherche du Québec (FRQS). This specific study was not supported by any sponsor or funder.

ORCID iD: Benedikt Fischer https://orcid.org/0000-0002-2186-4030
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