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SO-PREP: Strengthening synthetic opioids health system preparedness to respond to potential increases in prevalence and use of synthetic opioids


While North America has been experiencing an opioid epidemic for nearly a decade, highly potent synthetic opioids (SO) are also a growing threat in Europe. Many European countries report an increasing availability and use of SO and related incidents and overdoses.

The aim of the project SO-PREP is to contribute to the enhancement of SO preparedness of countries in Europe to effectively monitor and respond to increases in SO prevalence and incidents.

The objectives are

  1. To gain a better understanding of the current prevalence and trends of SO use and health harms in Europe,
  2. To strengthen national health systems’ SO preparedness by developing recommendations on national SO preparedness and response capacity,
  3. To develop an evidence-based toolkit for implementing key responses for SO monitoring and response capacity.

A wide range of activities will be conducted, including surveys to different European countries, interviews with experts from North America and Estonia, analyses of national health emergency preparedness strategies, and the development of a toolkit with implementation guides on 7 key responses to SO.

SO-PREP will produce a range of outcomes, including research reports, policy recommendations, and practical service implementation guidelines. These products will serve a divers group of beneficiaries at national and European level, such as policy makers, service providers, health managers, researchers, and people who use drugs. The expected impact of the project is that countries in Europe will be able to timely and adequately prepare policies and services for the increasing prevalence and harms of highly potent SO.

The project partnership involves 3 National Health agencies (including EMCDDA Reitox National Focal Points), 2 research agencies and 1 European network, thereby creating a balanced combination of expertise and capacities, including science, public policy support, program implementation, and networking.


Over the last decade, global drug markets have been experiencing two main new developments. Firstly, so-called New Psychoactive Substances (NPS) appeared on the market rapidly. Secondly, the role of the Internet as a platform for marketing and buying drugs increased substantially (e.g. EMCDDA, 2018). Both developments have led to a sharp increase in the availability of ‘new’ illicit substances, such as new Synthetic Opioids (SO) (EMCDDA, Early Warning Update). SO are substances with analgesic effects that are similar to those of heroin and morphine, but that are much stronger and more potent and therefore associated with a higher risk of overdose. Examples of SO are fentanyl, carfentanil and other fentanyl analogues. SO are often used in medicine for the treatment of severe pain and in palliative care.

There is an increased abuse of SO for non-medical purposes. Current drug markets show an increased availability of SO in pure form or as an adulterant in other substances, including counterfeit medicines. Sources of the increased availability of fentanyl and other SOs include the diversion of legal medications as well as illegally manufactured substances that are often designed to circumvent existing drug laws. The ever-changing new chemical structures of SO make it difficult to detect them in toxicological samples. Moreover, the potency of SO is such that small quantities can easily be shipped and transported, making them a profitable commodity in the illicit drug trade and a growing challenge for drug control.

The North American situation illustrates the potential magnitude of an SO epidemic. In the US in 2017 alone, over 47,600 people died of an opioid overdose, of which an estimated 28,000 were related to SO. In Canada, 2066 opioid-related overdoses were reported in first the 6 months of 2017, of which 72% involved SO. The number of opioid overdoses, including fentanyl-related overdose deaths, increased continuously in the US and Canada until 2018. After a brief slow down in 2019, it appears that the number of opioid overdoses are skyrocketing again in 2020 due to the COVID-19 pandemic.

There is a growing concern that similar developments of SO availability, use and related harms might occur in Europe. From 2013 to 2014, a significant increase (79%) in deaths due to synthetic opioids was reported in the EU. This was followed by another increase (72%) of deaths from 2014 to 2015. The most recent data shows an increase in SO prevalence and incidents in various European countries. As the number of SO related overdoses and overdose deaths are growing, SO are becoming a major public health threat in Europe.

Are European countries well prepared and equipped for a possible continued rise in SO prevalence, use and incidents? Our project aims to provide an answer to this question, and to produce evidence based recommendations for European countries on how to prepare for a potential SO crisis.