Germany Confronts the Looming Threat of Synthetic Opioids

The United States is grappling with a devastating drug crisis. According to the US government, the synthetic opioid fentanyl is now the leading cause of death for individuals between ages 18 and 49 years. It is estimated that around 108,000 people in the United States died from drug overdoses in 2021, a 17% increase from the previous year. More than 70,000 of these deaths were attributed to synthetic opioids.

A development like that in the United States is not expected in Germany, Professor Heino Stöver, from the Institute for Addiction Research in Frankfurt am Main, told the Medscape German edition. “The situation in the US has a different history and cannot be directly compared to that in Germany,” said Stöver, who also serves on the board of Akzept e.V., a federal association that advocates what it considers to be humane drug policy.

In the United States, prescription practices promoted dependence on synthetic opioids among large segments of the population. Some patients later sought illegal opioids. 

In Germany, however, opioid prescriptions are strictly regulated by the Narcotics Act, which requires a special R prescription and reporting to the Federal Opium Agency. This regulatory framework deters many doctors from prescribing opioids, including pain specialists who find them highly effective and fast-acting, said Stöver. Therefore, the mass prescription practices seen in the United States are not possible in Germany, creating a different starting situation.

German Fentanyl Surge

Addiction experts warn that synthetic opioids like fentanyl might flood the German market as early as next year.

This prediction follows the Taliban’s enforcement of a ban on poppy cultivation in Afghanistan, the world’s largest exporter of high-quality opium and heroin. With the poppy supply reduced by 95%, experts predict that heroin reserves will last through this year, but the shortfall in heroin production next year will likely be compensated by synthetic opioids. An estimated 170,000 people in Germany are dependent on opioids and typically use heroin. “We expect synthetic opioids to increasingly enter the German market from next year,” said Stöver.

The UN Office on Drugs and Crime has raised alarms about nitazenes, a new group of synthetic drugs deemed even more dangerous than fentanyl. These substances have recently appeared in several high-income countries and have led to increased drug-related deaths.

According to the World Drug Report 2024, nitazenes, mainly from China, have been detected in Belgium, Estonia, Latvia, Slovenia, the United Kingdom, the United States, and Canada. The European Monitoring Centre for Drugs and Drug Addiction has also expressed concern about nitazenes in its latest report.

The potential of mixing of fentanyl or nitazenes with heroin poses a severe risk. These substances are much more potent, sometimes 50-100 times, than heroin. While 200 mg of heroin can be lethal, just 2 mg of fentanyl can be deadly. If users are unaware of adulteration, their lives are at significant risk.

Fentanyl’s Market Presence

The German AIDS Help’s Rapid Fentanyl Tests in Drogenkonsumräumen (RaFT) project has revealed that fentanyl is already being mixed with heroin in Germany. Conducted at the end of 2023, the project found isolated positive results with regional concentrations, indicating that fentanyl is already present as an adulterant in street heroin.

Notable findings were reported in cities like Hamburg, Düsseldorf, and Münster, with additional positive tests in Berlin, Frankfurt am Main, Hanover, and Wuppertal. Overall, synthetic opioids were detected in 3.6% of 1401 heroin samples tested.

“This is a small percentage, but it goes beyond anecdotal evidence,” said Stöver. He emphasized that the implications of these results, especially for mixed products, suggest that fentanyl is already in the market and will continue to be a presence.

Situation in Europe

Other European countries are also reporting cases involving synthetic opioids. In Dublin, 54 drug emergencies related to nitazenes were reported within 4 days. The drug has appeared in England and Wales, with 30 people in Birmingham dying last summer from heroin mixed with synthetic opioids.

The RaFT project data provide an initial indication of the spread of fentanyl as an adulterant in Germany. In December, carfentanyl, an even more potent substance, was found during a police inspection in Munich.

Drug-Related Deaths Rise 

In 2023, the Federal Criminal Police Office registered 2227 drug-related deaths. This figure represents a 12% increase compared with the previous year’s cases, when 1990 deaths were recorded, and nearly double the figure from 10 years ago. Burkhard Blienert, the federal government commissioner for addiction and drug issues, disclosed these figures in Berlin in late May. Of the deceased, 1844 were men and 383 were women, with an average age of 41 years.

Multiple drug use involving various illegal substances was identified in 1479 cases, marking a 34% surge from 2022. Heroin contributed to 712 deaths, showing a slight decline, while deaths related to cocaine, crack, and opioid substitution saw significant increases.

Is Germany Prepared?

Addiction experts, like Professor Daniel Deimel from the Technical University of Nuremberg in Germany, foresee a looming fentanyl crisis in Germany within the next 12-18 months. “It’s crucial for German drug policy to act decisively at the federal, state, and local levels,” asserted Akzept e.V.

“We are fortunate to have a window to take precautionary measures now, but we need to act now; time is of the essence,” warned Claudia Schieren, managing director of Vision, a drug self-help association based in Cologne, Germany, and member of the federal board of Junkies, Former Users, and Substitutes (ie, patients being treated for addiction with methadone), as reported by the German newspaper Kölner Stadtanzeiger. In an interview with the German news show Tagesschau, Deimel stressed the need for a “paradigm shift in drug policy.”

Critical lessons learned from North America and other regions dealing with synthetic opioids are outlined in the SO-PREP publication, according to Stöver. They include the following seven key strategies: Early warning systems, Internet monitoring, e-health solutions, drug checking, supervised drug consumption rooms, naloxone distribution, and opioid agonist therapy.

To be well prepared, Germany must adopt these seven key strategies must be implemented, said Stöver. However, he noted, “Very few municipalities are currently equipped for this.”

The Akzept e.V. association proposed the formation of a national council to the Federal Ministry of Health and the Federal Drug Commissioner, aiming to bring together various stakeholders including drug help organizations, self-help groups, the German Medical Association, hospital administrators, law enforcement, laboratories, scientific institutes like IFT-Munich, public health services, substitution drug manufacturers, and health insurers.

While a national council is yet to materialize, Stöver mentioned plans for a technical discussion with the drug commissioner this month. The effectiveness of such talks in advancing the implementation of these strategies remains uncertain.

Meanwhile, the United States is rallying global cooperation against synthetic drugs. In July 2023, US Secretary of State Antony Blinken urged more than 80 countries to join forces, citing the United States’ experience as a cautionary tale for the world.

This story was translated from the Medscape German editionusing several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.