I tried fentanyl. Even ten years ago. A friend from whom I used to buy heroin, once he didn't have it, he offered me fentanyl patches," he says to Center for Investigative Journalism of Montenegro (CIN-CG) a man in his thirties, who wished to remain anonymous. He has been in recovery for a long time, that is, he no longer uses drugs, and he openly talks about the fatality of fentanyl.
Fentanyl was developed in 1959 by the company Janssen Pharmaceuticals (now Johnson&Johnson Innovative Medicine). It is a medicine for severe pain that is up to 100 times more powerful than morphine. It belongs to the category of opioids, synthetic substances, and can be given to patients in the form of injections, tablets and skin patches. Until the mid-90s of the last century, this drug spread rapidly in America and Europe, so it could be found more and more easily on the illegal market.
Fentanyl is 50 times more deadly than heroin. It quickly leads to the development of addiction, and an overdose can easily occur. Just one use of fentanyl can cause breathing and heart problems and lead to an overdose.
"I used fentanyl patches for about a month. Then they stopped being available, I had to go back to heroin. I was lucky that I didn't have anywhere to buy them anymore, because I know people went bankrupt because of it. Their seizures were terrible, a million times worse than heroin's. Some barely survived, some are still addicted (heroin), and some died," says CIN-CG's interlocutor.
One of his friends, who also used fentanyl, went for treatment at the "Kakaricka gora" prison.
"They thought there was no way out for him, but now he's fine," says this guy.
Ju "Kakaricka gora" told CIN-CG that several of their clients reported that they had used fentanyl.
"This was often followed by 'memory gaps' that lasted from a few hours to a few days. Most often, they mixed it with other substances or used fentanyl patches by dissolving them in the oral cavity.
Currently, 25 people who used various drugs are being treated in this institution.
The effect of fentanyl, says the "Kakaricka gora" JU, usually begins with a feeling of relaxation and euphoria, but is followed by dysphoria and apathy.
"Dependence on fentanyl can be recognized by certain signs in the user's behavior. These signs vary from person to person. They can be quite obvious, but very often they are also hidden and develop gradually. It is very important to notice the symptoms in time and start the treatment of fentanyl addiction as soon as possible in order to avoid the most serious consequences".
Some of these symptoms are lack of interest in activities that were once enjoyed, inability to perform daily duties, distance from family and friends...
From the NGO "Juventas", which for years through various projects and activities helps people who use drugs (OCD), with the tests they received through an international project in which they participated for several months in 2023, they discovered that the narcotic drug heroin is present fentanyl. In our country, only the Forensic Center can analyze the composition of substances. If such analyzes could be carried out by other actors involved in activities related to the presence of drugs on the market, it would help Montenegro provide services that would serve to warn people about the consequences of consuming unknown substances and other risks that exist on the black market. .
Until the Forensic Center announces that a new substance has been found as part of the analysis, it officially does not exist in Montenegro. Fentanyl has been in use here for over 10 years. CIN-CG, until the publication of this text, did not receive answers to numerous questions from the Forensic Center.
The black market of drugs is developing, new psychoactive substances (NPS) are appearing, the chemical structure of which has been changed to mimic the effects of controlled substances, i.e. substances whose use is illegal (heroin, cocaine, marijuana, fentanyl, LSD...). As international control, registries and legislation are not effective enough to follow the trends, NPS are consumed legally in many countries. The Montenegrin system is not even able to respond to the challenges posed by controlled substances.
The 2023 World Drug Report of the United Nations (UN) Office on Drugs and Crime warns that the war in Ukraine has disrupted heroin and cocaine trafficking routes.
"This could trigger the expansion of production and trade in synthetic drugs," the document says.
Montenegro currently does not have an updated National Strategy for the fight against drugs. The last one was done in 2013.
There are no tests that show the presence of new psychoactive substances
NGO "Juventas" told CIN-CG that OKDs in Montenegro cannot know with certainty what they are buying.
"The heroin that reaches us is mostly mixed with various other substances. One of them can be fentanyl," explains this NGO.
In Montenegro, a urine drug test can show the presence of around 10 controlled substances - marijuana, benzodiazepines, amphetamines, methylenedioxymethamphetamine, barbiturates, methamphetamine, methadone, cocaine, opiates, tricyclic antidepressants. According to CIN-CG's knowledge, NPS cannot be identified in this way.
This means that doctors cannot know how to react when a person comes to them who has overdosed on some new psychoactive substance.
"We support the idea of the necessity of NPS detection, however, guided by the experience in certain cases of overdose, we consider it equally important to prevent the use of benzodiazepines and alcohol," psychiatrist and coordinator of the Center for Substitution of the Center for Mental Health (CZMZ) Kotor Jovo Đedović tells CIN-CG.
A new psychoactive substance appears on the market practically every week, according to the annual drug reports of the United Nations (UN) Office on Drugs and Crime. In 2021, 52 new drugs were reported for the first time through the European Early Warning System (EWS), and the total number of NPS monitored by the European Monitoring Center for Drugs and Addictive Diseases (EMCDDA) was 880.
The largest wave of new drugs in Montenegro, as well as the largest number of overdose cases, as reported by the NGO "Juventas", usually occurs around New Year's and during the summer.
In addition to new drugs, new trends in the consumption of controlled substances are emerging. Cocaine, for example, is injected more and more often in Montenegro. In some cases, this can lead to certain health complications.
Montenegro has an "early warning system", but it does not include all actors in the state and social system that deal with the issue of drugs. It would be ideal if, according to the NGO "Juventas", all interested parties would be in that system.
In the last few months, 15 people died of overdose in Podgorica and Bar
Montenegro does not collect data on the number of people who died from overdose. A condition related to the overdose, such as cardiac arrest, is usually cited as the cause of death. The families of the deceased often do not want the cause of the deceased's death to be known due to stigma. However, these data would be important to improve the situation in the prevention of addiction.
KCCG told CIN-CG that no one has died from opiate poisoning in the Intensive Care Unit of the Internal Medicine Clinic in the last five years.
CIN-CG addressed all health centers in Montenegro. Many did not answer, and from those who did, they said that there have been no cases of overdose in the last five years.
In that time period, 87 people were tested in Kolašin.
"Everything was introduced through protocols and by computer," said the Kolasin Health Center.
From 2015 until today, not a single person with a clinical picture indicating an overdose has reported to the Kotor Mental Health Center.
"In addition, institutions that treat opiate overdoses do not submit data about these incidents to the Kotor Health Center, all the information we receive about it is based on unreliable data, so there is no register of these events," says Đedović.
However, data from the field of organizations that help people who use drugs (NGO "Juventasa" and the Montenegrin network for harm reduction - "Link") show otherwise.
"Just in the last few months, about 15 people died from overdoses in Podgorica and Bar," they told CIN-CG from "Link".
Well-informed sources told CIN-CG that in Podgorica at the beginning of August this year, within two days, three people who often used drugs together died. Those sources claim that it is possible that those people did not know what they were consuming, nor what the possible consequences were.
According to the United Nations Office on Drugs and Crime (UNODC) World Drug Report 2021, overdose deaths in the US and Canada, largely as a result of the epidemic of non-medical use of fentanyl, continue to break records. Preliminary estimates in the US point to more than 107 drug overdose deaths in 2021, up from nearly 92 in 2020.
Psychiatrist Sanela Kusturica, who works at the Herzegovinian Health Center for CIN-CG, says that overdose as a cause of death could be recorded in the Drug Addiction Registry of the Institute for Public Health of Montenegro.
"In this electronic register, along with the diagnosis of addiction, we are required to fill out an application. In the event of the user's death, we are obliged to deregister him from the register - and deregistration means stating the reason, emigration, death... This could be the official place where overdose as the cause of death (if it is the cause) could be registered".
Numerous researches conducted recently point to a growing trend in the number of people who use psychoactive substances, as well as to the fact that the first consumption of a substance starts earlier and earlier.
According to the results of the ESPAD (European School Survey Project on Alcohol and Other Drugs) report from 2019, the largest international research project on the adolescent use of psychoactive substances in the world, the use of various drugs increased significantly in Montenegro in the period from 2007 to 2019 ( cocaine, ecstasy/MDME, amphetamine, methamphetamine, heroin, marijuana-cannabis, LSD or other hallucinogenic drugs, magic mushrooms, GHB) among minors.
The analysis for the purposes of this report, which was carried out in Montenegro on a sample of about 6.200 students in the first grade of secondary schools in Montenegro, showed that about 18 percent of students had never tried any psychoactive substance until the age of sixteen. About nine percent of students in Montenegro have once tried cannabis. This rate is higher compared to the countries of the region, with the exception of Croatia, where about 20 percent of students once consumed cannabis. Minors in Montenegro usually try cannabis at the age of 15.
In the health system of Montenegro, there are substitution therapies (methadone therapy and buprenorphine therapy) that are provided exclusively by public health institutions and prisons, however, data on the number and characteristics of therapy users are not adequately collected. According to data from the publication "Satisfaction of users with OST programs in Montenegro", which was made by the NGO "Juventas" and the Montenegrin network for harm reduction - "Link", the number of users of OST therapy in 2021 on the first of September was 1.110.
After the introduction of buprenorphine therapy, this publication warns, there was a significant burden on certain health institutions. In terms of the number of users, the Podgorica Health Center (457), KCCG (113) and the Administration for the Execution of Criminal Sanctions (127) stand out.
According to the World Drug Report for 2023 of the United Nations (UN) Office on Drugs and Crime, in 2021, one out of 17 people in the world used drugs, which is 23 percent more than in the past decade. It is estimated that the number of people who inject drugs in 2021 has increased by as much as 18 percent compared to 2020. Overdoses are most often caused by the use of opioids, and the main cause of drug-related deaths is usually attributed to hepatitis C and related liver diseases.
"Most often, our clients start using marijuana in their teenage years, and after that, almost as a rule, they start using synthetic drugs and psychostimulants (cocaine). This is usually followed later by the use of sedatives and opiates (including heroin). This is the most common path that people with OCD go through before they decide to seek help," said the "Kakaricka gora" JU.
Hardly a life-saving drug
According to the knowledge of CIN-CG, in Montenegro, the drug "naloxone", which if administered in time, can save the life of a person who has overdosed, is not easily available to those who need it. It works by breaking the bonds between the receptor and the opiate, causing the opiate to stop working.
The Clinical Center of Montenegro told CIN-CG that they have this medicine in the Emergency Center (UC) and that it is most often given to life-threatening patients by an anesthesiologist when they are admitted to the Intensive Care Unit of the Internal Clinic after being diagnosed in the UC, with certain by the passage of time from the moment of poisoning.
"Patients with urgent and urgent conditions, including those with opiate intoxication, are generally admitted to the UC, where they are primarily provided with emergency medical assistance. The emergency center does not maintain a special protocol for patients presenting with opiate intoxication, but a unique protocol for all patients who seek medical help. If further hospital treatment is necessary, they will be admitted to the appropriate department", they state from KCCG.
Naloxone in Montenegro can only be administered by health workers to people who have overdosed. However, the question arises as to how often they are able to manage to use this drug in time, how aware people who have overdosed are that they should call for help and whether they have someone with them who can and wants to do it for them. Among these people, there are those who find it difficult to decide, since in such cases the police usually come with an emergency. Due to stigma and discrimination, many do not want to know about their condition.
In certain countries in Europe and America, naloxone is available to various subjects who may come into contact with people who are at risk of overdose. In Scotland and the USA this drug is part of standard police equipment. Taxi drivers also have it.
"The fact is that naloxone as an antidote should be made more available, because it saves lives. Naloxone should be administered by persons who are adequately educated, from the medical profession. As in any situation, the benefits should be weighed against the potential risks and harms. At the same time, we need to work on general awareness raising and education of the population (especially people who have opioid users in their family or in their environment) about how to recognize overdose symptoms and how to react in that case," says psychiatrist Kusturica.
“I thought drugs would help me deal with the life challenges I was facing. I wanted to forget about my problems and lived under the delusion that I found solutions in drugs. I was not aware of what was going to happen to me and how much drugs actually destroy my life. I struggled with psychological consequences long after I entered the recovery process," Marko Dragićević, a member of "Link", told CIN-CG.
He used drugs for 20 years, and he has been in recovery for over four years.
"I decided on treatment only when I wanted to die".
The NGO "Juventas" told CIN-CG that there are many more people who hide that they are in the process of recovery than those who use drugs. Because of the stigma, they don't want it to be known that they are being treated.
The recovery process is very long and difficult, but possible, says Dragićević.
"If, at the moment when I was starting to use drugs, I had the opportunity to see someone who has been in the story for a long time and who would have told me, don't, this will happen to you in a couple of years, maybe that would have changed something," says Naš. the interlocutor from the beginning of the text talks about the difficult process of recovery after taking fentanyl.
"We were going through hell, through much more difficult crises than heroin crises. Some barely survived after fentanyl,” he says.
Although fentanyl, as well as new psychoactive substances, are dangerous, the problem is that our institutions do not detect them, so there is no comprehensive strategy for harm reduction.
Bonus video:
