Heroin and other opioids – the current situation in Europe (European Drug Report 2023) (2024)

Heroin and other opioids continue to challenge harm reduction and treatment

Heroin remains Europe’s most commonly used illicit opioid and is also the drug responsible for a large share of the health burden attributed to illicit drug consumption. Europe’s opioid problem, however, has evolved over the last decade in ways that have important implications for how we respond to problems in this area.

Data on entry to drug treatment, as well as data from other indicators, support the conclusion that Europe’s cohort of heroin users is ageing, with little current evidence to suggest that the rate of recruitment into this behaviour is growing. Between 2010 and 2021, the mean age of all clients entering specialist drug treatment for heroin use and for those doing so for the first time increased, as did the proportion of older clients (see the figures Age distribution of all clients entering treatment with heroin as their primary drug, 2010 and 2021 and Age distribution of never previously treated clients entering treatment with heroin as their primary drug, 2010 and 2021, below). These changes in the characteristics of those seeking help raise important policy and service-level challenges. Services are faced with the need to respond to clients who present with a more complex and more chronic set of mental and physical health, employment and social care needs. As well as directly responding to drug-related problems, services are also increasingly faced with the need to provide care for older opioid users who may require additional support to prevent or treatage-related illness and disability. This signals the need to reorient existing models of care and services to these challenges and for increased emphasis on establishing effective multi-agency partnerships and referral pathways with general health and social support services.

While heroin continues to be involved in the majority of opioid-related deaths overall, the number of countries in which this is the case has decreased; at the same time, other opioids have become more prominent.Acute drug toxicity presentations to sentinel hospital emergency departments show that, in 2021, in some cities, other opioids – often those used for opioid agonist treatment – have overtaken heroin as a driver of presentations. In addition, in presentations to treatment services, a move away from injecting (see the Injecting drug use section) among both first-time and previously treated heroin clients has also been observed over the last decade, possibly reflecting the effect of safer-use messaging and harm reduction and prevention efforts (see the figure Trends in the main route of administration of clients entering treatment with heroin as primary drug, by treatment status). Only 19% of new clients entering treatment for heroin-related problems now report injection as their main route of administration. This is important, as this mode of administration is particularly associated with a range of negative health outcomes.

Although demand side data are not indicative of any observable increase in heroin prevalence, supply side indicators of availability have returned to or even surpassed the pre-pandemic levels. Following a drop in heroin seizures in 2020, the quantity seized by EU Member States more than doubled in 2021, while seizures in Türkiye increased to record levels (see the Heroin market infographic, below). These increases are associated with large amounts of this drug trafficked in individual shipments, reflecting a more general trend in drug trafficking practices. Despite the greater quantities seized in 2021, there is little evidence to suggest that this has significantly reduced availability, as only marginal changes are observable in indexed trends on retail level prices or purity, and the drug remains relatively affordable by historical standards.

While heroin or, to a lesser extent, medications used for opioid agonist treatment remains the focus for discussion on opioid-related problems in Europe, there are concerns that synthetic opioids may represent a growing threat for the future. New synthetic opioids (see the New psychoactive substances section) currently play a relatively small role in the drug market in Europe overall, although they are a significant problem in some countries. There is, for example, information to suggest an increase during 2022 in availability and harms, including drug-related deaths, associated with synthetic opioids in some northern and Baltic countries. Up to now, most concern in this area has been focused on the availability and use of fentanyl derivatives, such as carfentanil. However, more recently, the appearance of highly potent benzimidazole (nitazene) opioids, including protonitazene, metonitazene and isotonitazene, has been noted, as well as the detection of opioid mixtures containing new benzodiazepines and tranquilisers, albeit on small scale. These substances are discussed in more detail in the new psychoactive substance section of this report.

Key data and trends

Prevalence of opioid use

• Overall, the available indicators suggest that heroin use remained stable in 2021 compared with previous years. It is estimated that 0.33% of the EU population, around 1million people, used opioids in 2021.

Treatment entry for use of heroin and other opioids

• Opioid use was reported as the main reason for entering specialised drug treatment by 71000 clients in 2021, representing 25% of all those entering drug treatment in Europe. Heroin was the primary drug for 10000 (74%) of the 16000 first-time entrants who reported a specific opioid as their main problem drug. Another 2100 first-time opioid clients did not specify their primary drug.
• Because of disruptions to services due to the pandemic, 2020 and 2021 treatment entry data must be interpreted with caution. Nevertheless, the data suggest that the decline in the number of people entering treatment for heroin use continued. The latest European data reveal a time lag of 13years between first heroin use, on average at the age of 23, and first treatment for heroin-related problems, on average atthe age of 36.
• National data from 23 EU Member States show an estimated 419000 clients received opioid agonist treatment in 2021 (417000 in 2020).

Harms related to opioid use

• Heroin remained the third most commonly reported drug in acute drug toxicity presentations in Euro-DEN Plus hospitals in 2021, accounting for 15% of all reported cases. Opioids were found in 19 of the 23 European hospitals participating in 2021 (see the figures Proportion of the acute drug toxicity presentations with heroin involved in 2021, Euro-DEN Plus and Trends in presentations with heroin involved, selected hospitals). Of these, half of the hospitals reported that 6% or more of their presentations involved heroin (i.e. the median value of heroin presence was 6%, across the 19 hospitals in 2021). Heroin was reported in a fifth to a quarter of the drug-related presentations at centres in Drogheda and Dublin (Ireland), Ljubljana (Slovenia) and Msida (Malta) and one of the two centres in Oslo (Norway). Most presentations with heroin involved were among middle-aged men: in 12 of the 20 centres in 2021, no cases were aged less than 25 years. In half of the centres, women represented 11% or less of the presentations with heroin involved. Depending on the centres, the other drugs most commonly reported in these presentations included benzodiazepines, cocaine and amphetamine.
• Opioids were found in an estimated 74% of fatal overdoses reported in the European Union. It should be noted that multiple drugs are commonly found in toxicology reports from suspected drug-induced deaths.

Heroin and other opioids market data

• EU Member States reported 19000 heroin seizures amounting to 9.5tonnes in 2021 (4.4tonnes in 2020). Belgium (1.5tonnes), Romania (1.4tonnes), France (1.3tonnes), Bulgaria (1.2tonnes) and Italy (0.6tonnes) reported large quantities. Türkiye seized over 22.2tonnes of heroin in 2021 (13.4tonnes in 2020).
• The average purity of heroin at the retail level ranged from 13% to 47% in 2021, with half of the countries reporting an average purity between 16% and 24%. Indexed trends indicate the average purity of heroin rose by 38% between 2011 and 2021, while its price dropped by 16%. Slight increases in average price and falls in purity are observable in the most recent data(see the Heroin marketinfographic, below).
• Available data show that almost 11100 seizures of opioids other than heroin were reported in 2021, amounting to over 1.3tonnes, almost 33litres (mostly methadone) and 2.5million tablets (including, tramadol, buprenorphine, oxycodone, morphine, methadone and codeine) (see the table Other opioids: number of seizures and quantities seized, 2021). In the same year, 5.5kilograms and 5500 tablets of fentanyl derivatives were seized in Europe.
• Approximately 23500 offences for heroin use or possession were reported in 2021.

Source data

The data used to generate infographics and charts on this page may be found below.

Show source tables

About this page

Recommended citation:European Monitoring Centre for Drugs and Drug Addiction (2023), European Drug Report 2023: Trends and Developments, https://www.emcdda.europa.eu/publications/european-drug-report/2023_en

Identifiers:

HTML:TD-AT-23-001-EN-Q
ISBN: 978-92-9497-865-3
DOI:10.2810/161905