Data from the European Syringe Collection and Analysis Project Enterprise (ESCAPE): data explorer, analysis and key 2024 findings

Background and introduction

While evidence from drug treatment centres suggests that injecting drug use is declining among heroin clients in the European Union, the risk of overdose death and infectious diseases associated with this mode of administration remains high for the estimated 500 000 people who inject drugs. Reliable information on the substances that are being injected is necessary to guide prevention strategies and plan the provision of harm reduction interventions. 

Page last updated: 5 June 2026

Objective

ESCAPE – the European Syringe Collection and Analysis Project Enterprise – aims to identify the range of substances being used by people who inject drugs in a sentinel network of cities in the European Union and neighbouring countries, and to monitor changes in patterns of use over time. The city-level data it provides can complement other information and indicators on drug consumption and potential emerging health threats in the region.

Method

Each year since 2017, city-level study teams aim to collect at least 150 used syringes from low-threshold harm reduction services. After extraction of the syringe contents, samples are analysed in participating laboratories, using either targeted or non-targeted screening methods. The primary indicator shown here (in the data explorer) is the percentage of syringes testing positive, by drug category, by city and by year. The denominator is the number of syringes testing positive for at least one drug category, as defined in the generic protocol (link). Other indicators of interest include the percentage of syringes containing two or more drug categories, and the most frequent combinations detected. Detailed information on the network’s methodology can be found in the ESCAPE generic protocol.

Data limitations

  • The data are based on a sample of syringes and reflect specificities of the local drug markets, patterns of use and sub-populations of users accessing the participating harm reduction services. As a result, findings are not necessarily representative of the city or national situation, and limited sample size can reduce the ability to detect significant trends.
  • High proportions of syringes containing stimulant residues could reflect a higher frequency of injecting among stimulant users, rather than a higher prevalence of stimulant use among people who inject drugs (selection bias).
  • Drugs found in syringes may originate from blood drawn into the syringe during an injection, that is, from drugs consumed prior to the injection, possibly through other modes of administration (measurement bias).
  • It is not possible to distinguish diverted legal medicines from illicitly produced medicines.
  • It is not possible to distinguish a syringe containing residues of multiple drugs from a single use from a syringe that had been reused by one or several users.

Explore the data

Use the filters at the top of the map/graphs to view data by city, year and drug category. Click on a bubble or select a location from the city drop-down list to view results from the 2024 campaign.

Detection of drug categories (% of syringes), by city, by year

Use the filters at the top of the map to view data by year and detected substance. Click on a bubble or select a location from the City drop-down list to view details about a location and the selected drug. Note that when no data is available for a given combination of filters (substance, year, location), the button will be greyed out.

 

Key 2024 findings

Overall

  • The 2024 campaign resulted in the collection of 4 012 used syringes from sites in 23 participating cities in 16 countries (see map). The substances detected varied widely, reflecting local markets and different sub-populations of users. A total of 99 substances were detected (excluding substances classified as adulterants, metabolites or degradation products).
  • Half of the syringes collected contained residues from two or more drug categories, which may indicate that people who inject drugs often inject more than one substance or that syringes are reused. The most frequent combination is a mix of a stimulant and an opioid.

Opioids

  • Heroin was detected in more than 50% of analysed syringes in eight of the participating cities (Amsterdam, Athens, Barcelona, Cologne, Cork, Dublin, Limerick, Oslo).
  • Opioid agonist medications were detected in syringes including buprenorphine (more than 10% of syringes in Helsinki, Paris, Patras, Prague, Thessaloniki, Tunis and Volos) and methadone (more than 10% of syringes in Barcelona, Cork, Klaipeda, Madrid, Patras and Riga). Morphine was detected in 17% of syringes from Reykjavik and 13% from Paris.
  • Carfentanil – a derivative of fentanyl – was commonly found in syringes from Lithuania and Latvia: Vilnius (93%), Klaipeda (66%) and Riga (16%). Fentanyl was found in syringes from Riga and Klaipeda, but at lower levels (4% and 2%). Low levels of fentanyl were detected in syringes from Thessaloniki (2%), Madrid (1%) and Oslo (1%).
  • Nitazenes, a group of potent synthetic opioids, were detected in multiple cities. In Tallinn, metonitazene was found in 35% of syringes and protonitazene in 35%. In Riga, N-desethyletonitazene was found in 23% of syringes, isotonitazene in 21%, metonitazene in 20% and protonitazepyne in 4%. Nitazenes were also found for the first time in Lithuania – 4% of syringes in Klaipeda were positive for protonitazene and 1% for etonitazepyne.
  • Substances detected for the first time in 2024 included the synthetic opioids spirochlorphine (7% of syringes in Riga) and cychlorphine (6% in Riga).

Stimulants

  • Traces of stimulants (cocaine, synthetic cathinones or amphetamines) were found in more than 10% of syringes tested in 21 cities.
  • Cocaine was detected in more than 50% of syringes in 11 cities: Thessaloniki (95%), Barcelona (94%), Limerick (91%), Split (87%), Dublin (70%), Madrid (69%), Cork (69%), Volos (68%), Cologne (62%), Athens (61%) and Tunis (61%).
  • Amphetamine detection was most common in cities mainly located in the north and northeast of Europe – Tallinn (69%), Oslo (69%), Riga (52%), Budapest (28%), Reykjavik (22%) and Helsinki (21%). Methamphetamine detection was also higher in Prague (72%), and in cities in the northeast: Riga (38%) and Tallinn (28%). Detection in other cities (37% in Amsterdam and 25% in Paris) could reflect different patterns of use, such as chemsex when collection sites included services for men who have sex with men.
  • Twenty-seven synthetic cathinones were detected in the 2024 campaign, including two that were the focus of an initial EUDA report in 2025 (N-ethylnorpentedrone detected in Budapest, and 2-methylmethcathinone (2-MMC) detected in Amsterdam, Madrid and Paris). Synthetic cathinones were most frequently detected in Paris (71%), Budapest (58%), Madrid (30%), Riga (30%) and Helsinki (23%).

Other substances

  • Benzodiazepines were detected in more than 10% of syringes in Athens, Dublin, Volos, Cork, Helsinki, Tunis, Thessaloniki, Riga and Patras. Overall, the most detected benzodiazepines were diazepam, alprazolam and desmethyldiazepam.
  • Substances detected for the first time in 2024 included the antipsychotic drug promazine (10% in Riga) and the synthetic cannabinoid ADB-4en-PINACA (3% in Cologne).

 

EUDA resources on responding to harms associated with injecting drug use

This data explorer focuses on patterns and trends among people who inject drugs in specific locations across Europe. To accompany the situational overview, the EUDA offers a range of resources to support the prevention and reduction of harms associated with injecting drug use.

The interagency guidance on prevention and control of infectious diseases among people who inject drugs identifies evidence-based interventions for preventing and controlling HIV, viral hepatitis, sexually transmitted infections and soft tissue infections.

The threat assessment of highly potent synthetic opioids in the Baltic region describes a range of response options, including for people who inject drugs.

The Responses Miniguides on preventing drug-related infectious diseases and opioid-related deaths offer an overview of interventions available and evidence of effectiveness.

The Miniguide on the provision of harm reduction equipment for high-risk drug use provides an overview of key issues in the area, including service delivery, guidance and evidence, and considerations for implementation.

The Response Miniguides on stimulants and polydrug use consider responses to different patterns of use and specific substances.

 

City factsheets 2024

Amsterdam 2024

Estimated number of people who inject drugs in the country/city: The Netherlands: 940 [uncertainty interval (UI) = 780-960]; Amsterdam: no recent estimate.

ESCAPE Collection sites: four low-threshold services, including one service for men who have sex with men.

Laboratory: Brightlabs bv

Laboratory method: GC-MS analysis

Number of syringes analysed (with at least one drug category detected): 137

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were heroin (51%), methamphetamine (37%), cocaine (14%) and synthetic cathinones (mephedrone (2%), 2-mmc (1%)).
  • Most common combination of drug categories found in syringes was a mix of cocaine and heroin (4%)
  • Most frequently detected substances classified as adulterants were: caffeine (28%), paracetamol (26%) and phenacetin (2%).

Interpretation

  • The 3 main substances were mostly found independently of each other, suggesting distinct profiles of use (or sequential use rather than concomitant use): heroin, methamphetamine and cocaine.
  • Cocaine and heroin found in the same syringes could reflect the prevalence of a practice known as injecting ‘speedball’ among PWID attending the other services, a pattern of polydrug use that has been associated with a higher risk of overdose [1].   
  • Methamphetamine (crystal meth) use has been reported by men who have sex with men in Amsterdam (STI clinic and online survey in 2016) [2]. In these surveys, 6-7% of men who have sex with men reported injecting drugs in the last 6 months.
  • No new synthetic opioids were detected in Amsterdam in the 2024 ESCAPE campaign.

Related studies and/or monitoring data

Athens 2024

Estimated number of people who inject drugs in the country/city: Greece: 2 598; Athens: 2 150

ESCAPE Collection sites: one mobile needle and syringe programme, one drug consumption room, one automatic kit dispenser

Laboratory: Laboratory of Forensic Medicine and Toxicology - Faculty of Medicine of Thessaloniki

Laboratory method: Screening method (UPLC-MS/MS)

Number of syringes analysed (with at least one drug category detected): 294

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were heroin (83%), cocaine (61%), benzodiazepines (alprazolam, 46%; diazepam, 28%; desmethyldiazepam, 9%), followed by tramadol (10%), methadone (6%), other medicines (pregabalin, 6%) and methamphetamine (6%).
  • Fentanyl was detected in one syringe (<1%).
  • The most common combinations of drug categories (% of all syringes) were:
    • heroin, cocaine and benzodiazepines (18%)
    • heroin and cocaine (13%).
  • The most frequently detected substances classified as adulterants were caffeine (92%), paracetamol (85%), dextromethorphan (50%) and levamisole (18%).

Interpretation

  • Heroin and cocaine found in the same syringes could reflect the prevalence of a practice known as injecting ‘speedball’ among PWID, a pattern of polydrug use that has been associated with a higher risk of overdose [1]. High levels of all cause mortality were reported among PWID in Athens in 2018-22 [2].
  • The latest study on HIV transmission among PWID in Athens in 2014-20 suggested a possible link to cocaine injection [3].
  • The detection of methamphetamine decreased compared to the 2023 campaign, but it was still detected in 2024. It is not clear whether methamphetamine detection reflected its use in a context of ‘chemsex’, or whether it reflected the potential re-emergence of a pattern observed during the 2013 economic crisis among homeless people (street name ‘sisa’) [4,5].
  • Fentanyl was detected within the ESCAPE campaign for the first time in Athens in 2024. The detection of tramadol was a recurrent pattern of concern given its potential for acute toxicity [6].

Related studies and/or monitoring data

Barcelona 2024

Estimated number of people who inject drugs in the country/city: Spain: 6 862 [UI = 4 091-9 633]; Barcelona: no recent estimate (in 2024, there were 1 823 users of the drug consumption rooms in the city).

ESCAPE Collection sites: 4 collection sites, including drug consumption rooms and a mobile needle and syringe programme

Laboratory: Aquatic One Health Research Center (iARCUS), University of Santiago de Compostela

Laboratory method: High-performance liquid chromatography system coupled to high-resolution mass spectrometry (HPLC–QTOF), using auto MS/MS mode

Number of syringes analysed (with at least one drug category detected): 101

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were cocaine (94%), heroin (63%) and the medicine piracetam (57%). Other substances included methadone (12%), hydrocodone (6%) and methamphetamine (5%).
  • The most common combinations of drug categories (% of all syringes) were:
    • cocaine, heroin and other medicines (piracetam) (30%)
    • cocaine and heroin (16%).
  • Most frequently detected substances classified as adulterants were: caffeine (60%), phenacetin (57%), procaine (22%) and acetaminophen (20%).

Interpretation

  • Cocaine and heroin found in the same syringes could reflect the prevalence of a practice known as injecting ‘speedball’ among some PWID, a pattern of polydrug use that has been associated with a higher risk of overdose [1,2].  
  • There have been reports of piracetam being used as a heroin adulterant [3,4,5] (potentially without the knowledge of the user) or, which is less likely in this setting, misused for its performance and image-enhancing property [6].
  • Methamphetamine (5%), MDMA (2%) and cathinones (mexedrone, 1%) were relatively rare but reflected some of the substances reported in surveys conducted in Barcelona and Madrid from 2018-2020 describing sexualised drug injection among men who have sex with men [7].
  • Hydrocodone (a semi-synthetic opioid medicine used as painkiller) was found in 6% of syringes, but there was no evidence of new synthetic opioid use from the 2024 ESCAPE collection campaign in Barcelona.

Related studies and/or monitoring data

 

*This work has been funded by the Spanish Drugs Plan through the project SYDRES (Ref. 2022I003) and the Instituto de Salud Carlos III-Next Generation EU/PRTR/EDRF (RD21/0009/0012, RD21/0009/0015, RD24/0003/0001 & RD24/0003/0020 – RIAPAd Network). We want to specially acknowledge all the institutions involved in the sampling: Àmbit Prevenció Fundaciò: Xènia Ortiz, Eusebio Expósito, Marta Gassol, Carlos Delfa, Ona Gázquez, Emiliano Paccini, Mila González, Nicolás Piñeiro, Patricia Ruiz, , Marco Mitjans, Silvia Marqués, José Antonio Cano, Marta Franch, Alba Mielgo, Isaac Alonso, Marina Tort, Pau Fernández, Álvaro Polo, Joan Suqué; Grup ABD: Ester Aranda, Anna Lago, Marc Moya, Aldana Menéndez; ASPB: María Gabriela Barbaglia, Amaia Garrido, Montse Bartroli; IMIM-PSMAR: Joan Mestre, Marta Torrens, Francina Fonseca, Sandra Aguelo, Claudio Castillo; Metzineres: Aura Roig, Irene Otero and Alejandra Rivero

Budapest 2024

Estimated number of people who inject drugs in the country/city: Hungary: 6 700; Budapest: no recent estimate

ESCAPE Collection sites: one fixed needle and syringe programme

Laboratory: Toxicology Laboratory of the Institute of Forensic Medicine of the University of Debrecen

Laboratory method: Screening method - GC-MS

Number of syringes analysed (with at least one drug category detected): 147

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were synthetic cathinones (N-ethylnorpentedrone, 44%; 4-CMC, 9%; mephedrone, 8%), amphetamine (28%) and heroin (17%). Methadone was detected in 3% of syringes.
  • The most common combination of drug categories found in syringes was a mix of a synthetic cathinone (N-ethylnorpentedrone) with amphetamine (5%).
  • The most frequently detected substances classified as adulterants were caffeine (30%) and paracetamol (9%).

Interpretation

  • The 3 main substances were mostly found independently of each other, suggesting distinct profiles of use (or sequential use rather than concomitant use): synthetic cathinones, amphetamine and heroin.
  • Since the 2010 heroin shortage, cathinone injecting has established itself in Hungary [1].
  • Cathinone injecting has been associated with an increased risk of blood-borne virus transmission [2].
  • There was no evidence of new synthetic opioid use from the 2024 ESCAPE collection campaign in Budapest

Related studies and/or monitoring data

 

Cologne 2024

Estimated number of people who inject drugs in the country/city: Germany: 107 316 [UI=53 926-183 250]; Cologne: no recent estimate

ESCAPE Collection sites: four collection sites – two drug consumption rooms, two fixed needle and syringe programmes

Laboratory: Institute of Forensic Medicine, Medical Centre - University of Freiburg

Laboratory method: Targeted screening method - HPLC-MS

Number of syringes analysed (with at least one drug category detected): 259

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were heroin (66%) and cocaine (62%), followed by morphine (5%) and methadone (3%).
  • The synthetic cannabinoid ADB-4en-PINACA was found in 8 syringes (3%).
  • The opioid hydromorphone was found in 6 syringes (2%).
  • Most common combinations of drug categories found in syringes was a mix of cocaine and heroin (29%). The syringes containing ADB-4en-PINACA also contained either heroin or cocaine, or a mix of both.
  • The most frequently detected substances classified as adulterants were: caffeine (74%), paracetamol (71%) and dextromethorphan (13%).  

Interpretation

  • Cocaine and heroin found in the same syringes could reflect the prevalence of a practice known as injecting ‘speedball’ among PWID attending the other services, a pattern of polydrug use that has been associated with a higher risk of overdose [1,2].   
  • This pattern has been relatively stable over the years in Cologne and was already reported in field studies conducted in 2011-14 [3].
  • An HIV cluster linked to injecting drug use in the Cologne area was retrospectively detected in laboratory data in 2018.
  • Outbreaks of acute poisoning associated with heroin adulterated with synthetic cannabinoids have been reported from North America [4]. 

Related studies and/or monitoring data

Cork 2024

Estimated number of people who inject drugs in the country/city: Ireland: 6 173 [UI = 2 081-14 436]; Cork: no recent estimate

ESCAPE Collection sites: one fixed needle and syringe programme

Laboratory: HSE National Drug Treatment Centre Laboratory

Laboratory method: Targeted screening method - HPLC-MS/MS

Number of syringes analysed (with at least one drug category detected): 97

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were heroin (95%) and cocaine (69%).
  • Benzodiazepines (alprazolam (5%), diazepam (4%)) and other medicines (pregabalin (5%), benzocaine (4%)) were also detected.
  • Most common combinations of drug categories found in syringes was a mix of cocaine and heroin (53%)
  • Most frequently detected substances classified as adulterants were: caffeine (95%), paracetamol (87%) and levamisole (29%).

Interpretation

  • Cocaine and heroin found in the same syringes could reflect the prevalence of a practice known as injecting ‘speedball’ among PWID attending the other services, a pattern of polydrug use that has been associated with a higher risk of overdose [1,2].
  • A 2025 report on problem drug use in Cork [3] looked at the 140 drug-induced deaths from 2019-2024: opioids were the main drug implicated in poisoning deaths (75.7%), followed by benzodiazepines (59.3%), gabapentinoids (27.9%) and cocaine (14.3%).
  • The same report indicates that there has been a gradual reduction in the number of cases entering treatment for opioids since 2019, with an increase of treatment initiations for cocaine use [3].    

Related studies and/or monitoring data

Dublin 2024

Estimated number of people who inject drugs in the country/city: Ireland: 6 173 [UI = 2 081-14 436]; Cork: no recent estimate

ESCAPE Collection sites: one fixed needle and syringe programme

Laboratory: HSE National Drug Treatment Centre Laboratory

Laboratory method: Targeted screening method - HPLC-MS/MS

Number of syringes analysed (with at least one drug category detected): 146

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were heroin (92%), cocaine (70%) and benzodiazepines (diazepam, 40%; alprazolam, 15%).
  • Other medicines found included benzocaine (18%), zopiclone (16%) and pregabalin (8%). Other detected substances included ketamine (15%), dihydrocodeine (14%) and MDMA (9%).
  • The most common combination of drug categories found in syringes was a mix of cocaine and heroin (18%).
  • Most frequently detected substances classified as adulterants were: caffeine (77%), paracetamol (63%), dextromethorphan (53%) and phenacetin (34%).

Interpretation

  • Cocaine and heroin found in the same syringes could reflect the prevalence of a practice known as injecting ‘speedball’ among PWID attending the other services, a pattern of polydrug use that has been associated with a higher risk of overdose [1,2].   
  • Nitazenes were linked to a cluster of non-fatal overdoses documented in Dublin in 2023 [3], but no nitazenes were detected in Dublin in the 2023 and 2024 ESCAPE campaigns.
  • The presence of ketamine and MDMA raises the question of potential links to chemsex [4].

Related studies and/or monitoring data

 

Helsinki 2024

Estimated number of people who inject drugs in the country/city: Finland: 25 000; Helsinki: no recent estimate

ESCAPE Collection sites: five needle and syringe programmes

Laboratory: Forensic Toxicology Unit at National Institute for Health and Welfare, Helsinki

Laboratory method: Targeted and non-targeted screening methods (UHPLC-MS/MS, UHPLC-QTOF/MS)

Number of syringes analysed (with at least one drug category detected): 150

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were buprenorphine (45%), synthetic cathinones (alpha-PVP, 23%), amphetamine (21%), benzodiazepines (alprazolam, 19%), other amphetamines (N-formylamphetamine, 9%) and cocaine (9%).
  • Besides the common co-detection of buprenorphine and naloxone, the most common combinations of drug categories (% of all syringes) were:
    • amphetamine and other amphetamines (N-formylamphetamine) (7%)
    • buprenorphine and benzodiazepines (7%).
  • The most frequently detected substances classified as adulterants were caffeine (15%), mainly found with amphetamine, and creatine (9%).

Interpretation

  • The main substances were mostly found independently of each other, suggesting four to five distinct profiles of use (or sequential use rather than concomitant use): buprenorphine, benzodiazepines, amphetamine, synthetic cathinones and cocaine.
  • Injecting of buprenorphine and amphetamine in Finland has been well described from different sources, including drug treatment data [1].
  • Injecting of synthetic cathinones, and to a lesser extent, benzodiazepines, is a more recent phenomenon. The most commonly found synthetic cathinone in the sample of syringes in 2024 (alpha-PVP) was linked to the cause of death in 34 cases between 2018-23 in Finland [2].
  • An HIV outbreak related to injecting drug use was documented in the Helsinki region in 2022 (23 cases) [3]. No specific substance was linked to this cluster, but synthetic cathinones have been linked to past HIV outbreaks in Dublin (alpha-PVP) [4] and Munich (alpha-PVT and/or PV8) [5].
  • The level of cocaine detection in an ESCAPE campaign in Helsinki reached its maximum level in 2024 (9%), higher than its previous high in 2017 (4%). 
  • The severe clinical manifestations of injecting crushed tablets (including benzodiazepines and buprenorphine) have been documented in a retrospective study in Helsinki [6].
  • While there is evidence of nitazenes being available on the Finnish drugs market [7], there was no evidence of new synthetic opioid use from the 2024 ESCAPE collection campaign in Helsinki.

Related studies and/or monitoring data

 

Klaipeda 2024

Estimated number of people who inject drugs in the country/city: Lithuania: 8 868; Klaipeda: no recent estimate

ESCAPE Collection sites: five fixed needle and syringe programmes, one mobile needle and syringe programme

Laboratory: Forensic Science Centre of Lithuania

Laboratory method: Screening method – GC-MS

Number of syringes analysed (with at least one drug category detected): 96

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were fentanyl and derivatives (carfentanil, 66%; fentanyl, 2%), methadone (20%), amphetamine (8%) and cocaine (4%).
  • Other opioids detected included nitazenes (protonitazene, 4%; etonitazene, 1%).
  • There were very few syringes containing more than one drug category. The most common combination of drug categories was fentanyl and derivatives (carfentanil) and methadone, found in 2% of syringes.
  • The most frequently detected substance classified as an adulterant was diphenhydramine (77%).

Interpretation

  • The majority of syringes from Klaipeda tested positive for a potent synthetic opioid (carfentanil) or methadone, alone or mixed with diphenhydramine.
  • Carfentanil has been detected in used syringes in the capital Vilnius since the first ESCAPE campaign in 2019 and was risk-assessed by the EUDA in 2018 [1]. In 2021, carfentanil (alone or in combination) was identified in 16 out of 59 fatal overdoses in Lithuania [2].
  • Nitazenes were detected in Lithuania for the first time in this campaign, suggesting this group of potent synthetic opioids - already established in Estonia and Latvia - has reached the local drug market [3].

Related studies and/or monitoring data

 

Limerick 2024

Estimated number of people who inject drugs in the country/city: Ireland: 6 173 [UI = 2 081-14 436]; Limerick: no recent estimate

ESCAPE Collection sites: one fixed needle and syringe programme

Laboratory: HSE National Drug Treatment Centre Laboratory

Laboratory method: Targeted screening method - HPLC-MS/MS

Number of syringes analysed (with at least one drug category detected): 100

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were heroin (98%), cocaine (91%), methadone (34%), benzodiazepines (diazepam, 22%; alprazolam, 21%), other medicines (pregabalin, 16%; benzocaine, 14%; zopiclone, 7%), and methamphetamine (13%). Ketamine (2%) and other opioids (oxycodone, 2%) were also detected.
  • Most common combinations of drug categories found in syringes was a mix of cocaine and heroin (30%)
  • The most frequently detected substances classified as adulterants were caffeine (99%), paracetamol (95%), dextromethorphan (50%) and phenacetin (47%).

Interpretation

  • Cocaine and heroin found in the same syringes could reflect the prevalence of a practice known as injecting ‘speedball’ among PWID attending the other services, a pattern of polydrug use that has been associated with a higher risk of overdose [1,2].
  • The detection of dextromethorphan, a cough suppressant classified as an adulterant in the study, is a new trend for the Irish ESCAPE campaigns that was also observed in 2024 in Dublin. In Limerick, it was found in 50% of syringes containing heroin.

Related studies and/or monitoring data

 

Madrid 2024

Estimated number of people who inject drugs in the country/city: Spain: 6 862 [UI = 4 091-9 633]; Madrid: no recent estimate

ESCAPE Collection sites: 3 collection sites – 1 collection site has services related to chemsex

Laboratory: Aquatic One Health Research Center (iARCUS) - University of Santiago de Compostela

Laboratory method: High-performance liquid chromatography system coupled to high-resolution mass spectrometry (HPLC–QTOF), using auto MS/MS mode

Number of syringes analysed (with at least one drug category detected): 85

Main results

  • The most commonly detected drug category (excluding adulterants and metabolites) was cocaine (69%), followed by synthetic cathinones (2-MMC, 24%; 3-CMC, 21%; methedrone, 9%), methadone (21%), heroin (9%) and methamphetamine (4%).
  • Fentanyl and alfentanil were found in 1% of syringes.
  • The most common combinations of drug categories were:
    • cocaine and methadone (17%)
    • cocaine and heroin (8%).
  • The most frequently detected substances classified as adulterants were phenacetin (30%), acetaminophen (15%) and caffeine (12%).

Interpretation

  • Cocaine and heroin (or methadone) found in the same syringes could reflect the prevalence of a practice known as injecting ‘speedball’ among PWID, a pattern of polydrug use that has been associated with a higher risk of overdose [1].   
  • Cocaine use was commonly reported by field studies recruiting PWUD visiting an infectious diseases mobile screening unit in Madrid from 2017-23 [2].
  • While the demand for drug treatment entry (‘por abuso o dependencia’) when fentanyl and derivatives are mentioned as primary drugs has increased from 2014 to 2021 in Spain (from 28 to 174), it was still well below the number of patients entering drug treatment for heroin dependence over the same period (10911 and 7419), suggesting that the use of fentanyl and fentanyl derivatives is still marginal in Spain [3].
  • Cathinones and methamphetamine reflected some of the substances reported in surveys conducted in Barcelona and Madrid from 2018-2020 describing sexualised drug injection among men who have sex with men [4].

Related studies and/or monitoring data

 

*This work has been funded by the Spanish Drugs Plan through the project SYDRES (Ref. 2022I003) and the Instituto de Salud Carlos III-Next Generation EU/PRTR/EDRF (RD21/0009/0012, RD21/0009/0015, RD24/0003/0001 & RD24/0003/0020 – RIAPAd Network). We want to specially acknowledge all the institutions involved in the sampling: MadridSalud: Ruth Olmos and Antonio Sáez, Arquisocial: Patricia Jiménez and Jorge Álvarez and Fundación Salud y Comunidad: Ángeles Gutierrez.

Oslo 2024

Estimated number of people who inject drugs in the country/city: Norway: 12 979; Oslo: 4 326

ESCAPE Collection sites: two fixed needle and syringe programmes, one drug consumption room

Laboratory: Department of forensic Sciences, Oslo University Hospital

Laboratory method: Targeted screening method, UHPLC-MS/MS

Number of syringes analysed (with at least one drug category detected): 164

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were amphetamine (69%) and heroin (51%).
  • Two syringes tested positive for fentanyl (1%) and 1 for norfentanyl (1%)
  • The most common combination of drug categories found in syringes (excluding adulterants and metabolites) was amphetamine and heroin (16%).
  • The most frequently detected substances classified as adulterants were caffeine (92%) and paracetamol (65%).

Interpretation

  • A fourth of amphetamine syringes also contained heroin. The majority of remaining amphetamine syringes did not contain other drug categories.
  • Injecting of amphetamine and heroin in Oslo has been described from cross sectional studies in low threshold services from 2018-2024 [1,2]. One of the studies found a proportion of self-reported cocaine injection (last month) of 9% in 2024. The 2024 ESCAPE campaign found 2% of syringes testing positive for cocaine.

Related studies and/or monitoring data

Paris 2024

Estimated number of people who inject drugs in the country/city: France: 106 857 [UI = 103 368-110 346]; Paris: 26 328

ESCAPE Collection sites: 5 automatic injecting kit dispensers (AIKD)

Laboratory: Laboratory of Pharmacology—Toxicology, AP-HP, Raymond Poincaré Hospital-Paris Saclay University

Laboratory method: Non-targeted screening method - LC-HRMS

Number of syringes analysed (with at least one drug category detected): 142

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were synthetic cathinones (71% overall, including 2-MMC, 65%; methcathinone, 32%; N-ethylpentedrone, 27%; x-methoxymethcathinone, 23%; 3-CMC, 11%), followed by cocaine (49%), methamphetamine (25%), heroin (22%), morphine (13%), buprenorphine (11%) and benzodiazepines (7%).
  • The most common combinations of drug categories (% of all syringes) were:
    • synthetic cathinones and methamphetamine (8%)
    • synthetic cathinones and cocaine (7%)
    • synthetic cathinones, cocaine and heroin (6%).
  • The most frequently detected substances classified as adulterants were phenacetin (29%), dextromethorphan (18%) and paracetamol (11%).

Interpretation

  • In a context of increasing synthetic cathinone seizures at the EU level, 19 different cathinones were detected in the 2024 campaign in Paris, and cathinones were the most commonly detected drug category in four out of five collection sites (all AIKD).
  • The EUDA has undertaken risk assessments of three new synthetic cathinones: 2-methylmethcathinone (2-MMC), 4-bromomethcathinone (4-BMC) and N-ethylnorpentedrone (NEP) [1].
  • HIV clusters linked to synthetic cathinones injecting were documented in Dublin and Munich (2015) [2,3].
  • Field studies conducted among 665 people who inject drugs in four French cities from 2016-18 showed a prevalence of problematic stimulant use in this population of 76%, with daily use of cocaine and crack cocaine reported by 11% and 22%, respectively. The absence of self-reported cathinone injecting could be due to the different source populations or the lower availability of the drugs at the time of the study [4].
  • The detection of morphine in the absence of heroin metabolites in 13% of syringes is consistent with data from the drug consumption room in Paris and other field reports, which show diversion and injection of morphine sulphate (an opioid analgesic) [5].
  • There was no detection of new synthetic opioids in the 2024 ESCAPE collection campaign in Paris.

Related studies and/or monitoring data

 

Patras 2024

Estimated number of people who inject drugs in the country/city: Greece: 2598; Patras: no recent estimate

ESCAPE Collection sites: 3 collections sites, including low-threshold services with dormitory and open drug scenes

Laboratory: Laboratory of Forensic Medicine and Toxicology - Faculty of Medicine of Thessaloniki

Laboratory method: Screening method (UPLC-MS/MS)

Number of syringes analysed (with at least one drug category detected): 220

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were buprenorphine (74%), heroin (23%), cocaine (11%), methadone (10%), benzodiazepines (diazepam, 10%) and other medicines (pregabalin, 10%).
  • Fentanyl was detected in one syringe (<1%).
  • The most common combinations of drug categories (% of all syringes) were:
    • buprenorphine and other medicines (pregabalin, quetiapine) (6%)
    • buprenorphine, heroin and benzodiazepines (3%).
  • The most frequently detected substances classified as adulterants were caffeine (41%), paracetamol (39%) and dextromethorphan (6%).

Interpretation

  • Injecting of buprenorphine has been documented in the city of Thessaloniki, both in ESCAPE and in field studies [1].
  • Cocaine injection has been associated with HIV transmission among PWID in Athens and Thessaloniki [2,3].
  • However, cocaine detection has decreased since the 2023 campaign in Patras, partly reflecting a transition to smoking.
  • Fentanyl was detected within the ESCAPE campaign for the first time in Patras in 2024.

Related studies and/or monitoring data

 

Prague 2024

Estimated number of people who inject drugs in the country/city: Czechia: 42 700 [UI = 42 100-43 400]; Prague: no recent estimate

ESCAPE Collection sites: four needle and syringe programmes

Laboratory: Forensic Laboratory of Biologically Active Substances Department of Chemistry of Natural Compounds, University of Chemistry and Technology, Prague.

Laboratory method: Screening method and library search UHPLC-MS/MS

Number of syringes analysed (with at least one drug category detected): 135

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were methamphetamine (67%), heroin (29%) and buprenorphine (17%).
  • Besides the common co-detection of buprenorphine and naloxone, the most common combination of drug categories found in syringes was heroin and methamphetamine, found in 13% of all syringes.
  • The most frequently detected substances classified as adulterants were acetaminophen (13%) and caffeine (11%).

Interpretation

  • Injecting of methamphetamine, buprenorphine and heroin in Czechia has been described from different sources, including low threshold services [1].
  • The financial barrier to access OAT has been identified as one factor behind the misuse and injecting of of buprenorphine in Czechia [2].
  • There was no evidence of new synthetic opioid use from the 2024 ESCAPE collection campaign in Prague.

Related studies and/or monitoring data

 

Reykjavik 2024

Estimated number of people who inject drugs in the country/city: Reykjavik: 700

ESCAPE Collection sites: three emergency shelters for homeless (women, young men, older men), two apartment complexes for people with complex needs, one drug consumption room

Laboratory: Department of Pharmacology and Toxicology, University of Iceland

Laboratory method: GC/MS (and negative samples additionally screened on a qTOF)

Number of syringes analysed (with at least one drug category detected): 177

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were other medicines (methylphenidate (47%)), amphetamine (22%), morphine (17%), other opioids (oxycodone (16%)) and cocaine (11%).
  • Most common combinations of drug categories found in syringes was a mix of amphetamine and other medicines (methylphenidate) (3%).
  • Most frequently detected substance classified as adulterant was caffeine (23%).

Interpretation

  • The 3 main substances (methylphenidate, amphetamine and morphine) were mostly found independently of each other, suggesting distinct profiles of use (or sequential use rather than concomitant use)
  • The injection of methylphenidate had already been described as a common pattern among PWID entering inpatient detoxification centres in Iceland in 2013 [1].
  • Oxycodone was the most commonly implicated substance in fatal poisonings among people who use drugs in Iceland in 2022 (10/19) [2].

Related studies and/or monitoring data

Riga 2024

Estimated number of people who inject drugs in the country/city: Latvia: 7 715; Riga: no recent estimate

ESCAPE Collection sites: one fixed needle and syringe programme, four mobile needle and syringe programmes

Laboratory: Latvian Institute of Organic Synthesis

Laboratory method: Targeted and non-targeted screening method, library search - UHPLC-QTOF/MS

Number of syringes analysed (with at least one drug category detected): 181

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were amphetamine (52%), methamphetamine (38%), cocaine (38%), cathinones (alpha-PVP, 30%), methadone (23%), nitazenes (N-desethyletonitazene, 23%; isotonitazene, 21%; metonitazene, 20%; protonitazepyne, 4%) and fentanyl and derivatives (carfentanil, 16%).
  • Two new synthetic opioids were detected: spirochlorphine (7%) and cychlorphine (6%).
  • Benzodiazepines such as clonazepam (10%) and bromazolam (1%) were detected, as well as the medicine promazine (10%).
  • The most common combinations of substances (% of all syringes) were:
    • cocaine, methamphetamine and amphetamine (18%)
    • methamphetamine, amphetamine and alpha-PVP (9%).
  • The most frequently detected substances classified as adulterants were caffeine (75%), diphenhydramine (27%) and xylazine (7%).

Interpretation

  • More than 50% of syringes contained a combination of substances (excluding adulterants and metabolites), suggesting that in the source population a high proportion of people who inject drugs: (1) inject various substances at the same time using the same syringe; or (2) inject various substances sequentially, using the same syringe (reuse by same user); or (3) the syringes are reused by another user to inject another substance (reuse by different user); or a mix of the above. All these scenarios put the users at a higher risk of harmful effects (overdose and infectious diseases). There seem to be two main clusters of syringes: mix of stimulants and mix of synthetic opioids.
  • Nitazenes were first detected on the European drugs market in 2019 [1]. Since then, they became established in Estonia and Latvia, where they have been increasingly identified in post-mortem analyses of drug-induced deaths cases since 2022 [2].
  • Fentanyl and especially carfentanil were detected at higher levels in previous ESCAPE campaigns in Riga (2020-22), suggesting that nitazenes might be replacing fentanyl derivatives on the Latvian drugs market.
  • Field studies with information on self-reported injecting drug use conducted in 2023 among 443 people who inject drugs from Riga and 15 people who inject drugs from Liepāja [3] showed that the main drugs injected were amphetamine (58%), nitazenes (19%), fentanyl derivatives (10%), heroin (7%), buprenorphine (3%), methadone (2%) and cocaine (0.7%). The discrepancies between self-reported use and ESCAPE results could be explained by (1) different source populations in the two studies; (2) fast-changing availability of different drugs on the market; or (3) low awareness about actual substances injected by people who inject drugs.
  • Cocaine injecting, alone or with opioids, has been linked to HIV transmission in other European cities, including the cities of Athens, Thessaloniki, Luxembourg, Glasgow and Belfast [4-8].
  • All 13 syringes containing xylazine (classified as an adulterant) also contained fentanyl and derivatives, while nine also contained nitazenes. The adulteration of opioids with xylazine has already been detected in four EU Member States [9].

Related studies and/or monitoring data

Split 2024

Estimated number of people who inject drugs in the country/city: Croatia: 6 344; Split: no recent estimate

ESCAPE Collection sites: one fixed needle and syringe programme

Laboratory: Department for Food Supplements and Biologically Active Compounds, Zagreb

Laboratory method: High-performance liquid chromatography with diode array detection

Number of syringes analysed (with at least one drug category detected): 143

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were cocaine (87%), ketamine (13%), followed by methadone (2.8%) and synthetic cathinones (mephedrone (2.1%)).
  • Most common combination of drug categories found in syringes was a mix of cocaine and ketamine (4 syringes, 3%).
  • Most frequently detected substance classified as adulterant were caffeine (56%) and paracetamol (6%).

Interpretation

  • The main substance (cocaine) was mostly found alone, which differs from patterns observed in 2023 when it was often found with either methadone or heroin.
  • The 2024 ESCAPE campaign in Split saw a drop in methadone, amphetamine and heroin detection compared with 2023.
  • Cocaine injecting was also reported from RDS studies conduced in Croatian cities in 2022, and was highest for Split (32% of self-reported injection in last 30 days) [1], where heroin injecting was also commonly reported (65%).

Related studies and/or monitoring data

Tallinn 2024

Estimated number of people who inject drugs in the country/city: Estonia: 8 606; Tallinn: no recent estimate

ESCAPE Collection sites: one mobile needle and syringe programme, four fixed needle and syringe programmes

Laboratory: Estonian Forensic Science Institute

Laboratory method: Screening method - Liquid chromatography quadrupole time-of-flight mass spectrometry and, in rare cases, gas chromatography - mass spectrometry

Number of syringes analysed (with at least one drug category detected): 139

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were amphetamine (69%), nitazenes (metonitazene, 35%; protonitazene, 35%) and methamphetamine (28%).
  • The most common combinations of drug categories (% of all syringes) were:
    • amphetamine and methamphetamine (26%)
    • nitazenes and amphetamine (8%)
    • nitazenes and cocaine (2%).
  • The most frequently detected substance classified as an adulterant was caffeine (32%), mainly found with amphetamines.

Interpretation

  • Two main drug categories were mostly found independently of each other, suggesting two distinct profiles of use (or sequential use rather than concomitant use): amphetamines (amphetamine and/or methamphetamine) and nitazenes (protonitazene and metonitazene).
  • In Estonia, the share of all first-time drug treatment entrants reporting amphetamine as their primary drug in 2022 (irrespective of the administration mode) was the highest in the EU (>30%) [1].
  • Nitazenes were first detected on the European drugs market in 2019 [2]. Since then, they became established in Estonia and Latvia, where they have been increasingly identified in post-mortem analyses of drug-related death cases since 2022 [3].
  • Fentanyl and carfentanil were detected in previous ESCAPE campaigns in Tallinn (2021-22) at relatively low levels, but not in 2023-24, suggesting that nitazenes might have replaced fentanyl derivatives on the Estonian drugs market.
  • Field studies with information on self-reported injecting drug use conducted among 809 people who inject drugs in Tallinn, Kohtla-Järve and Narva from 2017 to 2022 showed that the main drugs were amphetamine (68%), fentanyl derivatives (17%) and isotonitazene (5%), suggesting that some users might think they inject fentanyl derivatives while they actually inject nitazenes [4].

Related studies and/or monitoring data

 

Thessaloniki 2024

Estimated number of people who inject drugs in the country/city: Greece: 2 598; Thessaloniki: >800

ESCAPE Collection sites: three mobile needle and syringe programmes, one low-threshold service

Laboratory: Laboratory of Forensic Medicine and Toxicology - Faculty of Medicine of Thessaloniki

Laboratory method: Screening method (UPLC-MS/MS)

Number of syringes analysed (with at least one drug category detected): 241

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were cocaine (95%), heroin (40%), benzodiazepines (diazepam, 13%; desmethyldiazepam, 6%), other medicines (pregabalin, 13%; quetiapine, 10%), followed by buprenorphine (12%) and methadone (7%).
  • Fentanyl was detected in five syringes (2%), norfentanyl in one syringe (<1%), tramadol in three syringes (1%).
  • The most common combinations of drug categories (% of all syringes) were:
    • heroin and cocaine (20%)
    • cocaine and buprenorphine (7%).
  • The most frequently detected substances classified as adulterants were caffeine (81%), paracetamol (76%), procaine (22%) and dextromethorphan (10%).

Interpretation

  • Heroin and cocaine found in the same syringes could reflect the prevalence of a practice known as injecting ‘speedball’ among PWID, a pattern of polydrug use that has been associated with a higher risk of overdose [1].
  • The latest study on HIV transmission among PWID in Thessaloniki in 2019-21 suggested a possible link to cocaine injection [2].
  • Injecting of buprenorphine has been documented in the city of Thessaloniki in field studies [3].
  • Fentanyl and derivatives were detected within the ESCAPE campaign for the first time in Thessaloniki in 2024.

Related studies and/or monitoring data

 

Tunis 2024

Estimated number of people who inject drugs in the country/city: Tunisia 7 000; Tunis: no data

ESCAPE Collection sites: four fixed needle and syringe programmes

Laboratory: Forensic laboratory of toxicology at the Mahmoud Yaccoub Center of Urgent Medical Assistance

Laboratory method: Screening method - HPLC-MS/MS

Number of syringes analysed (with at least one drug category detected): 117

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were cocaine (61%), buprenorphine (35%), other medicines (atropine, 35%), heroin (31%) and benzodiazepines (diazepam, 15%).
  • The most common combination of drug categories found in syringes was a mix of cocaine and other medicines (atropine, 19%).
  • The most frequently detected substances classified as adulterants were paracetamol (38%) and levamisole (36%).

Interpretation

  • The detection of cocaine in more than half of syringes was a significant increase compared to the 2022 campaign (2%) [1,2].
  • Cocaine injection has been associated with HIV transmission among people who inject drugs in several European cities [3].
  • The anticholinergic drug atropine was commonly found in syringes containing cocaine. While rarely documented, there are some reports of anticholinergic poisoning associated with heroin and cocaine adulterated with atropine in the United States in the 1990s [4].

Related studies and/or monitoring data

Vilnius 2024

Estimated number of people who inject drugs in the country/city: Lithuania: 8 868; Vilnius: 3 643

ESCAPE Collection sites: one fixed needle and syringe programme, three mobile needle and syringe programmes

Laboratory: Forensic Science Centre of Lithuania

Laboratory method: Screening method – GC-MS

Number of syringes analysed (with at least one drug category detected): 117

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were fentanyl and derivatives (carfentanil, 93%), followed by methadone (8%) and amphetamine (3%).
  • The most common combination of drug categories (excluding adulterants and metabolites) was: Fentanyl and derivatives (carfentanil) and methadone (7%).
  • The most frequently detected substances classified as adulterants were diphenhydramine (91%) (found with carfentanil and methadone) and caffeine (3%).

Interpretation

  • The majority of syringes from Vilnius tested positive for carfentanil (a fentanyl derivative); among these, the majority contained diphenhydramine (classified as an adulterant) but no other drug category.
  • Carfentanil has been detected in used syringes from Vilnius since the first ESCAPE campaign in 2019 and was risk-assessed by the EUDA in 2018 [1]. In 2021, carfentanil (alone or in combination) was identified in 16 out of 59 fatal overdoses in Lithuania [2].
  • Testosterone was detected for the first time in syringe residue from Vilnius in 2022 and again in 2023 (mostly found in combination with carfentanil). It was not detected in 2024.
  • Unlike in Klaipeda, Riga or Tallinn, no nitazenes have been detected in Vilnius within this project.

Related studies and/or monitoring data

  • [1] Report on the risk assessment of methyl 1-(2-phenylethyl)-4-[phenyl(propanoyl)amino]piperidine-4-carboxylate (carfentanil) in the framework of the Council Decision on new psychoactive substances, Lisbon, 16.07.2018 https://www.euda.europa.eu/publications/risk-assessments/carfentanil_en
  • [2] Drug,Tobacco and Alcohol Control Department, Lithuanian NFP

Volos 2024

Estimated number of people who inject drugs in the country/city: Greece: 2 598; Volos: no recent estimate

ESCAPE Collection sites: two collection sites, including a low-threshold service and an open drug scene

Laboratory: Laboratory of Forensic Medicine and Toxicology - Faculty of Medicine of Thessaloniki

Laboratory method: Screening method (UPLC-MS/MS)

Number of syringes analysed (with at least one drug category detected): 156

Main results

  • The most commonly detected drug categories (excluding adulterants and metabolites) were cocaine (68%), heroin (33%), benzodiazepines (diazepam, 26%; desmethyldiazepam, 19%), buprenorphine (23%) and other medicines (quetiapine, 23%; pregabalin, 17%).
  • The most common combinations of drug categories (% of all syringes) were:
    • cocaine, benzodiazepines and other medicines (8%)
    • cocaine, heroin and other medicines (5%).
  • The most frequently detected substances classified as adulterants were caffeine (65%) and paracetamol (60%).

Interpretation

  • Cocaine injection has been associated with HIV transmission among PWID in Athens and Thessaloniki [1,2].
  • Injecting of buprenorphine has been documented in the city of Thessaloniki, both in ESCAPE and in field studies [3].
  • Fatal and non-fatal overdoses linked to quetiapine misuse have been documented in other countries [4].
  • No new synthetic opioid was detected in Volos in the 2024 campaign.

Related studies and/or monitoring data

 

 

About the ESCAPE network

The work presented on this page is only possible through a dedicated network of researchers, organisations and institutions throughout Europe who collect, analyse and share syringe data with the EUDA.

Logos of the ESCAPE network members

Source data

The source data behind the data visualisations on this page may be found below. ESCAPE data and additional methodological information may also be found in the Syringe residues section of annual Statistical Bulletin.

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