Injecting drug use in Europe – the current situation (European Drug Report 2023)

Cover of the European Drug Report 2023 injecting drug use

Despite a continued decline in injecting drug use over the past decade in Europe, this behaviour is still responsible for a disproportionate level of health harms. On this page, you can find the latest analysis of injecting drug use in Europe, including key data on prevalence at national level and among clients entering specialised treatment, as well as insights from studies on syringe residue analysis and more.

This page is part of the European Drug Report 2023, the EMCDDA's annual overview of the drug situation in Europe.

Last update: 16 June 2023

Significant health harms from diversity of substances being injected

Despite a continued decline in injecting drug use over the past decade in Europe, this behaviour is still responsible for a disproportionate level of both acute and chronic health harms associated with the consumption of illicit drugs. Half a million Europeans are estimated to have injected an illicit drug in the last year, a figure that underlines both the scale of the challenges that still exist in this area and that reducing the harm associated with injecting drug use still remains an important priority for protecting public health.

People who inject drugs are at greater risk of contracting blood-borne infections or dying from a drug overdose. Injecting can also exacerbate other pre-existing health problems or be a cause of abscesses, septicaemia and nerve damage. Historically, heroin has been the main drug associated with injecting in Europe, but this has been changing in recent years. Increasingly today, other drugs, including amphetamines, cocaine, synthetic cathinones, opioid agonist medications and other medicines, are also injected, either alone or in combination. While it is known that there is considerable variation in injecting practices between countries, recent studies of syringe residues also reveal that there can also be considerable variation in the drugs injected between different sites within a country. Multiple substances are commonly detected in syringe residues, often including both stimulant and opioid drugs. Recognising the increasing complexity of injecting practices in Europe and the importance of polydrug consumption in this context is therefore likely to have important implications for both understanding the harms associated with this mode of administration and for interventions designed to reduce them.

Injecting stimulant drugs such as cocaine and synthetic cathinones tends to be more associated with high-frequency injecting patterns of use, and has been associated with local HIV outbreaks in recent years in Europe. Methamphetamine injecting carries similar risks. This is a concern, as there are a number of signals that stimulant injecting is becoming a more common behaviour among people who inject drugs.

There are multiple long-term risks linked to injecting dissolved medicine tablets and capsules, and also crack cocaine, including vascular damage and infective endocarditis and other bacterial infections. An additional concern is raised by the availability of highly potent opioids, such as fentanyl and its derivatives, which can cause rapid onset of life-threatening respiratory depression leading to fatal overdoses, and these risks are likely to be elevated when these substances are injected. Polydrug use can increase the risk of a drug overdose.

In addition to the provision of drug treatment, harm reduction interventions, such as the provision of sterile injecting equipment, remain among the most common public health measures targeting the risks associated with injecting drugs. Although, by international standards, such interventions are relatively well developed in Europe, it is also clear that some EU Member States face challenges in providing sufficient coverage and access to harm reduction and drug treatment interventions for people who inject drugs. Moreover, historically the need to reduce the risk of acquiring blood-borne infectious diseases has been a primary focus of many interventions in this area. This concern remains important but there is now greater recognition of the need to also do more to reduce overdose deaths and other negative health problems associated with injecting. Interventions targeting these outcomes are generally less well developed and this remains therefore an important area for investment and service development.

Changing patterns of drug injecting, an increasing diversity of substances and the adequacy of the type and level of existing responses remain key issues for both frontline responders and policymakers in the European Union. As the subgroups of people who inject drugs change, now encompassing primarily opioid and stimulant-based open drug scenes involving marginalised people who inject drugs, as well the use of substances like methamphetamine and cathinones in some settings and subgroups, responding effectively to the risk posed by drug injecting has become a more urgent and complex challenge.

Key data and trends

Prevalence of injecting drug use

  • Only 18 countries have estimates of the prevalence of injecting drug use since 2015, where they range from under 1 per 1 000 population aged 15 to 64 in the Netherlands, to over 7 per 1 000 in Estonia. Opioids are reported as the main injected drugs in the majority (19) of the 23 countries for which data are available for clients entering treatment in 2021.
  • Adjusting population estimates of high-risk opioid and stimulant users for the proportion of drug treatment entrants reporting injecting provides a prevalence estimate of injecting drug use of 1.8 per 1 000 population aged 15 to 64 years. This suggests there were an estimated 534 000 people who inject drugs in the European Union and Norway in 2021 (see the figure Estimated number and prevalence of people who inject drugs, by country, 2015 to 2021 below).
Figure. Estimated number and prevalence of people who inject drugs, by country, 2015 to 2021

Injecting drug use among clients entering specialised treatment

  • Among first-time clients entering specialised drug treatment in 2021, or most recent year available, with heroin as their primary drug, 19 % (down from 38 % in 2013) reported injecting as their main route of administration. In this group, levels of injecting vary between countries, from less than 10 % in Denmark, Spain, France and Portugal to 60 % or more in Czechia, Estonia, Latvia, Lithuania, Romania and Slovakia.
  • Available data indicate that injecting is reported as the main route of administration by less than 1 % of first-time cocaine clients, 3 % of first-time amphetamine clients and 22 % of first-time methamphetamine clients. It should be noted that Czechia and Slovakia account for more than 90 % of methamphetamine first-time entrants who reported injecting as their main route of administration.
  • Considering the four main injected drugs together, injecting as the main route of administration among first-time entrants to treatment in Europe has declined from 14 % in 2016 to 8 % in 2021.
Figure. Trends in injecting among first-time treatment entrants with heroin, cocaine, amphetamine or methamphetamine as primary drug: proportion reporting injecting as main route of administration

Trends in injecting among first-time treatment entrants are based on 23 countries. Only countries with data for at least 5 of the 6 years are included with the exception of Czechia, where 2 years were interpolated (2016, 2021). Missing values were interpolated from adjacent years.

Syringe residue analysis

  • Analysis of 1 845 used syringes by the ESCAPE network of 12 cities in 11 EU Member States between 2021 and 2022 detected 54 psychoactive substances. These data are not nationally representative and therefore should be understood as indicative of a diversity at local-level in drug use dynamics, rather than reflecting the overall national situations.
  • Heroin was still the most commonly detected drug in 5 out of the 12 participating cities, but stimulants, mostly cocaine, were found in syringes in all cities. They were found in a high proportion (over 50 %) of syringes sampled in Athens (cocaine ), Cologne (cocaine), Dublin (cocaine), Thessaloniki (cocaine), Prague (methamphetamine), Oslo (amphetamine), Tallinn (amphetamine) and Paris (synthetic cathinones) (see the table Percentage of used syringes tested positive by drug category, by city, 2021/2022).
Table. Percentage of used syringes tested positive by drug category, by city, 2021/2022
City Year Number
Heroin Methamphetamine Cocaine Cathinones Amphetamine Buprenorphine Fentanyl* Methadone Benzodiazepines Other opioids Ketamine MDMA Morphine Naloxone Other medicines Other amphetamines
Athens 2022 138 89.1 0.7 78.3     0.7   0.7   9.4     1.5   2.9  
Budapest 2022 132 40.9   24.2 34.1 7.6     3.0                
Cologne 2022 237 80.6 0.4 57.8 0.4 1.3 0.4   2.1 0.4           0.8  
Dublin 2022 99 73.7   71.7 1.0 2.0     34.3 7.1 1.0 3.0 7.1 1.0   25.3  
Helsinki 2022 150   10.7   23.3 24.7 41.3   0.7 14     2.0   12.7 4.0 6.0
Oslo 2022 158 57.0 7.0 2.5   52.5 0.6     4.4 0.6 0.6   4.4      
Prague 2022 153 20.3 54.9 0.7 0.7   38.6 2.0   0.7 0.7         13.1  
Riga 2022 194   18.6 5.7   47.4 4.1 28.9 32.5   27.3   9.8        
Tallinn 2022 149   28.2 3.4 18.8 77.9 8.1 5.4 7.4 6.7 13.4   2.0   6.0 1.3  
Thessaloniki 2022 174 51.2   69.5     32.8   1.7 3.5 0.6         9.8  
Vilnius 2022 141         7.1   91.5 34.0 0.7           0.7  
Paris 2021 120 5.0 6.7 10.8 89.2 1.7 5.0 2.5 11.7 0.8 1.7 0.8   8.3   0.8  

* Fentanyl = fentanyl and derivatives.

Shaded cells indicate most common drug categories by city:     = first |     = second |     = third

  • Injection of diverted opioid agonist medications, such as buprenorphine (>30 % of syringes in Helsinki, Prague and Thessaloniki) and methadone (>30 % of syringes in Dublin, Vilnius and Riga), was common in some cities. Benzodiazepines were also detected (more than 5 % of syringes in Helsinki, Dublin and Tallinn), to a lesser extent. Carfentanil was commonly found in syringes from Vilnius (92 %) and Riga (29 %). Another potent synthetic opioid, isotonitazene, was detected in 10 % and 26 % of syringes from Tallinn and Riga, respectively. Xylazine, a potent veterinary tranquilliser, was detected in 25 out of 194 syringes (13 %) from Riga, where it was found in the presence of isotonitazene or metonitazene in all 25 syringes and together with carfentanil in 3 syringes.
  • Overall, a third of syringes contained residues of two or more drug categories, indicating frequent polydrug use or re-use of injecting paraphernalia. The most frequent combination was a mixture of a stimulant and an opioid.

Source data

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

List of tables

Table 1a. Estimated number of people who inject drugs, by country, 2015 to 2021
Country Central estimate
France 106857
Italy 105652
Czechia 40500
Finland 25000
Portugal 13162
Bulgaria 9783
Lithuania 8868
Estonia 8606
Spain 8582
Norway 7878
Latvia 7715
Belgium 7018
Hungary 6707
Croatia 6344
Greece 2462
Netherlands 840
Luxembourg 822
Cyprus 627
Table 1b. Estimated prevalence of people who inject drugs, by country, 2015 to 2021 (per 1 000 population)
Country Central rate
France 2.7
Italy 2.8
Czechia 6.1
Finland 7.4
Portugal 2.1
Bulgaria 2.2
Lithuania 4.6
Estonia 10
Spain 0.3
Norway 2.2
Latvia 6.1
Belgium 0.8
Hungary 1
Croatia 2.2
Greece 0.4
Netherlands 0.1
Luxembourg 1.9
Cyprus 1
Table 2. Injecting among first-time treatment entrants with heroin, cocaine, amphetamine or methamphetamine as primary drug: proportion reporting injecting as main route of administration
Substance 2016 2017 2018 2019 2020 2021
Amphetamine 0.3 0.2 0.2 0.2 0.2 0.2
Cocaine 1 0.5 0.6 0.5 0.5 0.4
Methamphetamine 1.3 1.6 1.9 2.3 2.7 2.6
Heroin 10.9 8.1 6.9 6 5.9 4.6

About this page 

Recommended citation: European Monitoring Centre for Drugs and Drug Addiction (2023), European Drug Report 2023: Trends and Developments,


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