Injecting drug use in Europe – the current situation (European Drug Report 2024)

cover of the European Drug Report 2024: Injecting drug use

Despite a continued decline in injecting drug use over the past decade in the European Union, this behaviour is still responsible for a disproportionate level of both acute and chronic health harms associated with the consumption of illicit drugs. 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 specialist treatment, as well as insights from studies on syringe residue analysis and more.

This page is part of the European Drug Report 2024, the EMCDDA's annual overview of the drug situation in Europe.

Last update: 11 June 2024

Variety of substances now injected causing serious health harms

Despite a continued decline in injecting drug use over the past decade in the European Union, 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. This underlines the scale of the ongoing challenges in this area and the fact that reducing the harm associated with injecting drug use remains an important public health priority.

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 and various new psychoactive substances, are also injected, either alone or in combination. While it is known that there is considerable variation in injecting 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, and polydrug use can increase the risk of a drug overdose. Recognising the complexity of injecting drug use in Europe and the significance of polydrug use in this context is therefore likely to have important implications both for understanding the harms associated with this mode of administration and for designing interventions 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 the last decade 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. In addition, people who inject drugs may use stimulants as replacement substances, when opioids such as heroin are scarce.

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 synthetic 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 such substances are injected. The highly potent benzimidazole opioids (nitazenes), which can be more potent than fentanyl, were involved in three localised poisoning outbreaks in France (1) and Ireland (2) in 2023, where consumption of nitazenes mis-sold as heroin resulted in multiple overdoses (see also New psychoactive substances – the current situation in Europe).

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. For example, the coverage of needle and syringe programmes is low in Bulgaria, Italy, Cyprus, Hungary and Romania in comparison with other EU Member States with comparable estimates of injecting drug use. 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 that more also needs to be done to reduce overdose deaths and the broader range of health harms associated with injecting drug use. Forensic and toxicological analysis of drug batches suspected of containing highly potent substances (e.g. nitazenes), combined with rapid risk communication, is an important part of the overall approach to overdose prevention and needs to be scaled up. Other interventions targeting these outcomes, including take-home naloxone and drug consumption rooms, are generally less well developed, and therefore this remains 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 such as 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 0.1 per 1 000 population aged 15 to 64 in the Netherlands, to over 10 per 1 000 in Estonia. Opioids are reported as the main injected drugs in the majority (19) of the 22 countries for which data are available for clients entering treatment in 2022.
  • 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 504 000 people who inject drugs in the European Union in 2022 or 512 000 if Norway is included (Figure 9.1).
Figure 9.1a. Estimated number of people who inject drugs, by country
Figure 9.1b. Estimated prevalence of people who inject drugs (per 1000 people)

Based on the latest data available from each country.

Injecting drug use among clients entering specialised treatment

  • Among first-time clients entering specialised drug treatment in 2022, or most recent year available, with heroin as their primary drug, 18 % (down from 37 % in 2013) reported injecting as their main route of administration. In this group, levels of injecting vary between countries, from less than 10 % in Belgium, Spain, France and Portugal to 60 % or more in Bulgaria, 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, 2 % of first-time amphetamine clients and 16 % 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 10 % in 2017 to 7 % in 2022 (Figure 9.2).
Figure 9.2. Trends in injecting among first-time treatment entrants with heroin, cocaine, amphetamine or methamphetamine as primary drug: percentage reporting injecting as main route of administration

Trends in injecting among first-time treatment entrants are based on 22 countries with data for at least 5 of the 6 years (missing values were interpolated from adjacent years), and one country for which the final 2 years were extrapolated.

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 the syringes sampled in Athens (cocaine), Cologne (cocaine), Dublin (cocaine), Thessaloniki (cocaine), Prague (methamphetamine), Oslo (amphetamine), Tallinn (amphetamine) and Paris (synthetic cathinones) (Figure 9.3).
  • Injection of diverted opioid agonist medications was common in some cities, with buprenorphine detected in more than 30 % of the syringes in Helsinki, Prague and Thessaloniki and methadone detected in more than 30 % of the syringes in Dublin, Riga and Vilnius. Benzodiazepines were also detected, albeit to a lesser extent (in more than 5 % of the syringes in Helsinki, Dublin and Tallinn). Carfentanil was commonly found in syringes in 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 %) in 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 the 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.
  • Preliminary data on syringe residue analysis for 2023 confirm existing trends. In Tallinn, the potent synthetic opioid protonitazene was found in half of the syringes (77 of 154), suggesting nitazenes are continuously available on the local drug market. While no nitazenes were detected in the 155 syringes analysed in Dublin, heroin was observed in 150 (97 %) and cocaine in 139 (90 %), reflecting polydrug use or the re-use of syringes, or both. In Budapest, of the 147 syringes analysed, cathinones were found in 101 (69 %) and amphetamine in 35 (24 %), while heroin was detected in 22 (15 %), indicating a greater role for synthetic stimulants in the local drug market. Reflecting a different consumption dynamic, of the 159 syringes analysed in Split, methadone was found in 132 (83 %), while cocaine was detected in 67 (44 %), with amphetamine observed in 41 (24 %). Lastly, in Helsinki, out of the 163 syringes analysed, detections of buprenorphine and amphetamine remained high, while benzodiazepines, mostly alprazolam, were found in 60 syringes (37 %).
Figure 9.3. Percentage of used syringes tested positive by drug category, by city, 2022

Data source: ESCAPE project. For the complete data set and analysis, see ESCAPE: data explorer, analysis and key findings.

Source data

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