Opioid agonist treatment – the current situation in Europe (European Drug Report 2024)

cover of the European Drug Report 2024: Opioid agonist treatment

Opioid users represent the largest group undergoing specialist drug treatment, mainly in the form of opioid agonist treatment. On this page, you can find the latest analysis of the provision of opioid agonist treatment in Europe, including key data on coverage, the number of people in treatment, pathways to treatment 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

Treating opioid-related problems still consumes most treatment resources

While there is now greater heterogeneity in the characteristics of those seeking help for drug problems, due to the long-term nature of opioid agonist treatment, those receiving it still probably account for the greatest share of the resources invested in drug treatment services in most countries. An estimated 1.7 million people received treatment for problems related to the use of illicit drugs in the European Union in 2022 (2.0 million, including Norway and Türkiye). Specialist drug treatment encompasses a range of medical (including pharmacological), psychological, social and behavioural approaches to stop or reduce drug use and injecting. Generally, the majority will receive some form of opioid agonist treatment, which is the main pharmacological treatment approach and is typically combined with psychosocial interventions. The available evidence supports this approach, with positive outcomes found with respect to treatment retention, illicit opioid use, reported risk behaviour, drug-related harms and mortality. Recent guidance from the EMCDDA and ECDC on the prevention and control of infectious diseases among people who inject drugs recommends the provision of opioid agonist treatment in both community and prison settings to prevent transmission of HCV and HIV and to help reduce injecting risk behaviour and injecting frequency. The guidance also recommends the provision of sterile injecting equipment alongside opioid agonist treatment to maximise the coverage and effectiveness of the interventions among people who inject opioids.

There remain, however, important differences between countries in the settings and form in which treatment is provided and the extent to which the availability of opioid agonist treatment is sufficient to meet the needs of those requiring this form of care. The provision of opioid agonist treatment is still clearly insufficient in some countries (see Key data and trends, below). The relative importance of outpatient and inpatient provision within national treatment systems also varies greatly between countries. Almost a fifth of drug treatment in Europe is provided in inpatient settings, mainly hospital-based residential centres (e.g. psychiatric hospitals), but this can also include therapeutic communities and, in some countries, specialist residential treatment centres in prisons. Overall, however, opioid agonist treatment is more commonly provided in outpatient settings. These can include specialist drug treatment centres, low-threshold agencies, and primary healthcare centres, which can include general practitioners’ surgeries.

The available data suggest that the provision of opioid agonist treatment did not drop significantly during the COVID-19 pandemic, when public health-based restrictions on movement were in place. During that period, however, service delivery models may have been adapted. Examples of this include increased use of telemedicine and less restrictive approaches to providing take-home doses. There is also some information to suggest that access to care for new clients seeking opioid agonist treatment may have been disrupted temporarily during the pandemic period.

Meeting the more complex needs of an ageing cohort of opioid treatment clients

The long-term nature of opioid problems is underlined by the data available on the characteristics of those receiving opioid agonist treatment. The data also indicate that Europe’s cohort of those who have had problems with heroin is ageing. This is illustrated by the fact that almost 70 % of clients in opioid agonist treatment are now aged 40 or older, while less than 10 % are under 30 years old. This has important implications for service delivery, with services having to address a more complex set of healthcare needs in a population that is becoming ever more vulnerable. An important consideration here is the need to ensure the existence of effective referral pathways to more generic services offering treatment for other conditions associated with the ageing process. This is becoming increasingly necessary in order to support older opioid treatment clients in need of geriatric care due to the long-term effects of illicit drug use, but also tobacco and alcohol use, on their physical health. The treatment of this marginalised group also needs to respond to a complex and often long-established set of problems related to mental health issues, social isolation, employment and housing. The development of integrated, multidisciplinary and age-specialised care services for this group will remain an important consideration in policy and provision as the demographics of opioid use in Europe continue to change.

Polydrug use and the appearance of highly potent new synthetic opioids on local drug markets can increase the risks from opioid use, especially for older people and those with complex healthcare needs. Where highly potent opioids have become an established feature of drug markets, more research is needed to determine if adaptations are needed to ensure that current approaches to providing opioid agonist treatment remain optimal. In addition, as noted elsewhere in this report, should we see the reduced availability of heroin on the European market, this may increase the demand for care in this area.

More information on health and social responses to opioid use, including among older people, can be found in the EMCDDA’s Health and social responses to drug problems: A European guide.

Key data and trends

Number of people in treatment

  • A comparison with current estimates of the number of high-risk opioid users in Europe would suggest that, overall, opioid agonist treatment was received by about half of the number of high-risk opioid users in the European Union in 2022, an estimated 513 000 (526 000 including Norway and Türkiye) (Figure 12.1). However, there are differences between countries. In those countries where data from 2011 or 2012 are available for comparison, there was generally an increase in coverage. Levels of provision, however, remain low and insufficient in some countries estimated to have significant numbers of high-risk opioid users, such as Latvia, Lithuania, Poland, Romania and Slovakia (Figure 12.2).
Figure 12.1. Clients in opioid agonist treatment

Trends in the number of opioid agonist clients are based on 26 countries. Only countries with data for at least 7 of the 10 years are included in the trends graph. Missing values are interpolated from adjacent years. Data for age distribution are based on 16 countries representing 28 % (141 164) of all registered clients in the European Union. Data for gender are based on 17 countries representing 18 % (93 612) of all registered clients. Data for treatment duration are based on 7 countries representing 7 % of all registered clients (34 300).

Distribution of OAT clients by type of medication: SROM is slow-release oral morphine and DHC is dihydrocodeine.

Figure 12.2a. Coverage of opioid agonist treatment (percent) in 2022 or the most recent year
Figure 12.2b. Coverage of opioid agonist treatment (percent) in 2011/12

Coverage is defined as the share of high-risk opioid users receiving the intervention. Data are displayed as point estimates and uncertainty intervals.

  • Data from countries that consistently reported on clients receiving opioid agonist treatment between 2010 and 2022 show an overall stable trend in treatment levels during this period, with little fluctuation in the number of clients receiving this treatment. The reasons for this stability vary. In countries with high treatment provision, it may reflect the often chronic, relapsing nature of opioid dependence and the need for treatment over a prolonged period; in others (e.g. Latvia), it may reflect the low capacity of treatment systems.
  • At the onset of the COVID-19 pandemic, EU Member States sought to ensure continued access to opioid agonist treatment for people engaged in high-risk drug use. Comparing treatment data between 2019 and 2022 indicates that the number of clients remained stable, with only Croatia and Hungary reporting a decrease greater than 10 % of their opioid agonist treatment population during this period. These reductions may be partly due to decreased access to treatment during the pandemic.
  • In some countries, the number of people receiving opioid agonist treatment has increased, reflecting increased treatment provision, with 11 countries reporting an increase between 2016 and 2022, including Denmark (37 %), Poland (54 %), Romania (17 %) and Sweden (21 %).

Pathways to treatment

  • Client pathways through drug treatment are often characterised by the use of different services, multiple entries and varying lengths of stay. Self-referral continues to be the most common route into specialist drug treatment for opioid clients. This form of referral, which also includes referral by family members or friends, accounted for about two thirds (66 %) of those with primary opioid problems entering specialist drug treatment in Europe in 2022. Almost one fifth (23 %) of clients were referred by health, education and social services, including other drug treatment centres, while 7 % were referred by the criminal justice system.

Opioid agonist medications

  • The provision of more than one opioid agonist treatment medication in 2022 is reported by 26 countries. Methadone is the most commonly prescribed medication, received by more than half (56 %) of opioid agonist treatment clients across Europe. Another 35 % are treated with medications based on buprenorphine, which is the principal medication reported to be used in 8 countries. Other substances, such as slow-release morphine or diacetylmorphine (heroin), are more rarely prescribed, being received by almost 10 % of opioid agonist clients in Europe, with 5 countries reporting some provision of heroin-assisted treatment, if pilot projects are included (Figure 12.3).
Figure 12.3. Number of European countries implementing opioid agonist treatment, up to 2023

Implementation at any level, including pilot projects, is included.

Alternative treatment options

  • Although less common than opioid agonist treatment, alternative treatment options for opioid users are available in all European countries. In the 11 countries for which data are available, between 5 % and 47 % of all opioid users in treatment receive interventions not classified as opioid agonist treatment, such as medically assisted detoxification and outpatient or inpatient abstinence-oriented interventions.

Source data

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