Injecting drug use in Europe – the current situation (European Drug Report 2025)
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 2025, the EUDA’s annual overview of the drug situation in Europe.
Last update: 5 June 2025
Diversity of drugs injected and poly-substance use driving health risks
The downward trend in injecting drug use among first-time entrants to drug treatment services in the European Union over the past decade appeared to slow down in 2023. Injecting remains 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 becoming infected by blood-borne viruses, including HIV and hepatitis B and C viruses, 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 cocaine, amphetamines, synthetic cathinones, opioid agonist medications 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. In addition, various medicines, such as benzodiazepines, pregabalin and methylphenidate, as well as the anaesthetic benzocaine and the pyrrolidone or nootropic piracetam, have also been identified in syringe residues. Some might be used as adulterants without the users’ knowledge. 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. More frequent patterns of injecting may also result in a higher risk of re-infection with the hepatitis C virus (HCV), presenting a potential challenge to the positive impact of HCV treatment now being reported by some countries (see also Drug-related infectious diseases – the current situation in Europe). Methamphetamine injecting carries similar risks, and the drug continued to be detected in 2023 at high levels in used syringes from cities around Europe, including Athens, Barcelona, Madrid, Prague and Tallinn. This is a concern, as various signals continue to indicate 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 and benzimidazole opioids (nitazenes), where the risk of fatal overdoses are likely to be elevated when such substances are injected.
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, concern exists around the low, and in some cases decreasing, levels of provision of sterile syringes observed in Bulgaria, Croatia, Lithuania, Hungary, Malta, Poland, Romania and Slovakia in comparison with other EU Member States with comparable estimates of injecting drug use (see also Drug-related infectious diseases – the current situation in Europe). Reducing 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 injecting drug use continues to change, now encompassing primarily opioid and stimulant-based open drug scenes involving marginalised people who inject drugs, as well as 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
- Injecting drug use estimates range from 0.1 per 1000 population in the Netherlands to 10 per 1000 population in Estonia, with particularly high levels also reported in Finland (7.4 per 1000), Czechia (6.1 per 1000), Latvia (6.1 per 1000) and Lithuania (4.6 per 1000) (Figure 9.1a).
- Opioids were reported as the main injected drugs in the majority (20) of the 24 countries for which data are available for clients entering treatment in 2023. However, data from low-threshold services and syringe residue analysis from the ESCAPE project highlight the increasing role played by stimulants in injecting drug use, which is happening within patterns of predominantly polysubstance use.
- The highest estimated numbers of people who inject drugs in the European Union were reported by the most populous countries: Germany (107 316), Italy (105 652) and France (96 531) (Figure 9.1b).
- The overall prevalence of injecting drug use in the European Union is estimated at 1.8 cases per 1000 population aged 15 to 64 years (Figure 9.1). This suggests there were an estimated 520 000 people who inject drugs in the European Union in 2023, or 528 000 if Norway is included.
Injecting drug use among clients entering specialised treatment
- Based on data from 24 countries where historical data are available, among first-time clients entering specialised drug treatment in 2023 reporting heroin as their primary drug, 18 % reported injecting as their main route of administration; stable compared with 2022, but down from 33 % in 2013. In this group, levels of injecting vary between countries, from less than 10 % in Spain 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 1.5 % of first-time cocaine clients, 2 % of first-time amphetamine clients and 5 % of first-time methamphetamine clients. It should be noted that Slovakia accounts for almost 60 % of first-time methamphetamine 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 decreased to 5 % in 2023 (6 % in 2022) following several years of decline from 8 % in 2018 (Figure 9.2).
Syringe residue analysis
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 19 cities in the European Union and Norway. While not nationally representative, the data are indicative of diverse local-level drug use dynamics, rather than reflecting the overall national situations.
Diversity of substances injected
- As in previous years, the 2023 results showed that a wide diversity of substances were detected in used syringes across the participating cities (Figure 9.3), reflecting local markets and different sub-populations of people who use drugs.
- A total of 3276 used syringes tested positive for at least one drug category in the participating cities.
- In total, 91 distinct substances from 15 drug categories were detected.
- Another 39 substances were detected and classified as either adulterants (11) or metabolites and degradation products (28).
Combination of substances
- Half of the syringes contained residues of 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 of drugs found in syringes was a mixture of a stimulant and an opioid: heroin and cocaine (Amsterdam, Athens, Barcelona, Cologne, Dublin, Heraklion, Madrid, Patras, Thessaloniki); heroin and amphetamine (Oslo); buprenorphine/heroin and methamphetamine (Prague); methadone and cocaine (Split); nitazenes and cocaine (Riga).
- The exceptions were Budapest (synthetic cathinones and amphetamines), Helsinki (buprenorphine and benzodiazepines), Klaipeda (carfentanil and methadone), Paris (cocaine and synthetic cathinones), Tallinn (amphetamine and methamphetamine) and Vilnius (carfentanil and testosterone).
Opioids
- Reflecting its continued availability on local drug markets, heroin was still the most commonly detected drug in syringes from 6 of the 19 cities (Dublin, 99 %; Athens, 92 %; Cologne, 70 %; Oslo, 68 %; Heraklion, 47 %; Amsterdam, 43 %). In addition, the drug was detected in more than 50 % of syringes in Barcelona (58 %) and Thessaloniki (52 %).
- Carfentanil, a fentanyl derivative, was commonly found in syringes from the Lithuanian cities Vilnius (95 %) and Klaipeda (29 %) and to a lesser extent in Riga (6 %) in neighbouring Latvia.
- Nitazenes, a class of potent new synthetic opioids, were detected in Riga (metonitazene, 66 %; isotonitazene, 41 %) and Tallinn (protonitazene, 33 %; metonitazene, 12 %; isotonitazene, 6 %). Other substances were sometimes found alongside nitazenes in syringe residues, such as amphetamine and methadone in Tallinn and cocaine and methadone in Riga.
- Buprenorphine was commonly detected in Patras (58 %), Helsinki (39 %), Prague (37 %) and Heraklion (32 %), while methadone was frequently detected in syringes from Split (83 %), Klaipeda (54 %), Dublin (42 %) and Riga (39 %).
- Tramadol was detected in 17 % of syringes in Athens, and morphine was detected in 7 % of syringes from Paris.
Stimulants
- Cocaine was detected in more than 50 % of syringes in 6 out of 19 cities (Dublin, 90 %; Barcelona, 89 %; Thessaloniki, 73 %; Riga, 64 %; Cologne, 62 %; Madrid, 56 %).
- Synthetic cathinones were commonly detected in Budapest (69 %), Paris (65 %), Madrid (46 %), and to a lesser extent in Amsterdam (15 %) and Helsinki (14 %). A total of 13 distinct cathinones were identified across participating cities, with 3-CMC, N-ethylnorpentedrone, mephedrone, 4-CMC and alpha-PVP being the most frequently detected.
- Methamphetamine was detected in the majority of syringes from Prague (66 %), in a quarter of syringes from Athens (25 %), and in more than 10 % of syringes in Madrid (19 %), Tallinn (12 %) and Barcelona (11 %).
- Amphetamine was detected in the majority of syringes in Tallinn (67 %) and Oslo (52 %), and in 20 % or more of syringes in Split (26 %), Helsinki (23 %) and Budapest (20 %).
Benzodiazepines and other medicines
- Benzodiazepines were detected in 37 % of syringes from Helsinki (alprazolam, midazolam) and in 10 % of syringes from Athens and Dublin (alprazolam, diazepam).
- Pregabalin (an anti-convulsant medication) was found in 16 % of syringes from Dublin and at lower levels in Heraklion (5 %), Athens (1 %) and Thessaloniki (<1 %), whereas benzocaine (an anaesthetic medicine) was detected in 12 % of syringes from Dublin.
- Piracetam (used as a cognitive enhancer) was detected in 52 % of syringes in Barcelona.
- Methylphenidate (a stimulant medication for treating ADHD) was found in 15 % of syringes from Cologne.
- Testosterone was found in syringes from Vilnius (13 %) and Klaipeda (8 %).
Additional information can be found in Drug-related infectious diseases: health and social responses.
Source data
The data used to generate infographics and charts on this page may be found below.
The complete set of source data for the European Drug Report 2025, including metadata and methodological note,s is available in our data catalogue.
A subset of this data, used to generate infographics, charts and similar elements on this page, may be found below.