The main opioid sold on the illicit market in Europe is heroin. Most individuals using heroin are dependent users, often living on the margins of society and highly stigmatised. In contrast to most other drugs, there appear to be very few occasional users of heroin (Trautmann and McSweeney, 2013). This makes estimation of the size of the heroin-using population difficult, as heroin users are unlikely to be included in surveys of the general population. Nevertheless, national estimates obtained by a variety of indirect estimation techniques based on administrative data sources are available in many countries. These suggest an average annual prevalence rate for high-risk opioid use among adults aged 15–64 of 0.4 % (4 per 1 000 population), the equivalent of 1.3 million problem opioid users in Europe (EMCDDA, 2015a).
A third of people entering drug treatment in 2014 in Europe (150 000 clients) said that heroin was their primary problem drug. However, less than one-sixth (14 %) of those entering treatment for the first time (24 000 clients) cited heroin as their principal drug, less than half the number doing so in 2007, suggesting that recruitment into heroin use is declining.
Heroin comes in different forms (see box 'Opiates, opioids and heroin') and may be smoked, snorted or injected. There is no consistent data collection on patterns of use within EU countries, but it is clear from both treatment data and research studies that the preferred mode of use varies from country to country. For example, among first-time treatment entrants reporting heroin as their primary drug in 2013, the proportion reporting injecting as their main route of administration ranged from 8 % in the Netherlands to 100 % in Lithuania (EMCDDA, 2015a). Similarly, a three-country research study found that injecting was the main mode of use in Italy, while smoking was the main mode of use for the vast majority of participants in the Netherlands and just over half of those in England. Snorting heroin was less common (Trautmann and Frijns, 2013).
The same study also found variation between countries in the locations where heroin is most often consumed, which has implications for the level of harm associated with use. Consumption in the user’s own home or in someone else’s home were the locations most commonly mentioned, but in Italy two-thirds of participants mentioned using in the street or park (67 %), while in the Netherlands a significant proportion mentioned using a drug consumption room (40 %) (Trautmann and Frijns, 2013). These differences may be associated with differences in services (e.g. the availability of drug consumption rooms), but also factors associated with the markets and enforcement activity that might affect whether or not an open drug scene exists.
It is estimated that the quantity of heroin used in the EU in 2013 was at least 138 tonnes (121–162 tonnes) with a total value of approximately EUR 6.8 billion (EUR 6.0–7.8 billion). This makes it the second largest retail drug market in the EU.
These estimates have been calculated from national estimates of the number of problem opiate users, adjusted on the basis of treatment data to take account of the proportion likely to be users of opioids other than heroin. These estimates have also taken account of the fact that quite a large proportion of heroin users are in receipt of drug treatment, particularly opiate substitution treatment, and that when retained in treatment their drug use diminishes substantially.
A number of limitations affect the accuracy of these estimates (see box on 'The challenge of estimating the size of the illicit drug market'), and further details of the estimation methods are given in the technical paper published alongside this report (EMCDDA, 2016a). It is particularly difficult to estimate the number of users of heroin, which is fundamental to any estimate of market size, and hence the above figures must be viewed as preliminary estimates that will be improved in the future by the incorporation of new sources of data. Even less information is available about the use of other opioids, and so estimation of the value of the markets for these substances has not been attempted here.
While the incidence of heroin use in Europe appears to be declining, the data on those presenting for treatment suggest an increasingly diversified market in opioids. Although the majority of those entering treatment for opioid use problems still cite heroin as their primary problem drug, in 2013 one in 12 (8 %) clients entering treatment cited other opioids. The most commonly reported other opioids are methadone (which accounted for 60 % of those entering treatment for use of other opioids in 2013), buprenorphine (30 % of new presentations) and fentanyl. In just over one-third of European countries (11), more than 10 % of all opioid clients entering specialised services in 2013 were treated for problems primarily related to opioids other than heroin. In some countries, other opioids represent the most common form of problem opioid use. In Estonia, for example, the majority of treatment entrants reporting an opioid as their primary drug were using illicit fentanyl, while in Finland most opioid clients are reported to be primary misusers of buprenorphine (EMCDDA, 2015a). Thus, although heroin still predominates, the opioid market appears to be more dynamic and complex than in the past, with more substances available to consumers. Transitions between heroin and other opioids, such as fentanyl and substitution medicines, have been observed. Prescription medicines and new synthetic opioids, which can be purchased online, are also appearing and are likely to have increasing importance for both public health and law enforcement, with the potential for a growing problem of use of opioid-based medicines, as has been seen in the United States and Australia (see also Chapter 7).