Potent synthetic substances, new drug mixtures and changing patterns of use pose a growing threat in Europe. These are among the issues raised today by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) as it launches its European Drug Report 2024: Trends and Developments (1).
Drug availability remains high in Europe, where the market offers a diverse range of products. People who use drugs are now exposed to a wider range of psychoactive substances, often of high potency or purity, or in new forms, mixtures and combinations. With products sometimes mis-sold, consumers may be unaware of what they are taking and subject to greater health risks, including potentially fatal poisoning.
The report highlights concerns around potent synthetic opioids, sometimes mis-sold or mixed with medicines and other drugs; MDMA adulterated with synthetic cathinones; and cannabis products adulterated with synthetic cannabinoids. By the end of 2023, the EMCDDA was monitoring over 950 new psychoactive substances (NPS), 26 of which were first reported in Europe in that year.
A key message of this year’s report is that 'polysubstance use' — the use of two or more psychoactive substances at the same time or in sequence — is common in Europe today. Whether it involves using benzodiazepines with opioids, or cocaine with alcohol, this pattern of drug use can increase health risks and complicate the delivery of interventions (e.g. overdose response). These challenges are further complicated when drug mixtures are consumed unknowingly.
According to the report: ‘One of the challenges facing drug surveillance in 2024 is to gain a deeper understanding of what drugs are actually being consumed and in what combinations’. The priorities of the new European Union Drugs Agency (EUDA), launching on 2 July, will include enhancing the monitoring of patterns of polysubstance use and the understanding of what constitutes effective prevention, treatment and harm reduction interventions (2). The agency will also strengthen its analytical capacity, through an EU network of forensic and toxicological laboratories.
European Commissioner for Home Affairs Ylva Johansson says: 'The European drug market is fast moving and volatile, fuelling violence and corruption. And the flow of illicit drugs into Europe is coming particularly through our ports. That is why we have set up a European Ports Alliance to strengthen the resilience of our logistical hubs against the threats posed by organised crime. It takes a network to fight a network. Meanwhile, new drugs and dangers continue to arise. And that is why we have equipped our drugs agency with greater powers and resources. The drugs agency is doing a very important job, alerting us to the spread and dangers of drugs. The European Drug Report is a vital resource for policymakers. We need to be vigilant; we need to be prepared.'
Europe’s evolving opioid problem: nitazenes, an emerging threat
Heroin remains the most commonly used illicit opioid in Europe and accounts for a significant portion of the health problems associated with illicit drug use. Europe’s opioid market, however, is increasingly complex, featuring a variety of substances, including synthetic opioids. Compared to North America, synthetic opioids play a relatively small role in Europe’s drug market overall, but feature prominently in the opioids market in the Baltic countries. There is also growing concern about their use in some other EU Member States.
A total of 81 new synthetic opioids have appeared on the European drug market since 2009. These are often highly potent and carry a significant risk of poisoning and death. In 2023, six of the seven new synthetic opioids reported for the first time to the EU Early Warning System (EWS) were nitazenes. This was the highest number of nitazenes notified in a single year, with 16 in total detected in Europe since 2019.
Nitazenes are sometimes sold as ‘synthetic heroin’ and have been detected in fake medicines on the drug market. In 2023, nitazenes were associated with a sharp rise in deaths in Estonia and Latvia and with localised poisoning outbreaks in France and Ireland. Outside the EU, they have been linked to drug overdoses in Australia, North America and the UK. Currently, nitazenes and similar substances may not be detected in routine post-mortem toxicology tests in some countries, so associated deaths may be under-estimated. New synthetic opioids have been found in different mixtures containing new benzodiazepines or the animal sedative xylazine. These combinations, respectively known as ‘benzo-dope’ and ‘tranq-dope’, have been linked to poisonings, including deaths, in North America.
Most of the heroin consumed in Europe comes from Afghanistan, where the Taliban announced a ban on opium poppy cultivation and opium production in April 2022. Latest UNODC figures for 2023 show an estimated 95 % decline both in cultivation and in illicit opium production in the country compared to 2022. Currently, it is difficult to predict how Europe’s heroin market will be affected by the ban. Evidence suggests that substantial stocks of opium remain in Afghanistan, which may explain why, to date, there have been no strong signals of disrupted heroin flows towards the EU. However, there are concerns that a future heroin shortage could lead to market gaps being filled by potent synthetic opioids or synthetic stimulants. This could have potentially significant negative effects on public health and security.
The report underlines the need for Europe to improve its preparedness for any possible market shifts, by ensuring adequate prevention and treatment, including access to opioid agonist medicines and harm reduction services, as well as making available sufficient supplies of naloxone, the overdose-reversal drug. Having in place multiagency response and rapid communication plans can also help strengthen preparedness for the sudden appearance of highly potent substances on the illicit drug market in the EU.
EMCDDA Director Alexis Goosdeel says: 'In this year's European Drug Report, we highlight the growing challenges posed by a highly complex and rapidly evolving drug market, where established illicit drugs are widely accessible and potent new synthetic substances continue to emerge. We underline how widespread polysubstance use is driving a range of health risks, especially when drug mixtures are unknowingly consumed. We also reflect today on potential future problems in the drugs field and the need to be better prepared to face them. I am pleased to announce, therefore, that, as the new European Union Drugs Agency, we will have a stronger mandate to anticipate future emerging threats and trends, alert in real time on new risks for health and security, help the EU and Member States to respond, and learn from experience to adapt and improve our drug strategies and interventions'.
Sixth year of record cocaine seizures: impact on public health
For the sixth year in a row, record quantities of cocaine were seized by EU Member States, amounting to a reported 323 tonnes in 2022 (303 tonnes in 2021). European seizures now exceed those made in the United States, historically regarded as the world’s largest cocaine market. Belgium (111 tonnes), Spain (58.3 tonnes) and the Netherlands (51.5 tonnes) account for 68 % of the total quantity seized, reflecting the persistent targeting of logistical supply chains by drug traffickers. In 2023, Spain reported its largest ever individual seizure of cocaine (9.5 tonnes), concealed in banana shipments from Ecuador.
Trafficking of large volumes of cocaine in maritime shipping containers via Europe’s seaports remains a significant factor in the drug’s high availability in the region. Recent data from the port of Antwerp show that in 2023, the quantity of cocaine seized there rose to 116 tonnes (from 110 tonnes in 2022). As law-enforcement methods intensify, organised crime groups are also targeting smaller ports both in EU countries and those bordering the EU, which may be more vulnerable to drug trafficking. Reflecting this, some northern European countries, including Sweden and Norway, reported record cocaine seizures in seaports in 2023.
As part of the EU roadmap to fight drug trafficking and organised crime, the new European Ports Alliance (2024), a public-private partnership, aims to boost the resilience of ports and step up the fight against drug trafficking and criminal infiltration. Organised crime groups also supply European consumer markets by processing illicit cocaine products in several EU countries, with 39 cocaine laboratories reported to have been dismantled in 2022 (34 in 2021).
There are signs that the high availability of cocaine in Europe is having an increasingly negative impact on public health. It is the second most common illicit drug reported both by those entering drug treatment services for the first time (29 000 in 2022) and by those presenting at hospital emergency departments (mentioned in 28 % of acute drug toxicity presentations in Euro-DEN Plus sentinel hospitals in 2022). Available data suggest that the drug was also present in around one fifth of reported overdose deaths in 2022, often detected alongside other substances. As cocaine use can increase the risk of cardiovascular and other health problems, it is likely that its overall contribution to drug-related mortality in Europe is not sufficiently recognised.
Cocaine is Europe’s most commonly consumed illicit stimulant drug, used by around 1.4 % (4 million) of European adults (15–64 years) in the last year. Information suggests that cocaine is increasingly available in Europe, with a wider geographical and social distribution. The latest wastewater analysis data showed that of the 72 cities with data for 2022 and 2023, 49 reported an increase in cocaine residues. Of particular concern is that cocaine use appears to be becoming increasingly common in more vulnerable or marginalised groups in some countries. Both cocaine injection and the use of crack cocaine is reported in a growing number of countries. Stimulants such as cocaine are associated with a higher frequency of injection and have been involved in localised HIV outbreaks among people who inject drugs in a number of European cities over the last decade.
Changing cannabis markets create new challenges for drug policies
Developments in the cannabis market are creating new challenges for how countries respond to Europe’s most commonly consumed illicit drug. The average THC content of cannabis resin has doubled in the last 10 years and continues to rise (22.8 % in 2022), while that of herbal cannabis has been generally stable. And cannabis products are now increasingly diverse, including high-potency extracts and edibles. There are also reports that some products sold on the illicit market as cannabis may be adulterated with potent synthetic cannabinoids.
In 2023, the EU Early Warning System received reports of nine new cannabinoids, four of which were semi-synthetic. The most commonly detected semi-synthetic cannabinoid is hexahydrocannabinol (HHC), which in 2022 was the first of these substances to be reported in Europe. While knowledge of the effects of these substances on humans is limited, there have been reports of poisonings, including among children who had consumed edibles containing HHC. As of March 2024, HHC had been listed as a controlled drug in at least 18 EU Member States.
Around 8 % (22.8 million) of European adults (15–64 years) are estimated to have used cannabis in the last year, with prevalence rising to 15 % (15.1 million) among young adults (15–34 years). An estimated 92 000 clients entered specialised drug treatment for problems related to cannabis use in 2022, representing around one third (36 %) of all treatment entrants. Cannabis was also the most frequently reported substance by the Euro-DEN Plus hospital network in 2022, involved in 29 % of acute drug toxicity presentations (25 % in 2021).
Cannabis use can cause or exacerbate a range of physical and mental health problems, including chronic respiratory symptoms, dependence and psychotic symptoms. Given the complexity of the market and the variety of products available, assessing the risk of harms from cannabis use is challenging. There is a need for greater research into the specific challenges faced by people who use cannabis in order to identify the most effective treatment options. Psychological coping therapies are commonly offered to those with cannabis-related problems and e-health (online) interventions are increasingly available.
Five EU Member States (Czechia, Germany, Luxembourg, Malta and the Netherlands) plus Switzerland have changed, or are planning to change, their approach to recreational cannabis use and supply. These changes — which include home growing, non-profit growing clubs and cannabis use in private — are outlined in the report, which highlights the need to invest in monitoring and evaluation to fully understand their impact on public health and safety (3).
Chair of the EMCDDA Management Board Franz Pietsch says: ‘This is the last European Drug Report published by the EMCDDA, before it becomes the European Union Drugs Agency next month. This latest analysis demonstrates how much the drugs problem has changed since the first report some 30 years ago and why the agency has been given a broader mandate. I commend the EMCDDA for the immense value it has provided to its stakeholders over the years. I am convinced that, in its new form, the agency will provide even more value to those working in the drugs field as they tackle the causes and consequences of drug use’.
