Heroin and Opioids
Overview
top of the pageOpiates (opium, morphine, codeine) are natural derivatives of the poppy plant, whereas opioids are semi-synthetic (heroin, buprenorphine) or synthetic (fentanyl) compounds, which have much more powerful analgesic properties. The term “opioids” now tends to refer to all substances whether they are of natural or synthetic origin. One of their major characteristics is their ability to induce psychological and physical dependence.
Heroin comes as a white (acidic salt) or brown (basic salt) powder and can be injected intravenously, snorted or smoked. The pharmacological properties of heroin, a sedative substance, are comparable to those of morphine, but it acts faster, more intensely and for a shorter time.
Production/supply
Seizures
Since 2018, the quantities of heroin seized in France have exceeded one tonne, which is a high level compared to previous years. In 2021, they reached an unprecedented level of 1.3 tonnes.
Most of the heroin used in France comes from Afghanistan (brown heroin) and is transited via Iran by the Balkan route (Turkey, Greece, Albania).
Price and purity
In 2021, the current retail price of a gram of brown heroin was €33. In 2020, the average content of heroin seized in France, at 20.3%, was the highest measured for ten years according to the scientific police department (SNPS). The heroin sold frequently contains cutting agents, the most common being paracetamol and caffeine.
National market
The strength of the heroin market in France is strongly determined by its proximity to the Netherlands and Belgium, which are two major heroin storage and redistribution countries in Western Europe. It is therefore highly regionalised, with a large availability of the product in the north-north-east of France, fuelled by the intensity of cross-border traffic, and a smaller presence in the south. The most striking changes in recent years in terms of heroin supply have come from the Lyon region, with the emergence in recent years of new Albanian-speaking players.
Medicinal opioids
Since the introduction of substitution treatments in France in 1995, non-therapeutic uses of buprenorphine, methadone and also morphine sulphates have developed.
Reference
- OFDT. 1999-2019: changes in drug use and supply in France through the experience of the OFDT's TREND scheme. Summary. Paris, OFDT, Théma TREND, 2020, 9 p.
Use
Rare use in the adolescent and general population
In 2017, 0.7% of 17-year-olds had used heroin before (0.6% among girls and 0.7% among boys). After a period of stable development between 2000 and 2005, the level of heroin use increased until 2008 and has been in a phase of slow decline, particularly among boys (1.0% in 2014). Lifetime heroin use was marginal, at 1.1% of high school students (1.3% of boys and 1.0% of girls), and down from 1.5% in 2015.
The level of lifetime heroin use (use at least once in a lifetime) in the general population in France is low, at 1.3% (a slight decrease compared to 2014: 1.5%) among 18-64-year-olds (2.1% among men vs 0.5% among women) and current use (use in the last year) appears to be very rare (0.3% of respondents). The number of lifetime heroin users in France among 11-75-year-olds was estimated at 500 000 people in 2017.
A diversification of uses among drug users
Opioids play an important role in the use of active drug users: in 2019, 73% of those admitted to the CAARUD (harm reduction facilities) used at least one opioid in the past month. However, unlike the situation in the 1980s, this type of substance, and in particular heroin, no longer constitutes the bulk of the products used, but is now part of the range of substances used as part of polydrug use. Thus, among CAARUD users, 8.5% said that they used heroin on a daily basis.
The use of methadone (therapeutic or not) has continued to increase in this population, to the detriment of buprenorphine. This is partly explained by the fact that the prescription of this molecule as part of opioid substitution treatment (OST) has increased. According to the survey conducted in CAARUDs in 2019, methadone was the most commonly used opioid in the month preceding the survey, ahead of buprenorphine (48%). It was used daily in three out of four cases (75%). Morphine sulphate use concerned 32% of respondents.
References
- Spilka S., Le Nézet O., Janssen E., Brissot A., Philippon A., Shah J., Chyderiotis S. Drug use in 17-year-olds: analysis of the 2017 ESCAPAD survey. Tendances, OFDT, 2018, no. 123, 8 p.
- Cadet-Taïrou A., Janssen E., Guilbaud F. Profils et pratiques des usagers reçus en CAARUD en 2019. [Profiles and practices of users received at the CAARUD in 2019.] Tendances, OFDT, 2020, no. 142, 4 p.
Consequences
Clinical approach: the effects of heroin or other opioid use
Heroin use results in a feeling of calm and relaxation within a very short time, accompanied by a feeling of euphoria. The main side effects of its use are drowsiness, slowed breathing rate, constipation, sometimes nausea, vomiting and dizziness.
With repeated use, tolerance to the product develops: the pleasure derived from a dose becomes less and less significant, and the absence of use leads to an increasingly intense state of withdrawal. The user then seeks to increase the frequency and doses to compensate for this state of withdrawal and regain the sensations felt the first times they used it.
Taking too much heroin or other opioids (overdose) causes respiratory depression, which is often fatal. The risk is further increased when the use of this substance is combined with alcohol or benzodiazepines.
Injection drug use exposes people to abscesses and risks of contamination by HIV, HCV and HBV.
Opioids are very often the reason for treatment...
In terms of people treated in specialised drug treatment centres (CSAPAs) for illicit drugs other than cannabis, the dominant profile is that of multiple opioid users (8 out of 10 people), even though it decreased between 2015 and 2019 (-5%). The composition of this group has changed little since 2015. This is a population whose average age increased from 37.5 years in 2015 to 39.4 years in 2019. The number of people treated with opioid substitution drugs, which had been rising steadily since their introduction in 1995, tended to stabilise at around 180 000 in 2017. Of these, 162 000 were dispensed in pharmacies (87% of which were prescribed by private practitioners, almost exclusively general practitioners) and 23 000 in CSAPAs. The population reimbursed for these treatments, three quarters of whom were male and 40.5 years old on average, aged more than 4 years between 2011 and 2017. Treatment with buprenorphine remains the most common. Its use in 2017 was almost twice as high as that of methadone. However, the share of methadone in the total consumption of opioid substitution treatments has increased steadily since 1998.
Deaths
Opioids are strongly implicated (alone or in combination) in overdose deaths, the number of which has increased significantly in recent years. Of the 503 overdose deaths documented in 2019 by the DRAMES scheme (Drug and substance abuse-related deaths), the presence of opioids was stable and concerned 77% of fatal overdoses. Methadone has been the leading drug for several years (35% of cases in 2019), ahead of heroin (22%). The remaining cases of overdose were divided between opioid analgesics - mainly morphine - (10%) and buprenorphine (9%).
References
- CEIP-A Grenoble. DRAMES (Décès en relation avec l'abus de médicaments et de substances). Principaux résultats de l'enquête 2017. [DRAMES (Drug and substance abuse-related deaths). Main results of the 2017 survey.] Saint-Denis, ANSM, 2019, 2 p.
- Palle C. Les personnes accueillies dans les CSAPA. Situation en 2019 et évolution sur la période 2015-2019. [The people received at the CSAPA. Situation in 2019 and evolution over the period 2015-2019.] Tendances, OFDT, 2021, no. 146, 6 p.
Perceptions /opinions
In 2018, 84% of French people aged 15 to 75 considered heroin to be a dangerous drug, just ahead of cocaine but well above cannabis, tobacco and alcohol. The proportion of people who held this view fell slightly since 1999. As with other (especially licit) products, opinions about heroin and its users hardened in recent years. For example, 84% of French people believed that heroin users were dangerous to those around them. In contrast, the perception of users as ‘suffering from an illness’ rose sharply from 19% in 2012 to 56% in 2018.
As regards harm reduction, which is still very much associated with heroin use, three-quarters of French people (75%) were in favour of informing users about the least dangerous way of using psychoactive products. This level has decreased (it was 72% in 2008). At the same time, a large majority of French people (80%) were in favour of drug consumption rooms in France.
Reference
- Spilka S., Le Nézet O., Janssen E., Brissot A., Philippon A., Chyderiotis S. Drugs: perceptions of substances, public policies and users. Tendances, OFDT, 2019, no. 131, 8 p.
Legal framework and recent public policies
Heroin is a classified drug and its use is prohibited. Buying, using, possessing, giving away, dealing, producing, transporting or driving after using heroin are all offences against the law and are subject to severe penalties in court, regardless of the amount of product involved.
The law of 31 December 1970, which punishes the use of and trafficking in narcotics, was strongly inspired by the health situation of heroin addicts: it provides for health alternatives to criminal prosecution, in particular the therapeutic injunction, which the judge can order for a user who is recognised as being addicted rather than prosecuting the user.
As with other illicit drugs, heroin trafficking is severely penalised. Penalties have become harsher since the late 1980s: they can go up to life imprisonment and a fine of €7.5 million for the most organised forms of trafficking.
Recent public policies
On 26 January 2016, the law on the modernisation of the health system adopted two major provisions in the field of addictions: the trial of drug consumption rooms for a maximum of six years (currently, two rooms exist in Paris and Strasbourg) and the extension of the practice of rapid diagnostic tests (RDT) to the staff of prevention structures or associations who have received appropriate training.
In view of the positive results of the evaluation conducted by Inserm, the trial of drug consumption rooms has been renewed under the name of Haltes Soins Addictions (HAS in French). The Social Security Financing Act 2022 enshrines this name.
In 2016, a programme was also set up to distribute naloxone (antidote to opioid overdoses) to drug users in France: two specialities are currently marketed, the Nalscue® nasal naloxone kit available since July 2016 and the Prenoxad® intramuscular naloxone kit marketed since June 2019. These kits are distributed in specialised structures (CSAPA, CAARUD) and in health care institutions. Prenoxad® is also available in pharmacies.
Last update: September 2022
Drugs in Europe
2023 EMCDDA European Drug Report
The European Drug Report 2023: Trends and Developments presents the EMCDDA’s latest analysis of the drug situation in Europe. Focusing on illicit drug use, related harms and drug supply, the report contains a comprehensive set of national data across these themes and key harm-reduction interventions. This report is based on information provided to the EMCDDA by the EU Member States, the candidate country Türkiye, and Norway, in an annual reporting process.
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The European Union and the drug phenomenon
The European Union & the drug phenomenon : Frequently asked questions, joint publication between the EMCDDA and the European Commission, october 2010, 12 p.
