Heroin and opioids - Overview

Heroin is an opiate derived from morphine produced from poppies. Its pharmacological properties are comparable to those of morphine, but it acts faster, more intensely, and more briefly.

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héroine

Introduction/Background

Opiates (opium, morphine, codeine) are natural derivatives of the poppy, while opioids are semisynthetic (heroin, buprenorphine), or synthetic (fentanyl) compounds, the analgesic properties of which are much more powerful. The term “opioids” now tends to refer to all substances, whether they are of natural or synthetic origin. One of their main characteristics is their capacity to induce a psychological and physical dependence.

Heroin exists in the form of a white (acidic salt) or brown (base salt) powder, and can be injected intravenously, snorted, or smoked. The pharmacological properties of heroin, a sedative, are comparable to those of morphine, but it acts faster, more intensely, and more briefly.

Production/Supply

Seizures

Since 2018, the quantities of heroin seized in France have exceeded over one tonne per year, which is a higher level than that of previous years. In 2022, it reached an unprecedented level of 1.4 tonnes (SNPS data 2022).

The heroin used in France mainly hails from Afghanistan (brown heroin) and passes through Iran via the Balkan route (Turkey, Greece, Albania). Nevertheless, following the ban on poppy cultivation by the Afghan authorities in 2022, opium production decreased by 95% in 2023, according to the United Nations Office on Drugs and Crime (UNODC).

Price and purity

In 2022, the current retail price of a gram of brown heroin stood at €30. In 2022, the average potency of the heroin seized in France, at 20%, was the second highest measured for a decade (SNPS data 2022). According to observations from the OFDT’s monitoring scheme for Emerging Trends and New Drugs (TREND), the current price of heroin fluctuates significantly according to the region, quantity purchased, and supposed quality.

The OFDT’s National Identification System for Toxics and Substances (SINTES) monitors the mis-selling and atypical adulterations of substances. In 2022, the compliance rate was 94%, and no adulteration with a new psychoactive substance (NPS) was reported.

National market

The strength of the heroin market in France is heavily determined by its proximity to the Netherlands and Belgium, which are two large heroin storage and redistribution countries in Western Europe. It is therefore heavily regionalised with a large availability of the substance in Northern and North-Eastern France, fed by the intensity of cross-border traffic, and a reduced presence in the South. The most significant changes in the heroin supply in recent years come from the Lyon region, with the emergence of new Albanian-speaking actors over several years.

Prescription opioids

Since the introduction of substitution treatments in France in 1995, non-therapeutic uses of buprenorphine, methadone, and also morphine sulphates have been developed.

Use in the adolescent population

In 2022, 0.4% of 17-year-olds had tried heroin. Following a period of stability between 2000 and 2005, the level of heroin use increased up to 2008, and is currently undergoing a slow decline, notably among boys (1.0% in 2014). At regional level, Nouvelle-Aquitaine is characterised by a lifetime heroin use level which is higher than the national level (0.9%). On the other hand, the proportion of high school students who had tried heroin reached 0.8% in 2022.

Use in the adult population

The lifetime use level (use at least once in a lifetime) of heroin in the general population in France is low, standing at 1.3% in 2017 among 18–64-year-olds (2.1% among men vs. 0.5% among women) and use in the previous year appears to be very rare (0.2% of respondents). The number of lifetime heroin users in France among 11–75-year-olds was estimated to be 500 000 people in 2017. In 2021, almost 130 000 people had used it in the last month.

At European level, heroin use remained stable in 2020 in comparison with previous years, and it was estimated that around 1 million individuals used opioids. Almost 510 000 people received opioid substitution treatments in Europe in 2019.

A diversification of uses among drug users

Opioids feature prominently in use by active drug users: in 2019, 73% of those who attended harm reduction facilities (CAARUD) had used at least one opioid during the month. However, contrary to the situation in the 1980s, this type of substances, and notably heroin, were not the crux of substances used, but part of the range feeding polydrug use. Thus, of CAARUD’s patients, 8.5% state that they use heroin on a daily basis.

The use of methadone, therapeutic or not, continues to evolve within this population, at the expense of buprenorphine. This is partially attributable to the face that the prescription of this molecule as part of opioid substitution treatment (OST) is increasing. According to the survey conducted in CAARUD in 2019, methadone is now ahead of buprenorphine, the most used opioid in the month preceding the survey (48%). It is used on a daily basis in three out of four cases (75%). The use of morphine sulphate concerns 32% of respondents.

Impacts

Clinical approach: the effects of using heroin or other opioids

The use of heroin quickly induces a feeling of calm and relaxation, accompanied by euphoria. The main side effects resulting from its use are a state of drowsiness, reduced respiratory rate, constipation, often with nausea, vomiting, and vertigo.

With repeated use, tolerance to the substance builds: the pleasure brought about by a dose diminishes, and the absence of use causes an increasingly intense withdrawal. The user also seeks to increase frequency and doses to tackle the withdrawal and rediscover the feelings experienced when taking it the first couple of times.

The absorption of a very high dose of heroin, or other opioids (overdose) causes an often fatal respiratory depression. The risk is also increased when the use of this substance is combined with alcohol or benzodiazepines.

Injectable use exposes you to abscesses, and the risk of contracting HIV, HCV, and HBV.

Opioid substitution treatments

In 2019, it was estimated that 177 000 people had received a delivery of opioid substitution medications in France. Buprenorphine and methadone are the best-selling opioid substitution medications and represent 57% and 43% of sales respectively. The estimated coverage rate of opioid substitution treatments among problematic opioid users is 87%.

Seeking treatment

In 2021, almost 41 000 patients consulted a specialised drug treatment centre (CSAPA) for the use of an illicit substance other than cannabis. Among these patients, the most used opioids were heroin (58%), methadone (9%), buprenorphine (8%), and “other opiates” (12%). The use of heroin began 10 or more years ago for the majority of patients in this group (84%).

Mortality

Opioids are, alone or in conjunction with other substances, heavily implicated in overdose deaths, the number of which has significantly increased in recent years (data from 2021 DRAMES Survey, CEIP-A Grenoble-ANSM). In 2021, 627 overdose deaths were documented by the DRAMES scheme. Methadone is the main substance in question (37% of overdose deaths) ahead of heroin (alone or in conjunction) which is implicated in 28% of deaths. The other cases of overdoses are distributed between analgesic opioid medications (morphine, tramadol, etc.), and buprenorphine. At European level, opioids are associated with 76% of overdose deaths.

Perceptions/Opinions

In 2018, 84% of French people aged 15 to 75 consider heroin to be a dangerous drug, even when just trying it, just in front of cocaine, but far beyond cannabis, tobacco, and alcohol. The proportion of people sharing this opinion has decreased slightly since 1999. In the case of other substances, notably those which are legal, opinions concerning heroin, and its users, have hardened in recent years. Thus, 84% of French people believe that heroin users are dangerous to those around them. In contrast, the perception of users as “suffering from an illness” has sharply increased, rising from 19% in 2013 to 56% in 2018.

For harm reduction, still closely linked to heroin use, three quarters of French people (75%) are in favour of informing users of the least dangerous way to use psychoactive substances. This level is declining (it reached 72% in 2008). At the same time, the vast majority of French people (80%) welcome drug consumption rooms in France.

Legal framework and recent public guidelines

Heroin is classified as a narcotic, and its use is banned. Purchasing, using, possessing, offering, reselling, producing, carrying, or driving after having used it, are all law offences, subject to heavy penalties in court, regardless of the quantity of substance in question.

The law of 31 December 1970, which punishes the use and trafficking of narcotics, was heavily inspired by the health situation of heroin addicts: it proposes health alternatives to prosecution, notably a treatment order, which the judge may serve to a recognised drug addict as opposed to prosecuting them.

As for other illicit drugs, heroin trafficking is subject to severe penalties, which have been hardened since the late 1980s: the sentences incurred may extend to life imprisonment and a fine of 7.5 million euros for the most established forms of organised trafficking.

The law on health system reform adopted two major provisions in the field of addictions on 26 January 2016: lifetime use of drug consumption rooms (DCR) for a maximum duration of six years (there are currently two rooms, in Paris and Strasbourg) and the extension of the practice of rapid diagnostic tests (RDT) to staff in prevention or association structures who have received appropriate training.

In light of the positive results of the assessment conducted by Inserm, the drug consumption rooms scheme has been renewed under the name of “Addiction care drop-offs”. The Social Security Financing Act 2022 endorses this name.

In 2016, a naloxone distribution programme (antidote to opioid overdose) for drug users in France was implemented: two are currently sold, the nasal naloxone kit Nalscue® which has been available since July 2016, and the injection naloxone kit Prenoxad®, sold since June 2019. These kits are distributed in specialised structures (CSAPA, CAARUD) and health institutions. Prenoxad® is also available in community pharmacies.