Balancing access to opioid substitution treatment with preventing the diversion of opioid substitution medications in Europe : challenges and implications.
Date: 2021-02-10
Institutions: European Monitoring Centre for Drugs and Drug Addiction
Subjects: drug addiction, drug traffic, health risk, illicit trade, information, medical research, medicinal product, research report, therapeutics

TECHNICAL REPORT
Balancing access to opioid substitution 
treatment with preventing the diversion 
of opioid substitution medications in 
Europe: challenges and implications 

February 2021

 
I  Legal notice

This publication of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is 
protected by copyright. The EMCDDA accepts no responsibility or liability for any consequences 
arising from the use of the data contained in this document. The contents of this publication do 
not necessarily reflect the official opinions of the EMCDDA’s partners, any EU Member State or any 
agency orinstitution of the European Union.

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doi:  10.2810/312876

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© European Monitoring Centre for Drugs and Drug Addiction, 2021

Reproduction is authorised provided the source is acknowledged.

Recommended citation: European Monitoring Centre for Drugs and Drug Addiction (2021), Balancing 
access to opioid substitution treatment with preventing the diversion of opioid substitution medications 
in Europe: challenges and implications, Technical report, Publications Office of the European Union, 
Luxembourg.

About this report

Opioid substitution treatment (OST) is a key evidence-based tool in managing opioid 
dependence across Europe, but increasing reports of the diversion and misuse of 
prescription OST medications are a cause of concern. This report reviews how OST is 
implemented in European countries and examines the public health consequences of 
the diversion and misuse of prescription OST medications. It looks at how OST 
medications are diverted to the illicit market, the motivations behind diversion and 
misuse, and considers the measures to prevent diversion and how they must ensure 
that the treatment remains available and accessible for those who need it.

About the EMCDDA

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the 
central source and confirmed authority on drug-related issues in Europe. For over 
25 years, it has been collecting, analysing and disseminating scientifically sound 
information on drugs and drug addiction and their consequences, providing its 
audiences with an evidence-based picture of the drug phenomenon at 
European level.

The EMCDDA’s publications are a prime source of information for a wide range of 
audiences including policymakers and their advisors; professionals and researchers 
working in the drugs field; and, more broadly, the media and general public. Based in 
Lisbon, the EMCDDA is one of the decentralised agencies of the European Union.

Praça Europa 1, Cais do Sodré, 1249-289 Lisbon, Portugal
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info@emcdda.europa.eu I  www.emcdda.europa.eu
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Acknowledgements 

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) would like to thank 
Alessandro Pirona; 

The EMCDDA project group: Dagmar Hedrich, Linda Montanari, Bruno Guarita, Jane 
Mounteney, Andre Noor, and Paul Griffiths;  

The Reitox network of national focal points: Sanna Rönkä and Airi Partanen (Finland); Marion 
Weigl, Ilonka Horvath and Martin Bush (Austria); Suzi Lyons (Ireland); Anne-Claire Brisacier and 
Christophe Palle (France); Esther Neumeier, Krystallia Karachaliou and Tim Pfeiffer-Gerschel 
(Germany); Bogusława Bukowska (Poland); and Viktor Mravčík and Barbara Janikova 
(Czechia). 

Statement regarding the United Kingdom 

This report covers a reference period until 2019. The United Kingdom had left the European 
Union as of 1 February 2020. Unless stated otherwise, for the purpose of this report, the term 
‘Member States’ includes the United Kingdom. 

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Contents 

Acknowledgements ................................................................................................................ 3

Abstract .................................................................................................................................. 5

1.

Introduction ...................................................................................................................... 6

1.1.
1.2.
1.3.

Aim and objective of the report ................................................................................ 7
Background ............................................................................................................. 7
Methods .................................................................................................................. 9

2.

Access to opioid substitution treatment in Europe ............................................................ 9

2.1.
2.2.
2.3.

Availability of opioid substitution treatment medications in Europe ........................ 10
Accessibility of opioid substitution treatment ......................................................... 15
How good is the overall access to opioid substitution treatment in Europe? .......... 16

3.

Diversion and misuse of prescription opioid substitution treatment medications ............. 19

3.1.
3.2.

3.3.

3.4.

3.5.

3.6.

3.7.

Seizures of prescription opioid substitution treatment medications ........................ 20
Sources and mechanisms for diverting prescription opioid substitution treatment 
medications ........................................................................................................... 21
Recent trends in the misuse of prescription opioid substitution treatment 
medications ........................................................................................................... 23
Characteristics of clients seeking treatment for misuse of prescription 
methadone, buprenorphine and/or heroin ............................................................. 25
Why do individuals misuse prescribed and non-prescribed opioid substitution 
treatment medications? ......................................................................................... 28
What is the public health impact of the misuse of prescription opioid substitution 
treatment medications in Europe? ......................................................................... 30
What are the treatment options for people who seek treatment for the misuse of 
opioid substitution treatment medications?............................................................ 32

4.

Prevention of diversion of opioid substitution treatment medications .............................. 33

4.1.
4.2.

4.3.

The need for country-specific anti-diversion measures.......................................... 34
Would stricter anti-diversion policies and higher thresholds for opioid substitution 
treatment be effective? ......................................................................................... 35
The role of the criminal justice system .................................................................. 35

5.

Discussion ..................................................................................................................... 36

5.1.
5.2.

Addressing harms ................................................................................................. 36
Implications for monitoring .................................................................................... 37

6.

Conclusion ..................................................................................................................... 38

Glossary ............................................................................................................................... 39

References ........................................................................................................................... 40

Further reading ..................................................................................................................... 45

Appendix .............................................................................................................................. 46 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Abstract 

Opioid use and its consequences represent a serious global public health concern, with high 
levels of opioid-related deaths. Compelling scientific evidence has been accumulated over 
recent decades regarding the benefits of opioid substitution treatment (OST) in treating opioid 
dependence and in ameliorating its associated health and social consequences. It is estimated 
that in 2018 nearly half of the 1.3 million high-risk opioid users in the European Union were 
receiving this treatment. 

However, recent years have seen increasing debate about the worrying levels of diversion and 
misuse of OST medications, which appear to be playing an increasing role in the European drug 
problem. For example, nearly 15 % of clients entering specialised drug treatment for an opioid 
problem in recent years in the European Union, Norway and Turkey sought treatment for 
problems associated with the misuse of an OST medication. Available European data indicate 
that diverted prescription OST medications originate principally from domestic supplies. In 
Europe, the primary sources for high-risk opioid users to acquire OST medications for non-
medical use are friends and family (who generally obtain them through legitimate medical 
supply), drug dealers and their own legitimate medical prescriptions. Cross-border trafficking 
and the internet appear to play a lesser role in supply. 

The large majority of individuals misusing prescription OST medications in the European Union 
are long-term high-risk opioid users with a history of opioid dependence and past treatment 
experiences. Two out of three treatment entrants for primary methadone misuse reported 
having been in OST before. According to European studies, not being in OST remains, 
however, one of the most important factors in the misuse of prescription OST medications and, 
in this case, OST medications may be used primarily for self-medication purposes. Clearly, it is 
a challenge for, but also a responsibility of, the stakeholders involved in the provision of OST to 
ensure the availability and accessibility of this effective treatment while developing and 
implementing effective anti-diversion policies. 

To improve our understanding of the underlying factors associated with the increasing levels of 
misuse of OST medications in Europe, the current report analyses various dimensions of the 
history, availability, diversion and misuse of OST medications in European countries. The 
objective is to explore, at a systemic level, the relationship between these dimensions and to 
identify potential implications for policy and practice at national and European levels. 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

1. 

Introduction 

Opioid use and its consequences represent a serious global public health concern and, in 
recent years, a number of new policy and public health concerns have emerged, including high 
levels of drug-related deaths. Opioid substitution treatment (OST) represents the main approach 
to the treatment of opioid dependence and is part of a wider range of treatment options 
available to heroin users. 

It is estimated that nearly half of the 1.3 million problem opioid users in the European Union are 
receiving this treatment, a considerably higher rate than in most other world regions (EMCDDA, 
2019a). The wide use of this treatment is supported by scientific evidence accumulated over 
recent decades regarding the benefits of OST in treating opioid dependence and in ameliorating 
its associated health and social consequences. 

In spite of these clear benefits, recent years have seen increasing debate about the worrying 
levels of diversion and misuse of OST medications in Europe (EMCDDA, 2019a), which appear 
to be playing an increasing role in the European drug problem. In 2017, 19 European countries 
reported that more than 10 % of all opioid clients entering specialised services presented for 
problems primarily related to opioids other than heroin, most commonly problems associated 
with the misuse of methadone or buprenorphine (EMCDDA, 2019a). A rise in overdose deaths 
associated with methadone and buprenorphine, although not necessarily diverted, has also 
been observed in recent years in Europe (EMCDDA, 2019a). These deaths currently represent 
a substantial proportion of overdose deaths in some European countries. 

In addition to increases in mortality rates, the consequences of the misuse of OST medications 
may include poor adherence to treatment, negative-impact treatment outcomes, somatic 
complications associated with injection of the medication and a risk of contracting blood-borne 
viruses. Diversion of OST medicines has also been associated with increases in crime, has had 
a negative impact on prescribers’ practice, has threatened the reputation of treatment services 
and has compromised public acceptance of the long-term treatment of opioid-dependent 
individuals (Alho et al., 2015; Wright et al., 2016; Reimer et al., 2016). The consequences of the 
diversion and misuse of prescription OST medications in Europe are a continuing public health 
concern and require heightened vigilance, particularly in light of the recent opioid epidemics in 
the United States. 

In this context, it is a challenge for but also a responsibility of the stakeholders involved in the 
provision of OST to ensure the availability and accessibility of this effective treatment while 
developing and implementing effective anti-diversion policies. Therefore, it is important that the 
principle of balance (Box 1) is applied. 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Box 1. Principle of balance (WHO, 2011) 

The World Health Organization (WHO) considers the public health outcome of controlled 
medicines, including OST medications, to be at its maximum (or to be ‘balanced’) when the 
optimum is reached between maximising access for rational medical use and minimising 
substance abuse. All countries have a dual obligation with regard to these medicines based on 
legal, political, public health and moral grounds. The dual obligation is to ensure that essential 
medicines such as methadone and buprenorphine are safely accessible and available for 
medical purposes while protecting populations against the harms derived from the abuse and 
misuse of, and dependence on, these medicines. Countries should aim for a policy that 
ultimately achieves both objectives, in other words a ‘balanced policy’. 

1.1.  Aim and objective of the report 

To improve our understanding of the underlying factors associated with the increasing levels of 
misuse of OST medications in Europe, the current report analyses various dimensions of the 
history, availability, diversion and misuse of OST in European countries. The objective is to 
explore, at a systemic level, the relation between these dimensions and identify potential 
implications for policy and practice at national and European levels. This should in turn inform 
national efforts in implementing balanced and evidence-based OST and anti-diversion policies. 

1.2.  Background 

Prevalence of opioid use and related harms 
It is estimated that, globally, 53 million people used opioids (i.e. persons who used opiates and 
persons who used prescription opioids for non-medical purposes) in 2017, corresponding to 
1.1 % of the global population aged 15-64 years (UNODC, 2019). In the European Union, the 
prevalence of high-risk opioid use among adults (15-64 years) is estimated to be 0.4 % of the 
EU population, the equivalent of 1.3 million high-risk opioid users in 2017. High-risk opioid use 
is defined by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) as 
‘injecting drug use or long duration/regular use of opioids’ (EMCDDA, 2019b). Heroin remains 
the most common opioid used among high-risk opioid users in Europe, and opioids were found 
in 78 % of the total 8 238 overdose deaths involving at least one illicit drug in the European 
Union in 2017 (EMCDDA, 2019a). In addition to drug-related deaths, the consequences of 
opioid use include dependency, a high risk of infection with HIV and viral hepatitis through 
sharing of injecting equipment, engaging in risky sexual behaviours, criminal activity, a loss of 
social and family cohesion, and economic costs for societies (Best et al., 2003; Fischer et al., 
2006; Donmall et al., 2012). 

Evidence base for opioid substitution treatment 
A large evidence base exists for the health and cost benefits of OST, especially when it is 
combined with psychosocial and other interventions. These benefits include reductions in the 
risk of HIV and other blood-borne infections (in particular when combined with needle and 
syringe exchange interventions), risky sexual behaviours, the risk of overdose, participation in 
criminal activity and illicit drug use. The evidence also indicates that OST is associated with 
increased levels of retention in treatment and social reintegration (Mattick et al., 2004; Amato et 
al., 2005, 2011; Gowing et al., 2008, 2011; Lawrinson et al., 2008; ECDC and EMCDDA, 2011; 
Havnes et al., 2012; MacArthur et al., 2012). 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Opioid substitution treatment goals and outcomes 
Over the past three decades, the introduction and scaling-up of OST has been a key response 
geared towards reducing the number of opioid-related deaths, the levels of high-risk opioid use 
and the number of HIV infections among injecting drug users in Europe (Hedrich et al., 2008). 

A range of OST outcomes and goals exist, including the reduction and management of drug-
related problems, abstinence and social integration by facilitating employment and greater 
social cohesion (WHO, 2009a; Rao et al., 2014). 

At the start of OST, initial treatment goals are generally aimed at enabling clients to control 
opioid withdrawal symptoms and cravings, addressing any medical or psychosocial crisis faced 
by clients, and establishing a rapport with clients and educating them about the treatment 
process. After the initial stage, goals generally focus on maintaining clients on adequate doses 
of OST medication, addressing other substance use by the client, if any, and preventing clients 
from shifting to use of another substance; motivating clients and referring them to other 
services, including HIV and hepatitis C virus diagnosis and treatment; helping clients in 
regaining occupational, financial and familial stability; retaining clients in treatment and helping 
them to adhere to the treatment regime; and helping clients to prevent relapse to opioid use. 

There is no specified duration for clients to be maintained on OST. OST may last for months or 
years. The endpoint is generally reached when the client achieves the treatment goals decided 
mutually by the client and the service provider during the initiation of OST. The treatment goals 
are not limited to the client stopping drug use; they also include successful reintegration of 
clients into their family, society and work. 

The achievement of these outcomes depends greatly on the motivation and circumstances of 
each individual and on the quality and effectiveness of the treatment delivered, as well as on the 
wider treatment, health and social services supporting the recovery of the client in OST. It is 
important to acknowledge that pharmacological treatment by itself will not enable an individual 
to achieve a full range of outcomes (ACMD, 2015). 

Number of clients in opioid substitution treatment and coverage in Europe 
In 1993, the estimated number of clients in OST in the 15 countries that were EU Member 
States at the time (1) was about 73 000 and, by 2005, the number for the same countries had 
risen to above half a million. The provision of OST in the 28 Member States of the European 
Union in 2017 reached its peak in 2010-2011, with about 700 000 cases. The latest figures 
show that an estimated 654 000 high-risk opioid users received OST in the European Union in 
2017 (EMCDDA, 2019a). 

A comparison with current estimates of the number of high-risk opioid users would suggest that 
one in two high-risk opioid users receive this treatment in the European Union, but large 
variations between countries exist, ranging from 10 % in Latvia to over 80 % in France 
(EMCDDA, 2019a). Differences in OST coverage between the countries can be explained by 
variation in the availability of and access to OST. As with any other medical or pharmacological 
treatment, the accessibility, availability, affordability and acceptability have an impact on how 
many individuals in need have access to this treatment. Multiple factors determine this, 

(1) Timeline of the European Union’s enlargement by country and year of joining the European Union: 
Belgium, Germany, France, Italy, Luxembourg and the Netherlands (1957); Denmark, Ireland and the 
United Kingdom (1973); Greece (1981); Spain and Portugal (1986); Austria, Finland and Sweden (1995); 
Czechia, Estonia, Cyprus, Latvia, Lithuania, Hungary, Malta, Poland, Slovenia and Slovakia (2004); 
Bulgaria and Romania (2007); and Croatia (2013). 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

including the impact of past drug epidemics, drug policies, geographical availability, health 
service funding, health insurance reimbursement schemes and legal prescribing frameworks 
(Vranken et al., 2014; Hedrich and Pirona, 2017). 

1.3.  Methods 

For this report, a non-systematic review of the international literature was carried out. Primary 
analyses, including not previously published analyses, used national epidemiological data 
submitted by the Reitox national focal points to the EMCDDA. The main national datasets used 
in this report were the treatment demand, health and social responses, overdose deaths, 
seizures of drugs and problem drug use datasets published annually in the EMCDDA’s 
Statistical Bulletin. Previously published data were also used, namely from the EMCDDA’s 
European Drug Report, EMCDDA-Europol EU Drug Markets Report and Statistical Bulletin. 
Data sources are referenced in the report where necessary. Further national information on the 
history, availability, accessibility and affordability of OST, as well as on the misuse and diversion 
of OST medications at the national level, was collected through a dedicated survey among 
national focal points from Czechia, Germany, Ireland, France, Austria, Poland and Finland. 

2.  Access to opioid substitution treatment in Europe 

Access to OST can be understood as a general concept that includes a set of more specific 
dimensions describing the fit between the patient and the system providing OST. These 
dimensions include availability and accessibility, but also the affordability and acceptability of 
OST (see the Glossary). In a country, these dimensions are affected by moderating factors, 
each of which can have an impact on one or more of the dimensions. For example, legal 
frameworks or national regulations will determine which OST medications can be prescribed for 
the treatment of opioid dependence and which medical professionals are allowed to prescribe 
them. Limitations in one or more of these dimensions will have an impact on the overall level of 
access to OST in a country (or region or city) (Figure 1). 

Figure 1. System dimensions and their moderating factors affecting access to opioid substitution 
treatment 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Figure 2. Year of introduction by OST medication in EU Member States, Norway and Turkey 

Source: EMCDDA (2019c) (see Appendix Table A1). 

2.1.  Availability of opioid substitution treatment medications in Europe 

A wide range of medications are available in Europe for the treatment of opioid dependence. 
Methadone (as well as levo-methadone) and buprenorphine (as well as the combination 
buprenorphine-naloxone) are the two main medications prescribed for this purpose in Europe 
and, by 2005, they were available in nearly all Member States (see Figure 2). Slow-release 
morphine, codeine, dihydrocodeine and diacetylmorphine are also used in some of the 
countries. Large differences in the availability and provision of these medications exist between 
countries owing to historical, economic and legal reasons. 

Methadone 
Methadone as a treatment for opioid dependence was pioneered in Europe by Denmark, the 
Netherlands, Sweden and the United Kingdom in the late 1960s and the early 1970s (Hedrich et 
al., 2008). Over the course of the 1980s, levels of heroin use and injecting drug use rose in 
many western European countries. In 1985, HIV antibody tests were introduced, leading to the 
discovery of high rates of infection in numerous western European cities among people who 
inject drugs. The fear and realisation of an HIV/AIDS epidemic, as well as concern over crime 
and public safety, meant that drugs became a political priority at both the national and the EU 
levels, leading to a wider diffusion of harm reduction interventions, including OST (Figure 3). 
This diffusion is reflected in an acceleration of the introduction rate at which methadone became 
an official treatment modality in other European countries in the mid-1980s. Some countries 
adopted harm reduction policies that led to an increase in the availability of methadone 
maintenance treatment quite rapidly. It should be noted that these developments occurred 
almost entirely in western Europe; the countries of central and eastern Europe, most of which 
were under Soviet influence until the fall of the Berlin Wall in 1989, were barely affected by the 
increased opioid use observed elsewhere. Of these countries, all of which joined the European 
Union in or after 2004, only a few embraced OST as a harm reduction measure and most 
continued to emphasise high-threshold, often abstinence-oriented treatment services (Cook et 
al., 2010). 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Figure 3. Year of introduction of OST in the community and in custodial settings in Europe 

Source: EMCDDA (2019c) (see Appendix Table A1). 

Buprenorphine 
A breakthrough occurred in the early 1990s with the development of high-dosage buprenorphine 
treatment. Owing to its unique pharmacological profile, buprenorphine has, in principle, a 
number of advantages over methadone for use as an opioid substitution medication. For 
example, buprenorphine is not as potent as a full mu agonist, such as methadone, and has less 
analgesic and euphoric (‘high’) effects than methadone, but nonetheless ameliorates withdrawal 
symptoms. As a partial agonist, buprenorphine has a ‘ceiling effect’, that is, after a certain point, 
taking more will not increase any of the effects of the drug. In addition, buprenorphine has a 
high affinity for the mu receptor, which means that it reduces the effects of additional opioid use. 
Buprenorphine causes less respiratory depression than methadone owing to its ceiling effect 
and, thus, has a lower overdose potential. This particular pharmacological profile of 
buprenorphine makes it safer to use on an outpatient basis and this has encouraged non-
addiction specialists, such as general practitioners, to be involved in the prescribing and scaling-
up of OST to opioid-dependent patients in some countries. However, when used in combination 
with other respiratory depressants, such as alcohol or benzodiazepines, buprenorphine use can 
result in sedation, coma and death. In addition, patients who use additional opioids to seek a 
‘high’ are at risk of an overdose when the effects of buprenorphine wear off. High-dosage 
buprenorphine treatment became available first in Spain and France in 1996 and was rapidly 
introduced in more countries thereafter. 

As rising concerns emerged about the potential of diversion, misuse and harms caused by 
available OST medications, an abuse-deterrent form of buprenorphine was introduced in 2004 
in Europe. This medication combines two active ingredients, buprenorphine and naloxone, with 
the latter being an opioid receptor antagonist. With sublingual administration, the 
pharmacodynamic effect of the buprenorphine-naloxone combination is comparable to that of 
buprenorphine alone, because naloxone is only minimally absorbed by that route or not at all. 
However, when the combination is administered by the intravenous or nasal routes, naloxone 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

binds to the opioid receptors more rapidly than buprenorphine, which precipitates withdrawal 
(Mendelson and Jones, 2003). To date, half of the Member States have introduced the 
combination buprenorphine-naloxone. It should be noted that a wide range of formulations of 
the active substance, such as buprenorphine, may be available in a country. In France, for 
example, over 61 buprenorphine-based medications for the treatment of opioid dependence are 
available with different dosages (0.4 mg, 1 mg, 2 mg, 4 mg and 8 mg) including 42 generics, five 
original products for buprenorphine alone and four original products for the combination 
buprenorphine-naloxone. 

Diacetylmorphine and slow-release morphine 
Diacetylmorphine (pharmaceutical-grade heroin) has been available for supervised provision to 
a small number of individuals since 2006 in the Netherlands, 2008 in Denmark, 2009 in 
Germany, 2012 in the United Kingdom and 2017 in Luxembourg. Trials have been conducted in 
Belgium and Spain (see EMCDDA, 2012a, for further information on supervised heroin-assisted 
treatment in Europe). It should be noted that unsupervised provision of diacetylmorphine as an 
option in the treatment of opioid dependence has been available in the United Kingdom since 
the 1920s (EMCDDA, 2012a).  

Slow-release morphine is a legal medication used in substitution treatment in only seven 
countries (Bulgaria, Germany, Luxembourg, Austria, Poland, Slovenia and Slovakia), where it 
has been introduced over the past 15 years, apart from Austria, where it has been available 
since the late 1990s. 

Current levels of provision of opioid substitution treatment in the European Union 
OST remains the most common treatment for opioid dependence in the European Union. An 
estimated 654 000 opioid users received substitution treatment in 2017. The European OST 
client cohort is ageing, with the majority of clients now being over 40 years old, predominantly 
male, most commonly prescribed methadone and typically receiving treatment for more than 
2 years (EMCDDA, 2019a).  

Figure 4 shows historical trends in the provision of substitution treatment in the European Union 
and Norway over 24 years. The current total estimated number of clients in OST is down from 
the peak in the provision of OST in the EU and Norway, which was 710 000 clients in 2010. The 
period prior to this peak reflects the scaling-up process of OST in the majority of EU Member 
States. A decline was observed between 2010 and 2015, which may have been due to several 
factors, including changes in estimation methodologies and shrinking cohorts of ageing opioid 
users in larger western European countries. Between 2015 and 2017, increases were observed 
in 17 Member States, including Sweden (an increase of 21 %), Romania (21 %) and Italy 
(16 %).  

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Figure 4. Trends in OST in the European Union and Norway (1993-2017) 

Note: Until 2001/2002, the data include only EU-15 countries (orange bars). Data from the United Kingdom were 
available only from 2005 onwards. 
Source: EMCDDA (2019c). 

Proportions of opioid substitution treatment medications prescribed 
Owing to its earlier introduction and lower cost than buprenorphine, methadone is currently the 
most commonly prescribed opioid substitution medication in the European Union, provided to 
around two thirds (63 %) of all patients in OST. A further 34 % of patients in OST are prescribed 
buprenorphine-based medications (high-dosage buprenorphine treatment and/or 
buprenorphine-naloxone combination). Slow-release morphine and diacetylmorphine (heroin-
assisted treatment) are less commonly prescribed for OST. 

Although both methadone- and buprenorphine-based OST medications are legally available for 
prescription in all EU Member States, data on the proportions of OST medications provided in 
the EU Member States show large differences in terms of the predominance of a particular 
medication. Note that WHO recommends that both methadone and buprenorphine should be 
available and offered to patients (see Box 2). In some countries, methadone is the only 
medication prescribed for OST. In 20 of the 28 Member States in 2017, methadone was 
provided to over 50 % of all OST clients (Figure 5). In eight of those Member States, methadone 
was prescribed to more than 90 % of all clients, including Estonia, Ireland, the Netherlands and 
Romania, where all or nearly all clients were prescribed methadone. In eight Member States, 
buprenorphine-based medications were prescribed to 50 % or more of all clients, ranging from 
50 % (Croatia) to 75 % (Greece). In Austria, slow-release morphine was the most commonly 
prescribed OST medication (54 %). 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Box 2. WHO recommendations on the availability of OST medications 

If countries are able to afford it, it is best to have both methadone and buprenorphine available 
for opioid agonist maintenance treatment. Having both treatment options available means that 
patients who experience adverse effects of one of the medications, or fail to respond, can try 
the alternative. This situation may increase the proportion of people with opioid dependence 
staying in opioid agonist treatment; it may also increase the effectiveness of treatment through 
better matching of treatments to patients. 

Source: WHO, 2009a. 

Figure 5. Proportion of clients receiving different types of prescribed opioid substitution 
medication in 2017 

Note: In the Netherlands, about 10 % of clients receiving methadone are also prescribed diacetylmorphine. In 
Finland, buprenorphine includes the medication alone or combined with naloxone. UK data are for Wales only. 
Source: EMCDDA (2019c). 

Country examples shed some light on factors influencing the prominence of one OST 
medication over another. For example, 96 % of the 2 685 clients in OST in Poland were 
prescribed methadone, 4 % were prescribed buprenorphine-based medications and less than 
1 % were prescribed slow-release morphine. Although all of the above medications are 
available in Poland, in practice, methadone is the most commonly prescribed owing to its low 
cost. The National Health Fund (NHF) provides fixed budgets for OST programmes regardless 
of the medications prescribed (all costs connected with OST are incurred by the NHF). As a 
result, OST programmes prescribe the medication that is the cheapest, to keep the costs low 
and serve as many patients as possible. 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

In Ireland, almost all clients receive methadone as their opioid substitute, not necessarily for 
economic reasons but because historically this has been the first-choice drug for treating opioid 
dependency. In 2011, an expert group concluded that methadone should remain the first-choice 
drug for treating opioid dependency, but that buprenorphine-naloxone may be appropriate for 
some patient cohorts in certain circumstances. Since November 2017, Suboxone 
(buprenorphine and naloxone in combination) has been available for patients when clinically 
appropriate, but so far it has been prescribed to a very low number. 

2.2.  Accessibility of opioid substitution treatment 

According to WHO guidelines, OST should be accessible to all those in need and therefore 
treatment programmes should be designed to be as accessible as possible; for example, 
programmes should be physically accessible, open at convenient times, have no undue 
restrictions on accessibility and have the capacity to be expanded to accommodate the likely 
demand. National laws usually define who is permitted to prescribe OST and thereby directly 
influence availability and accessibility of OST in a country. 

Legal frameworks and provision models of opioid substitution treatment in Europe 
The scope of the legal framework for OST varies considerably between Member States. In 
some countries, OST is covered by a specific parliamentary law, such as Belgium and Finland 
and, in the latter, the implementation of OST is based on a decree of the Ministry of Social 
Affairs and Health. In other countries, however, such as Cyprus, OST implementation is subject 
to interpretation of the laws on controlled substances. The national laws normally designate 
those substances that can be used for substitution treatment. In most cases, only methadone or 
only methadone and buprenorphine can be prescribed; however, in a few countries, other 
medications such as slow-release morphine or diacetylmorphine are permitted. National laws 
normally also designate which medical professionals are allowed to prescribe OST medications 
and under which conditions (e.g. only those with a specific accreditation or with a specialisation 
in addictive behaviours). In some countries, such as Czechia, France and Luxembourg, any 
medical doctor is allowed to prescribe OST medications (for an overview of legal frameworks in 
Europe, see the legal framework datasets of the EMCDDA Statistical Bulletin’s health and social 
responses dataset (EMCDDA, 2019c)). 

In Europe, various OST provision models exist, but, overall, nearly all OST in the European 
Union is provided on an outpatient basis. A common feature of these models is the role of 
outpatient specialised drug treatment centres as access points to OST. In all EU countries, OST 
is available in specialised outpatient drug treatment centres; however, the importance of these 
centres varies greatly, from being the only access point to OST (e.g. in Italy and in nearly all 
eastern EU countries) to being only moderately involved in OST (e.g. in Germany, France, 
Luxembourg and Austria). 

Another provision model that is nearly exclusively observed in western European countries is 
the provision of OST in low-threshold agencies and in primary healthcare settings. Unless 
specialised treatment centres are widely available and accessible, the involvement of primary 
healthcare and low-threshold points greatly increases the geographical coverage of OST, 
especially in rural areas. Treatment numbers have increased rapidly in countries that have 
adopted models based on primary healthcare involvement. According to WHO guidelines, 
treatment in primary care also has the advantage of integrating medical and psychiatric 
addiction services into mainstream services and reducing the stigma of addiction and the 
professional isolation of medical staff. On the downside, primary healthcare settings are 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

generally not equipped to address psychiatric comorbidities or to provide psychosocial 
counselling. WHO guidelines underline that primary care practitioners will usually need support 
from the specialist system through mentoring, training, consultation and referral. Only a few 
European countries provide OST as a treatment option in inpatient settings. 

2.3.  How good is the overall access to opioid substitution treatment in Europe? 

As described at the beginning of this section, the overall access to treatment in a country is 
dependent on various dimensions, such as availability, accessibility, affordability and 
acceptability. For example, a treatment may be highly available and accessible, but not 
affordable. As a result, access to treatment will be low. These dimensions are, however, hard to 
quantify for evaluation purposes owing to their qualitative nature, their complexity and often a 
lack of reliable data. As an alternative, waiting times and treatment coverage may be used as 
proxy measures of the overall level of access to OST in a country. 

Waiting times to enter opioid substitution treatment 
Because of the severity of the health risks associated with opioid dependence, waiting times to 
enter OST should be minimised. According to data reported to the EMCDDA by the Reitox 
national focal points, average national waiting times for OST vary greatly between countries. It 
should be noted that, in many cases, reported national waiting times are based on expert 
opinion of the national situation and may hide important variations within countries. In nearly 
one third of the Member States, no waiting times are reported for clients wanting to enter OST. 
In six Member States, national average waiting times are estimated to be less than 2 weeks, 
while, in five countries, waiting times can reach up to 1 month. In four countries, national waiting 
times exceed 1 month and can reach up to 6 months. According to national experts, the main 
causes of lengthy waiting times are limited service availability and insufficient professional or 
financial resources to provide OST. In some countries, waiting times are primarily due to the 
formal procedures required prior to accessing OST. 

In Poland, it is estimated that the waiting times are approximately 1 to 2 weeks before starting 
OST, while in Ireland the average waiting time is 28 days from assessment to accessing OST 
(or removal from the waiting list). However, waiting lists for OST in Ireland may be longer 
outside the main urban areas, and clients living in more rural areas may have difficulties 
travelling to clinics owing to limited public transport infrastructure. In Austria, clients receiving 
OST from general practitioners should, in theory, not experience waiting times, but this varies 
from region to region because of differences in the availability of medical doctors eligible for 
prescribing OST. Those receiving OST in specialised treatment centres in Austria often do 
experience waiting times, but this also varies from region to region. According to national 
Finnish experts, the total waiting time between the first request for OST and the start of OST in 
Finland might be several months owing to formal procedural processes (assessment and formal 
medical decision). 

Coverage of opioid substitution treatment in Europe 
The coverage of OST is considered the most informative indicator of the overall level of access 
to treatment. The coverage of a specific treatment is generally calculated by assessing the 
proportion of people in need of the treatment who actually receive it. In addition, coverage data 
alongside other data can provide information on potential shortcomings within the system. For 
example, short waiting times but low coverage levels in a country may indicate that the 
acceptability of OST among clients is problematic, as they do not seek this particular treatment. 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Not all European countries produce estimates of the number of people in need of OST (e.g. 
estimates of the number of high-risk opioid users). Therefore, a first analysis of the coverage of 
the total number of people receiving OST in a year (see Appendix Table A2) per 1 000 
population in each Member State provides a first indication of the level of access to OST. 
Results show that Member States in western Europe, primarily the 15 countries that had joined 
the European Union by 1995, tend to have higher rates of OST provision than countries in 
eastern Europe (Figure 6). Sweden, the Netherlands and Finland appear to be exceptions within 
this group, with lower rates (<1 per 1 000 population) than other EU-15 countries. On the other 
hand, countries that have joined the European Union since 2004 generally show lower rates, 
with several countries presenting rates below 0.3 per 1 000 population (see Figure 6). Among 
these countries, Croatia and Estonia show rates similar to most EU-15 countries. These first 
results are in line with the historical developments described earlier about the differences in 
OST implementation between western and eastern EU countries. 

Figure 6. OST provision: number of people receiving OST per 1 000 in the general population in 
2017 

Sources: Eurostat and EMCDDA (2019c). 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

However, OST coverage calculations based on general population figures are influenced by a 
number of factors, among which are differences between countries in the size of the high-risk 
opioid user population who are in need of this particular treatment. 

Therefore, a more accurate indication of the level of coverage of OST is to calculate how many 
high-risk opioid users (in need of treatment) are actually receiving OST. 

To assess the size of the population in need, countries produce estimates of the high-risk opioid 
user population. These estimates can be found on the EMCDDA Statistical Bulletin’s health and 
social responses web page (EMCDDA, 2019c). Thus, an analysis of the total number of people 
receiving OST as a percentage of the estimated high-risk opioid user population in a country 
shows that in 10 of the 18 EU countries where recent data are available, the coverage is 
considered high, according to United Nations targets for universal access to HIV prevention, 
treatment and care (WHO, 2009b). In these 10 countries, it is estimated that more than once 
every second a problem opioid user (>50 % coverage) receives OST, with France reaching 
coverage levels above 80 %, which represents four out of five high-risk opioid users receiving 
OST at the national level (Figure 7). Medium coverage levels, of between 30 % and 50 %, are 
reported in Italy, Czechia and Portugal. Suboptimal (low) coverage levels (below 30 %) are 
observed in Poland, Cyprus, Lithuania, Latvia and Romania, with the two latter countries 
reporting that only about 10 % of their high-risk opioid user population receives OST. 

Figure 7. Coverage of OST (percentage of estimated high-risk opioid users receiving the 
intervention) in 2017 or in the most recent year and in 2007/2008 

Note: Data are displayed as point estimates with uncertainty intervals. 
Source: EMCDDA (2019c,d). 

It could be argued that people already receiving OST should not be included in the overall 
estimate of the high-risk opioid user population, as the majority of these are in recovery and 
should no longer be considered high-risk opioid users. However, as with any other medical 
chronic disorder requiring long-term treatment, the calculation of the coverage of a medical 
treatment applies to the overall population in need of continuous, long-term treatment, whether 
they are currently in or out of treatment. A practical implication of this principle involves the 
planning, commissioning and funding of OST required in a given year. In simple terms, the 

18 

 
TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

funding to be earmarked for the next financial year would need to consider the individuals 
already in treatment and a proportion of those out of treatment who may possibly access OST in 
the future. This coverage calculation also allows the number in need who have not yet been 
reached with OST to be determined. 

Furthermore, data on the overall number of high-risk opioid users in any kind of drug treatment 
are available for 11 countries (Figure 8). An analysis of the data of all high-risk opioid users in 
any kind of treatment and in OST shows that OST is the treatment of choice in all countries. 
Between 2 % and 17 % of all opioid users in treatment receive interventions not involving opioid 
substitution (Figure 8). In addition, these data show that, in low OST coverage countries 
(Cyprus, Lithuania and Latvia), but also in Italy, the overall treatment coverage beyond OST is 
estimated to be low, with a significant proportion of high-risk opioid users not in drug treatment. 

Figure 8. Overall estimated number of high-risk opioid users in treatment (in OST and other 
treatments) as a percentage of the estimated number of high-risk opioid users in 2017 in selected 
countries 

Source: EMCDDA (2019c,d). 

3.  Diversion and misuse of prescription opioid substitution 

treatment medications 

The diversion and misuse of opioid substitution medications is of particular concern in Europe. 
The demand for specialised treatment related to the misuse of OST medications and the 
number of deaths associated with these medications have been increasing over the past 
decade. This growing problem requires close monitoring and adequate interventions. For this 
reason, it is important to describe and understand the national contexts, groups and drivers 
behind these observed increases. 

First, it is important to clarify the terminology pertinent to such analysis and to draw a distinction 
between prescription opioids and prescribed opioids. Prescribed opioid medications, such as 

19 

 
TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

methadone and buprenorphine, are prescribed by a physician to a patient and dispensed by a 
pharmacy. Prescription (or prescriptible) opioids refer to opioid medications that are intended to 
be prescribed as medicines and that can be diverted anywhere in the system without 
necessarily being prescribed (Scholten, 2017). For example, it is estimated that about 75 % of 
fatal overdoses from prescription opioids in the United States (primarily opioids used for pain 
relief) occur in people who have not been prescribed opioids during the 3 months preceding 
their deaths (Scholten and Henningfield, 2016). The majority of these people probably obtained 
these prescription opioids on the illicit market. Thus, the diversion of prescription opioid 
medications, such as buprenorphine and methadone, refers to the act of redirecting these 
medications from legitimate sources to illegitimate or illegal ones. 

3.1.  Seizures of prescription opioid substitution treatment medications 

In the European Union, heroin remains the most common opioid seized by law enforcement 
agencies, with 37 000 seizures, amounting to 5.4 tonnes, being reported in 2017. Prescription 
methadone and buprenorphine represent a small fraction of all non-heroin opioids seized (see 
Table 1), but in some countries these represent an important proportion of the national illicit 
opioid market. Over three quarters (77 %) of all buprenorphine tablets seized in Europe in 2017 
(i.e. 45 637 tablets) were reported by Sweden and Finland alone (see EMCDDA, 2019e for 
detailed national breakdowns). Similarly, Greece reported 57 % of all European seizures of 
methadone in solid form (kilograms) and Italy reported 71 % of all European seizures of 
methadone in liquid form (litres) in 2017 (EMCDDA, 2019e). This may indicate that, during that 
year, large quantities were seized at the wholesale or retail level in these countries. The number 
of seizures across the reporting countries for these two medications indicates that trafficking 
and diversion at the retail level is not negligible. 

Table 1. Seizures of opioids other than heroin in the European Union, Norway and Turkey in 2017 

Opioid 

Number 

Quantity 

Kilograms  Litres 

Tablets 

Patches 

1 428 

2 649 

4 290 

940 

358 

17.2 

0.5 

13.8 

14.3 

246.0 

1 837 

2 177.9 

522 

21 

560 

0.1 

0.0001 

26.4 

0.01 

30 381 

58 682 

0.1 

118 935 898 

1.9 

1.3 

10 551 

2 291  

9 337 

18 475 

1 436 

18 035 

Methadone  

Buprenorphine  

Tramadol  

Fentanyl derivatives  

Morphine  

Opium  

Codeine  

Dihydrocodeine  

Oxycodone  

Source: EMCDDA (2019e). 

Number 
of 
countries 

18 

17 

11 

13 

13 

17 

8 

4 

8 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

3.2.  Sources and mechanisms for diverting prescription opioid substitution 

treatment medications 

Studies on the sources and mechanisms for diverting prescription OST medications within 
European countries are scarce. Available international and European studies indicate that 
diverted prescription OST medications originate principally from domestic supplies and, to a 
lesser extent, from cross-border trafficking. The role of the internet (darknet and surface web) 
for acquiring OST medications appears to be very limited (Hulme et al., 2018; EMCDDA and 
Europol, 2019; EMCDDA, 2020). 

Domestic supply channels used by end users to illicitly obtain OST medications can be divided 
into two main interlinked categories: non-medical sourcing and medical sourcing of prescription 
OST medications (Hulme et al., 2018) (Figure 9). 

Figure 9. Main pathways of misused prescription OST medications 

Non-medical sourcing 
Friends and relatives are the most common and predominant source for high-risk opioid users 
to obtain these medications in an illegitimate manner. These are generally gifted rather than 
traded or sold. High-risk opioid users regularly socialise with other users in OST programmes 
with ready access to medications (a legitimate medical source). Within these communities, 
informal medication sharing occurs and is often driven by altruistic motives or the desire to help 
another who may be experiencing the e
ects of withdrawal or have no access to treatment. The 
exchange of OST medications for money (and other medications or illicit drugs) may also take 
place between high-risk opioid users. Diversion, in this case, occurs when friends and relatives 
who have access to legitimate OST medications divert their own medications. 

ﬀ

Drug dealers are also a common source for obtaining OST medications, which are most often 
part of a wider range of products on offer to potential consumers (pharmaceuticals and illicit 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

drugs) (Rigg et al., 2012; Vuolo et al., 2014). Little is yet known about where drug dealers are 
obtaining their supplies of OST medications. Investigations have revealed that organised crime 
groups in Finland are operating through large-scale cross-border trafficking of buprenorphine 
medications, which supplies the national illicit market. 

Medical sourcing 
Legitimate medical sourcing is also a relatively common channel for end users to obtain 
prescription OST medications for non-medical use. Medications are obtained legitimately by the 
end user (e.g. in the context of a treatment programme), but partial or excess supplies of 
medications are not used according to clinical guidance (e.g. injected) or are stockpiled for later 
use. Studies have also shown the occurrence of diversion of supervised OST doses such as 
methadone, whereby clients have removed all or part of their dose at the time of administration 
(Tompkins et al., 2009; Winstock et al., 2009a,b; Larance et al., 2011). This is commonly done 
for the purpose of saving medications for later personal use (Larance et al., 2011), but it has 
also been documented that others may coerce treatment clients to share or sell their doses 
(Green et al., 2013; Allen and Harocopos, 2016). 

ﬀ

Illegitimate medical sourcing refers to the sourcing of OST medications through the medical 
system by faking opioid dependence, prescription forgery or doctor shopping. According to the 
available literature, these practices are relatively uncommon, as they require considerable time 
and e
ort to gather medical knowledge, identify the most amenable practitioners to target, 
develop a particular proﬁle or appearance, and build rapport with practitioners (Worley and 
Thomas, 2014; Van Hout and Hearne, 2016; Rönkä and Katainen, 2017). Doctor shopping and 
prescription fraud are more likely in countries with fewer regulations and incomplete or limited 
patient registration systems. Illegitimate medical sourcing is a common phenomenon in 
Czechia, where high-risk opioid users sell parts of the illegally obtained buprenorphine 
medications to finance their own use for self-medication purposes. As a consequence, large 
quantities of this medication enter the illicit market via this diversion mechanism. 

Country examples of the main sources of diverted prescription opioid substitution 
treatment medications 
European data reveal that the importance of these different sources for acquiring diverted 
prescription OST medications differs between countries. 

The large quantities of buprenorphine seized in Finland and Sweden in 2017 indicate that 
organised crime groups are involved in the trafficking of these substances. According to national 
experts and the last EU Drug Markets Report (EMCDDA and Europol, 2019), large-scale 
smuggling and distribution of mono-preparations of buprenorphine into Finland is primarily 
organised by Finnish, West African, Lithuanian and Estonian nationals. Evidence from law 
enforcement agencies suggests that the majority of the buprenorphine seized in Finland 
originates from within the French healthcare system. Individuals with legitimate access to 
treatment in France sell their doctor prescriptions to individuals called ‘collectors’. They also use 
stolen health insurance cards to collect buprenorphine prescriptions. These collectors collect up 
to 10 prescriptions a day, which can amount to over 1 000 buprenorphine tablets daily (112 
tablets per prescription). Strips of seven tablets are then being sold for EUR 10 each to 
wholesalers who are then selling them to smugglers for EUR 15 each. These smugglers are 
then reselling them to dealers at the retail level for EUR 35 per seven tablets. The final price in 
the capital region around Helsinki is between EUR 30 and 50 per tablet. In December 2017, a 
Europol-supported operation dismantled a trafficking ring that had smuggled high-dose 
buprenorphine tablets (Subutex) from France to Finland in significant quantities (EMCDDA and 
Europol, 2019). 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Information on the origin and the destination of large quantities of buprenorphine tablets recently 
seized in Sweden is not known. However, a recent Swedish study investigated the sources of 
non-prescribed OST medications among patients in OST who reported having ever used non-
prescribed OST medications (Johnson and Richert, 2019). Most respondents had bought or 
received the substances from other Swedish patients in OST, but dealers were also a significant 
source of non-prescribed methadone and buprenorphine. Another group of Swedish patients 
stated that they had purchased methadone from Danish patients and/or dealers in Denmark, 
smuggling small amounts for personal use. There was no corresponding cross-border trade for 
buprenorphine, which has historically not been much used in Danish OST programmes (see 
Figure 5). 

Findings from a 2015 study in England and Wales showed that during the 5-year study period 
(2007-2012), only negligible amounts of prescription OST medications were seized by UK 
customs, about 4 000 methadone doses, while the average annual number of methadone doses 
prescribed over the same period exceeded 38 million doses (Marteau et al., 2015). There were 
also no reports of detection of any illegal manufacture of methadone or buprenorphine in the 
United Kingdom during that period. The authors concluded that domestic diversion was the 
probable source of black-market OST medications implicated in the observed increase in 
prescription methadone- and buprenorphine-related deaths in England and Wales. Another UK 
study indicated that large proportions of participants had obtained illicit methadone for use in the 
last year, with smaller proportions doing so in the last month. The proportions of participants 
buying and being given methadone were similar. The exchange of methadone primarily took 
place between friends and associates, with established dealers rarely involved (Duffy and 
Baldwin, 2012). 

In Germany, two studies were conducted on the misuse and diversion of prescription OST 
medications (Casati et al., 2014; Schulte et al., 2016). An analysis of 422 police records of 
seizures of OST medications found that the amounts seized averaged from three to four daily 
dosages and the persons found dealing were mostly drug users. There were no indications of 
larger amounts entering the illicit market or involving organised crime groups. Austrian national 
focal point experts participating in the current study indicated that prescription OST medications 
were mainly diverted from patients in treatment. According to Goulão and Stöver (2012), survey 
data showed that 28 % of OST patients in Austria reported having given their prescribed OST 
medication to others, exchanged it or sold it at least once. 

In France, the low-threshold access to prescription OST medications through general 
practitioners and pharmacies results in domestic diversion being the probable main source of 
illicit-market OST medications (Milhet and Cadet-Taïrou, 2017). In Czechia, a recent study 
indicated that the majority of the large-scale misuse of buprenorphine among injecting drug 
users originates from domestic distribution channels through doctor shopping and re-selling of 
buprenorphine tablets on the illicit market (Mravcik et al., 2018). 

3.3.  Recent trends in the misuse of prescription opioid substitution treatment 

medications 

Some insight into the characteristics of individuals with problematic use of prescription OST 
medications can be obtained from the European treatment demand indicator. It should, 
however, be noted that data from the treatment demand indicator do not provide information on 
the source of the OST medications (legitimate or illegitimate medical sourcing). 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Overall, trends among clients entering treatment for the misuse of OST medications in Europe 
follow closely the trends of clients entering treatment for heroin. A decrease in numbers for both 
groups is observed up to 2013, followed by a stable trend. The number of treatment entrants for 
problems with other opioids such as tramadol and fentanyl has been increasing in recent years, 
highlighting the dynamic nature of the opioid market in Europe within a relatively contained 
group of high-risk opioid users. 

However, heroin remains the opioid for which most people seek treatment in Europe. Between 
2006 and 2017, the annual number of persons in the European Union who were admitted to 
treatment with a primary heroin problem decreased from 145 000 to 101 000 (Figure 10). During 
the same period, the number of treatment entrants citing misuse of methadone as the primary 
problem decreased from 7 275 in 2006 to 4 644 in 2017. The number of admissions for misuse 
of buprenorphine in the European Union remained stable, with 4 740 treatment entrants in 2013 
and 4 560 in 2017. Overall, 78 % of all clients entering specialised drug treatment services with 
an opioid problem did so for heroin, while 22 % sought treatment for problems associated with 
opioids other than heroin, including for problems associated with the misuse of methadone 
(9 %) and buprenorphine (5 %) (EMCDDA, 2019a). 

National treatment demand data for 2017 show that the highest proportion of all opioid-related 
treatment entrants citing misuse of methadone as the primary drug were reported by Germany 
(33 %), Denmark (19 %), Bulgaria (13 %), the Netherlands (11 %) and Estonia (10 %). Finland 
(83 %), Czechia (22 %) and Germany (12 %) reported the largest proportions of treatment 
entrants citing misuse of buprenorphine as the primary drug among all opioid-related treatment 
entrants (see Appendix Table A3). In France, the proportion of treatment entrants citing misuse 
of methadone (8 %) and buprenorphine (10 %) among all opioid-related treatment entrants 
amounted to 18 %. The remaining countries reported that less than 10 % of treatment entrants 
were related to misuse of prescription OST medications. 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Figure 10. Trends in the number of clients entering treatment for heroin and for opioids other than 
heroin in the European Union (2006-2017) 

Note: Available data from 22 countries were used for the heroin trends (2006-2017) and for opioids other than heroin 
trends (2013-2017). Data are not available prior to 2013 for buprenorphine and other opioids due to the revision of 
the EMCDDA TDI data collection protocol (EMCDDA, 2012b). Data are for clients entering treatment during the 
calendar year who report an opioid as their main problem drug. 
Source: EMCDDA (2019f). 

3.4.  Characteristics of clients seeking treatment for misuse of prescription 

methadone, buprenorphine and/or heroin 

In comparison with individuals entering treatment in the European Union, Norway and Turkey in 
2017 for either heroin or misuse of buprenorphine as the primary drug, individuals citing misuse 
of methadone as the primary drug tended to be slightly older and were more likely to be first 
admissions (Table 2). 

All three groups of treatment entrants have a high mean age, reflecting the overall ageing 
opioid-using population in the European Union. The initiation of misuse methadone or 
buprenorphine tends, however, to be on average 5 years later than that of heroin. This could 
indicate that the misuse of OST medications has developed after a heroin problem, rather than 
individuals initiating an opioid problem through prescription OST medications. Additional data 
reveal that 67 % of treatment entrants for primary methadone misuse reported having been in 
OST before, while this is true of 57 % of entrants with primary buprenorphine misuse. 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Table 2. Characteristics and main secondary drugs among clients entering treatment for heroin, 
misuse of methadone or misuse of buprenorphine in the European Union in 2017 

Primary drug problem for entering treatment 

Mean age 

Heroin  

37.8 years  

Methadone misuse 

Buprenorphine misuse 

39.4 years  

37.1 years  

Mean age of first use 

22.8 years  

27.7 years  

27.4 years  

Previously treated 
(any drug treatment) 

81 % (n = 89 663) 

71 % (n = 3 661) 

75 % (n = 3 657) 

Ever been in OST 

71 % (n = 49 216) 

67 % (n = 2 129) 

57 % (n = 1 867) 

Never previously 
treated 

Main secondary 
drugs reported 

16 % (n = 18 118) 

21 % (n = 1 067) 

18 % (n = 891) 

Heroin (48 %) 
Cannabis (11 %) 
Alcohol (10 %) 
Benzodiazepines (9 %) 
Other opioids (6 %) 
Powder cocaine (5 %) 
(Buprenorphine 
misuse: 2 %) 
(total n = 4 251) 

Heroin (20 %) 
Cannabis (17 %) 
Alcohol (12 %) 
Benzodiazepines (12 %) 
Powder cocaine (7 %) 
Amphetamines (5 %) 
(Methadone misuse: 2 %) 
(total n = 3 900) 

Cannabis (17 %) 
Powder cocaine (10 %) 
Benzodiazepines (9 %) 
Alcohol (7 %) 
Other opioids (3 %) 
Methadone misuse: 
(4 %); 
Buprenorphine misuse: 
(2 %) 
Crack cocaine (32 %) - 
(5 % when excluding 
UK data) 
(total n = 86 549) 

Source: EMCDDA (2019f). 

Treatment entrants reported different patterns in terms of their secondary problem drugs. For 
those with a primary heroin problem, cannabis, powder cocaine and benzodiazepines were the 
three most common secondary problem drug (Table 2). The majority of those with a primary 
problem of misuse of methadone mentioned heroin (48 %) as a secondary drug, followed by 
cannabis (11 %) and alcohol (10 %). A slightly different pattern of secondary drugs 
characterises those with primary problems with misuse of buprenorphine. These people were 
less likely than the methadone group to report heroin as a secondary drug (20 %). These data 
suggest that methadone could be primarily misused or develop as a primary problem in the 
context of an existing heroin dependence. On the other hand, the misuse of buprenorphine may 
develop into the main opioid problem within an overall highly problematic polydrug use pattern. 

Information on the frequency of use indicates that the majority of treatment entrants across 
these three groups use the primary drug for which they seek treatment on a daily basis, with 
individuals citing misuse of methadone with the highest daily use (78 %) (Figure 11). Information 
on the route of administration reflects primarily the form available of each substance (Figure 12). 
Thus, among treatment entrants with heroin, which is available most commonly in powder form, 
as the primary problem, 36 % reported injecting as the main route of administration, while 52 % 
reported inhaling/smoking as the primary route of administration. Nearly all clients seeking 
treatment for misuse of methadone (93 %) reported drinking the medication as the main route of 

26 

 
 
TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

administration — in most Member States, methadone as an OST medication is most commonly 
available and prescribed in liquid form. In addition, 65 % of treatment entrants reporting misuse 
of buprenorphine as the primary problem reported eating, swallowing or sublingual 
administration of buprenorphine, which is available most commonly in tablet form, as the 
primary route of administration, while 11 % reported sniffing the substance and 20 % reported 
injecting it. These two latter routes of administration generally involve crushing the tablet into 
powder. Furthermore, of the total number of treatment entrants in the European Union reporting 
that they inject buprenorphine, 34 % are reported by Finland alone, where injecting is reported 
by about 80 % of all clients entering treatment for the misuse of buprenorphine. 

Figure 11. Frequency of use of the primary drug among all clients entering treatment for heroin, 
misuse of methadone or misuse of buprenorphine in the European Union in 2017 

Source: EMCDDA (2019f). 

Figure 12. Route of administration of the primary drug among all clients entering treatment for 
heroin, misuse of methadone or misuse of buprenorphine in the European Union in 2017 

Source: EMCDDA (2019f). 

The misuse of medications, including OST medications, refers to their use outside legitimate 
therapeutic guidance. It is important to stress that among those that misuse prescription OST 
medications, there are also individuals who are under therapeutic supervision but, from time to 
time, use their medication not as intended (or not as prescribed). The misuse of prescribed OST 

27 

 
 
 
 
TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

medication while under therapeutic supervision may include consumption of higher doses than 
prescribed and injecting or sniffing prescribed take-home medications. Although they are often 
referred to interchangeably in the literature, a distinction should be made between individuals 
who misuse diverted prescription OST medications and are not in treatment and those that 
misuse their prescribed OST medication while under therapeutic supervision. 

A German study compared prevalence levels of use of non-prescribed (diverted) OST 
medications among three groups of high-risk opioid users: (1) a group not in OST and attending 
drug consumption rooms, (2) a group in legitimate OST and attending drug consumption rooms 
and (3) a group in OST under therapeutic supervision in a doctor’s practice (Schulte et al., 
2016). Results showed that recent use of non-prescribed OST medications decreased 
significantly depending on individuals’ treatment status, with prevalence levels of misuse of 
diverted OST medications in the last 30 days among these three groups as follows: 47 %, 25 % 
and 3 %, respectively. These results confirm the findings of other studies that have shown that 
not being in OST remains one of the most important factors of misuse of non-prescribed OST 
medications. 

French survey data from low-threshold centres indicated that 35 % of clients participating in the 
survey reported having used buprenorphine in the last month and that only 18 % of these 
obtained it without prescription. In addition, 34 % of clients participating in the survey reported 
having used methadone in the last month, of whom 20 % obtained it without prescription. 
Finally, 77 % of those who used buprenorphine and had a prescription reported that they were 
undergoing treatment under medical supervision. The authors estimated that about 52 % of 
buprenorphine users (and 7 % of methadone users) misused it at some point while being under 
medical supervision (Milhet and Cadet-Taïrou, 2017). 

3.5.  Why do individuals misuse prescribed and non-prescribed opioid 

substitution treatment medications? 

Understanding the underlying motives for the non-medical use of prescription OST medications 
is crucial for developing adequate responses. European data and national studies show that the 
large majority of individuals misusing prescribed and/or non-prescribed OST medications in 
Europe are generally long-term high-risk opioid users with a history of opioid dependence and 
past treatment experiences. These user characteristics are in line with findings from studies 
showing that users tend to use OST medications outside therapeutic guidance primarily for self-
medication purposes, as a replacement for their drug of choice, while a smaller percentage of 
individuals tend to use them for euphoric purposes. 

The most common reason reported in the literature for misusing OST medications is for the 
intended therapeutic purpose of OST medications (whether with methadone or buprenorphine). 
This includes to avoid or ease withdrawals, to maintain abstinence from heroin (self-managed 
OST) and to try weaning oneself off illicit drugs (Roche et al., 2008; Gwin Mitchell et al., 2009; 
Schuman-Olivier et al., 2010; Yokell et al., 2011; Lofwall and Walsh, 2014; Richert and 
Johnson, 2015). A Swedish study investigated buprenorphine misuse among injecting drug 
users in a survey of 350 attendees of needle and syringe exchange programmes. Among heroin 
users, 87 % reported having misused buprenorphine in the last year for withdrawal treatment or 
self-detoxification and 11 % reported having done so for euphoria (Johnson and Richert, 2019). 

Similar findings were reported by low-threshold users in France, where 66 % of those who had 
used buprenorphine in the last month reported doing so for self-therapeutic purposes (to reduce 
consumption or maintain abstinence), while 13 % reported doing so for euphoria and 8 % to 

28 

TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

ease withdrawal. Self-managed OST with diverted OST medications involves regular use of 
roughly equal amounts of diverted medication taken daily for an extended period with the 
primary aim to abstain from other opioids, primarily heroin. Such suboptimal treatment practices 
have been documented in several studies (e.g. Peterson et al., 2010; Schuman-Olivier et al., 
2010; Stöver, 2011; Richert and Johnson, 2015). 

A recent German study showed that the most frequent motives reported by opioid users for 
misusing OST medications were insufficient substitution dosage and barriers to accessing OST 
(Schulte et al., 2016). Thus, patients in OST may acquire diverted medications to supplement 
legitimately prescribed OST medications in order to eliminate withdrawal symptoms resulting 
from an inadequate dose. A German multicentre study carried out in 2014 found that 41 % of 
OST patients experienced inadequate substitution dosage according to the Opiate Adequacy 
Scale (Reimer et al., 2014). Inadequate or conservative OST dosages (not in line with 
recommended doses in clinical guidelines) have been documented in a number of European 
countries and have recently been suggested as one of the factors associated with increases in 
opioid-related deaths observed in Scotland (House of Commons Scottish Affairs Committee, 
2019). 

It is well established that prescribing lower doses than clinically recommended (under-
prescribing) is not effective in reducing opioid withdrawal symptoms and cravings (WHO, 
2009a). Suboptimal prescribing practices may contribute to increasing demand for diverted OST 
medications among patients to ‘top up’ and achieve effective opioid levels in the body. 
Prescribing low doses may be the result of doctors’ apprehension to prescribe higher doses to 
patients suspected of using illicit substances. This becomes a circular problem, as misuse and 
low doses become both the cause and the consequence of one another. Doctors may be 
reluctant to prescribe higher doses out of fear of direct harm to the patient, of investigations for 
malpractice and potentially of legal consequences in the case of serious harm. 

Lack of access to OST has also been documented as a driver for the misuse of OST in other 
European studies. Common barriers to OST include difficulties in accessing treatment (strict 
admission criteria, limited availability or demanding assessment processes), difficulties in 
adhering to treatment (involuntary discharge owing to relapsing, frequent urine testing, medical 
expectations and treatment protocols not in line with individuals’ real-life circumstances) and a 
reluctance to seek treatment (stigma or fear of disciplinary actions) (Johnson and Richert, 
2019). 

Economic factors acting as barriers to accessing OST have also been documented as playing a 
role in the misuse of prescription OST medications. A recent study by Mravcik et al. (2018) on 
the underlying drivers of large-scale diversion and misuse of buprenorphine in Czechia 
indicated that most legitimately prescribed buprenorphine in the country is not covered by 
current national health insurance schemes. Fewer than 300 of the nearly 4 000 patients enrolled 
in buprenorphine programmes had the cost of their medication reimbursed, while the monthly 
average cost for the remaining patients at 8 mg/day was estimated to be EUR 70 for Suboxone 
and EUR 220 for buprenorphine mono-preparations. Considering the legal minimum monthly 
wage of EUR 370 in Czechia, the authors concluded that the affordability of this treatment, 
especially at effective therapeutic dosages, constituted a major barrier to accessibility. As a 
result, large-scale doctor shopping is observed, with the primary aim being to obtain 
prescriptions of higher amounts in order to re-sell some of the medications on the illicit market at 
a higher price to finance one’s own medication (Nechanská et al., 2012; Malinovská and 
Mravčik, 2017). 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Economic motives are also reported to play a role in the non-prescribed use of diverted 
methadone or buprenorphine, when these are available at lower prices than heroin on the illicit 
market (Jenkinson et al., 2005; Aitken et al., 2008; Schmidt et al., 2013) or when they are used 
as a replacement for heroin during heroin shortages, namely when heroin prices are high or 
when it is difficult to access a supplier (Rettig and Yarmolinsky, 1995). In this context, the 
reason for the misuse of OST medications may be to avoid withdrawal symptoms induced by 
the absence of heroin or potentially for euphoric purposes. The latter is a less common motive 
than the former, at least in studies with experienced drug users whose main drug is heroin or 
other opioids (Roche et al., 2008; Yokell et al., 2011; Schulte et al., 2016), but it may be more 
common among high-risk users of other substances. A Swedish study on this topic showed that 
62 % of primary amphetamine users misusing buprenorphine did so for euphoric purposes, 
while only 11 % did so among primary heroin users (Hakansson et al., 2007). The misuse of 
buprenorphine for euphoric purposes may, however, be more common in countries where it has 
become the predominant illicit opioid, especially among individuals misusing OST medications 
with no past heroin experience, as reported in Finland (Simojoki and Alho, 2013; Uosukainen et 
al., 2013). 

Different routes of administration can also provide some insight into the motives for use, as well 
as the availability, of different formulations. Oral administration of methadone and sublingual 
use of buprenorphine are the most common routes for the administration of these drugs in a 
self-medication context (Daniulaityte et al., 2012; Harris and Rhodes, 2013; Bretteville-Jensen 
et al., 2015). Among the reasons for injecting prescription OST medications are the fact that 
withdrawal symptoms are alleviated more quickly if the drugs are injected and that injecting is 
the most economic route of administration (less product is required for similar effects). For long-
term injectors, the very ritual of injecting can be closely associated with pleasure and can make 
the habit extremely hard to break, regardless of the motive for misuse (McBride et al., 2001; 
Horyniak et al., 2007). However, these reasons seem to be connected not to a particular 
substance, but rather to the injecting culture and customs among high-risk opioid users in 
certain European regions or cities. 

3.6.  What is the public health impact of the misuse of prescription opioid 

substitution treatment medications in Europe? 

The public health burden of the diversion and misuse of opioid substitution medications includes 
an excess of mortality, an increased risk of contracting blood-borne viruses such as HIV and 
hepatitis C virus, increased somatic complications associated with injecting OST medications, 
negative impacts on treatment outcomes (associated with poor adherence to recommended 
treatment), a negative impact on prescribers’ practice, and a threat to the reputation of 
treatment services and compromised public acceptance of OST (Alho et al., 2015; Reimer et al., 
2016). 

Hospital emergency data can provide an insight into acute drug-related harms and the public 
health impact of the use of drugs in Europe. Drug-related acute toxicity presentations to 26 
(sentinel) hospitals in 18 European countries are monitored by the European Drug Emergencies 
Network (Euro-DEN Plus; EMCDDA, 2019a). In 2017, the hospitals recorded 7 267 drug-related 
acute toxicity presentations; heroin was the second most commonly involved drug in 
presentations after cocaine. Presentations involving methadone (the 11th most common drug) 
and buprenorphine (the 19th most common drug) represented, respectively, 3 % and 1 % of all 
presentations. The overall trend for the 14 centres from the eight countries that reported data for 
2014-2017 shows a decrease in the number of presentations related to heroin and 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

buprenorphine, while the number of presentations involving methadone remained stable during 
this period. The origin and use of the OST medications (misused or not) involved in the hospital 
presentations is, however, not known. 

According to the 2019 European Drug Report, opioids, mainly heroin and its metabolites, are 
found in the majority of drug-related deaths in Europe (EMCDDA, 2019a). Methadone and to a 
lesser extent buprenorphine, are among the non-heroin opioids regularly found in toxicological 
reports. It should be noted that national data submitted to the EMCDDA do not indicate or 
provide information on the treatment status of the deceased or whether the role of the OST 
medication in the death was causal, contributing or independent. In 2017, there was mention of 
methadone in 17 % of all overdose deaths in 13 countries that reported a breakdown by 
substance. In some countries, methadone was present in a substantial number of overdose 
deaths, often in combination with other drugs. The percentage of overdose deaths mentioning 
methadone in 2017 reached 66 % in Romania, 42 % in Portugal, 38 % in Luxembourg, 37 % in 
France, 32 % in Latvia, 22 % in Lithuania, 15 % in Hungary and below 15 % in the remaining 
countries. Data provided to the EMCDDA on drug-related deaths from six major Spanish cities 
in 2016 indicated that methadone was mentioned in 30 % of all drug-related fatalities in these 
six cities. 

In 2017, buprenorphine was mentioned among all drug-related fatalities reported to the 
EMCDDA in only four countries: Finland (55 %), France (8 %), Germany (2 %) and Austria 
(1 %). Comparison with the 2010/11 data in these same countries shows little change. 
Buprenorphine was mentioned among all drug-related deaths in 2010/11 in Finland in 54 % of 
cases, in 3 % of cases in France and in 1 % of cases in both Germany and Austria. However, 
there are a number of challenges in interpreting drug-related deaths data mentioning 
prescription OST medications (Box 3). One of the main challenges is related to the lack of 
information regarding the origin and usage of the OST medication (i.e. whether it was misused 
or not) detected in the post mortem toxicology report. 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Box 3. Main challenges in interpreting drug-related deaths data mentioning 
prescription OST medications (Rettig and Yarmolinsky, 1995) 

There are three main caveats when using mentions of prescription OST medications in drug-
related deaths data (as well in emergency data) to infer the extent of the diversion or misuse 
problems in a country, and more so at the European level.  

First, with typical maintenance dosing, methadone has a half-life of about 24 hours. As with all 
opioids, toxicity is thought to be the result of respiratory depression due to decreased sensitivity 
of the brain’s respiratory centre to the stimulatory effect of carbon dioxide. There is, however, no 
clear definition of what constitutes a toxic or fatal blood methadone level. One reason for the 
difficulty of determining a toxic blood methadone level is drug interaction. A given blood 
methadone level may or may not be toxic depending on the presence of other drugs, which may 
augment or counteract any toxic effects of methadone.  

Another factor that complicates establishing a toxic methadone level is individual variability in 
susceptibility to methadone’s effects. Opioid tolerance is a major determinant of this variability. 
As opioid users develop tolerance, they need progressively higher doses to achieve the desired 
effect. The rate at which tolerance develops depends in part on the pattern of use. Some 
patients who are highly tolerant to methadone suffer no toxic effects at blood methadone levels 
that would be toxic to a person lacking tolerance. Therefore, because of the phenomena of drug 
interactions and tolerance, considerable overlap exists between therapeutic and toxic blood 
methadone levels.  

Finally, the number of deaths in which methadone has been detected in the body is a direct 
function of the number of people who are enrolled in methadone or buprenorphine treatment. As 
the number of methadone patients increases, so will the number of deaths in which methadone 
is detected. If all heroin users were enrolled in methadone and other types of treatment 
programmes and if these treatment programmes were successful in greatly reducing, if not 
eliminating, heroin use, then long-acting methadone would be detected in virtually all deaths 
involving opioid (Wright, 1992).  

The sharp increase in methadone-related deaths in France may be an illustration of this 
phenomenon. Between 2008 and 2017 in France, the percentage of deaths involving 
methadone increased from 29 % to 37 % of all drug-related deaths, exceeding the greatest 
percentage of heroin-related deaths since 2010. However, the number of clients enrolled in 
methadone maintenance treatment increased two-fold during the same period, from 37 000 in 
2008 to 74 000 clients in 2017. This is why any sophisticated analysis of methadone’s 
involvement in drug-related deaths (or in emergency room mentions) should include the 
treatment status of the deceased and a clinical assessment of whether the presence of 
methadone in the deceased was causal, contributing or independent. 

3.7.  What are the treatment options for people who seek treatment for the misuse 

of opioid substitution treatment medications? 

Although the scientific literature is limited, it recommends that individuals with a history of 
misuse of OST outside therapeutic guidance be encouraged to access treatment and be 
provided OST as the first-line treatment (e.g. Clinical Guidelines on Drug Misuse and 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Dependence Update 2017 Independent Expert Working Group, 2017). The main difficulty for 
patients who are using non-prescribed OST medications is that it is not possible for doctors to 
accurately predict equivalent therapeutic doses in most cases at the start of treatment. This is 
especially true for street methadone or buprenorphine, as the purity is variable, or when past 
dosages are unknown. It is also problematic to convert the dosage from one medication to 
another when the half-lives are not equivalent (e.g. between methadone and buprenorphine). 
Clinicians must therefore apply careful clinical judgement and monitor the progress of treatment 
carefully, especially during the early stages of treatment. The initial OST dose should aim to 
achieve an effective level of comfort, both physical and psychological, while minimising the 
likelihood of overdose. 

4.  Prevention of diversion of opioid substitution treatment 

medications 

OST medications such as methadone and buprenorphine are controlled drugs for medical (and 
scientific uses) and can be obtained only by prescription from a doctor. Depending on the 
country, specialised doctors (e.g. psychiatrists or accredited medical doctors) or non-specialised 
doctors (e.g. general practitioners) can prescribe these medications (for an overview, see 
EMCDDA, 2019b). These controlled medications are subject to strict record keeping and 
storage in pharmacies, either at community pharmacies or at OST treatment centres. Despite 
these precautions, the diversion of prescription OST medications for non-medical use remains a 
common problem in Europe. 

European countries have implemented a number of strategies at the national level to control 
and prevent the diversion of OST medications (EMCDDA, 2016). These include providing 
training for clinicians and patients, implementing strategies to assure therapeutic compliance by 
appropriate prescription of dosing, the use of electronic medicine dispensers and employing 
control measures such as patient toxicology tests, pill counts and unannounced monitoring. 
Monitoring of prescribing practices can take place through registers of patients and/or pharmacy 
transactions and the enforcement of appropriate prescribing through disciplinary measures or 
administrative sanctions. Other control measures include legal restrictions on the medical 
professions and clinical settings and dispensaries of pharmaceuticals that are allowed to 
prescribe and/or dispense OST medications, pre-authorisation procedures, the use of special 
prescribing forms and regulations stipulating that administration of doses must be under direct 
supervision in specialised treatment centres or pharmacies. 

One strategy to prevent the diversion of OST medications is to register patients receiving OST 
and, in some countries, one central register records all patients at the national level. This has a 
number of advantages, as it prevents patients from receiving methadone, buprenorphine or 
other OST medications from more than one source. It can be used to limit access to other 
controlled medicines requiring central approval, such as other opioids, and it can provide more 
accurate data on treatment numbers than would be available in situations in which central 
registration is not used. A potential disadvantage, however, of the central registration of patients 
is that it can risk breaches of privacy, and this may deter some patients from entering treatment. 
According to WHO guidelines, safe and effective treatment of opioid dependence can be 
achieved without central registration. Because such registration could cause harm if privacy is 
breached, it should be used only if government agencies have effective systems for maintaining 
privacy and personal data security. In addition, in most Member States, especially in eastern 
European countries, medical doctors have to use special prescription forms, often in multiple 
copies, to inform the central registration system. These forms are not always free of charge, and 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

complex reporting requirements can be applicable to medical doctors authorised to prescribe, 
which was reported to delay the commencement of treatment and deter practitioners from 
engaging in OST prescribing (Vranken et al., 2014, Radbruch et al., 2012). 

According to information provided by the Reitox national focal points to the EMCDDA, the 
majority of Member States and Norway (22 countries) have one specific registry recording OST 
patients. Six Member States have two registers in which OST patient data are recorded, while 
the Netherlands has three registers. These registers are often maintained by national health 
departments or institutes or at national medicines agencies. In 11 countries, OST patient data 
are recorded as part of the general national drug treatment monitoring register, which is where, 
for example, data on treatment demands for all patients entering drug treatment are recorded. In 
four countries, a data flow exists between the OST register and other drug treatment monitoring 
databases as a result of the existence of unique client identification codes, which allows the 
merging of the databases. In seven countries, there is no flow of data between databases owing 
to the absence of unique identifiers. 

4.1.  The need for country-specific anti-diversion measures 

While European countries may have some commonalities, certain patterns of use, motives, and 
drivers for misuse or diversion appear to be country specific. For example, in some countries 
where access to the treatment is limited, OST medications are mentioned in relatively high 
numbers of drug-related deaths or seized in significant quantities by law enforcement agencies. 
Large-scale OST provision and low-threshold OST programmes are therefore unlikely to be the 
main drivers of diversion and misuse in these countries. On the other hand, the diversion and 
misuse of these medications may be facilitated by high OST accessibility or liberal therapeutic 
supervision and limited prescribing monitoring in other countries. 

As a consequence, ‘one size fits all’ recommendations and policies to prevent diversion and 
reduce the levels of misuse will most likely be ineffective in addressing specific national causes 
of the observed problems. In each country, the design and implementation of such measures 
will present difficult trade-offs, as the advantages of offering easily accessible, effective and 
user-customised treatment for a large group of individuals must be weighed against the 
negative effects of diversion. The fact that the end users on the illicit market mainly consist of 
opiate- or opioid-dependent individuals, many of whom appear to be using these substances for 
self-medication purposes and are generally out of treatment, needs to be taken into account in 
those trade-offs. 

The current literature on responses to the misuse and diversion of OST medications focuses 
primarily on improving treatment quality (e.g. optimal dosing), the supervision of patients (urine 
testing, supervised dispensing), monitoring prescribing practices to prevent doctor shopping and 
improving the availability of abuse-deterrent formulations such as the buprenorphine-naloxone 
combination (Reimer et al., 2016; Wright et al., 2016). It should be noted that most of the 
literature on anti-diversion measures originates from countries with long-established and highly 
available OST programmes. Therefore, these anti-diversion measures assume that a majority of 
high-risk opioid users are effectively accessing OST. The data presented in this report show that 
in nearly half of the Member States for which data are available (8 out of 18), the coverage 
levels of OST remain below 50 % of the target population. In a number of countries, primarily 
eastern EU countries, coverage levels are even below 20 % of the target population. 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

4.2.  Would stricter anti-diversion policies and higher thresholds for opioid 

substitution treatment be effective? 

Stricter anti-diversion policies may seem an intuitive choice when facing domestic diversion or 
misuse of non-prescribed OST medications. However, increased control of treatment 
procedures and prescribing modalities in low-coverage countries runs the risk of further limiting 
access to OST or deterring users from accessing this treatment. Such measures may 
subsequently result in unintended consequences, namely further fuelling demand on the illicit 
market for non-prescribed OST medications or other opioids. In contrast, policies that aim to 
increase availability and facilitate access by removing structural barriers linked to legal 
prescribing requirements, increased affordability, geographical coverage and easing contractual 
treatment obligations of OST patients may prove, in some instances, to be a more effective 
solution (Pompidou Group, 2017). Such policies should address high-threshold inclusion 
criteria; long waiting times; arduous and bureaucratic admission processes; negative attitudes 
towards OST by the public, users and professionals; fear of stigmatisation and disciplinary 
actions — which all constitute further barriers to seeking OST. Increasing access to attractive 
OST programmes as an anti-diversion strategy in some countries could encourage out-of-
treatment users of non-prescribed OST medications to engage with legitimate therapeutic 
processes and thereby improve overall treatment quality and outcomes and reduce harms and 
demand associated with non-prescribed OST on the black market. 

In medium- to high-OST coverage countries, which are characterised by high availability and 
accessibility to treatment and where domestic diversion and trafficking are problematic, the 
policies described in the literature that aim for greater scrutiny of prescribing practices and 
improved treatment adherence may be more appropriate. The French National Health 
Accreditation and Assessment Agency has issued recommendations for prescribers and 
dispensers on a range of factors associated with the diversion and misuse of OST in the 
country. These recommendations address prescribing and dispensing modalities, the 
assessment of patients’ motivations, the monitoring of prescriptions, and initial and continuous 
training of health professionals (Milhet and Cadet-Taïrou, 2017). 

4.3.  The role of the criminal justice system 

The criminal justice system and law enforcement agencies, in collaboration with health 
authorities and stakeholders, can also play an important role in the prevention of diversion and 
in the reduction of misuse of prescription OST medications. Illegal possession of controlled 
medications without proper prescription constitutes an offence in European countries, with legal 
and financial consequences. Individuals caught with diverted prescription OST medications with 
the intent to use them may benefit from proactive referral to treatment that would support efforts 
to engage individuals in the legitimate treatment system. Coordinated law enforcement 
operations can also be beneficial in reducing cross-border trafficking between Member States, 
especially from high- to low-OST coverage countries. In December 2017, a Europol-supported 
operation dismantled a trafficking ring that was smuggling high-dose buprenorphine tablets from 
France to Finland in significant quantities (EMCDDA and Europol, 2019). 

It is, however, important to understand that illicit methadone and buprenorphine markets rely on 
a highly controlled system, in which substances are produced and commercialised by 
pharmaceutical companies, prescribed by medical doctors and distributed by pharmacies. In 
contrast with international and domestic markets trafficking illicit drugs, illicit methadone and 
buprenorphine markets are more decentralised and unorganised, with many small actors selling 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

or distributing smaller quantities of medications that generally they have themselves been 
prescribed (Fountain et al., 2000; Fountain and Strang, 2003; Cicero and Inciardi, 2005; Mravcik 
et al., 2018). These are comparatively closed systems of current opioid users and patients 
undergoing OST (Spunt et al., 1986; Johnson and Richert, 2015). Small quantities of OST 
medications are re-sold or handed over for free between family members, friends and 
acquaintances with similar drug experiences (Johnson and Richert, 2015). Among some groups 
of high-risk opioid users, it may be considered morally right to share one’s medication with those 
who do not have access to OST programmes and are at risk of experiencing withdrawal 
symptoms (Havnes et al., 2013). Effective anti-diversion policies will necessarily require an 
understanding of these morally driven transactions at the local level. 

5.  Discussion 

European countries have experienced unprecedented health and social consequences of 
increasing heroin use and drug injecting that emerged in the 1980s, in particular rising HIV/AIDS 
and overdose deaths, as well as crime and open drug scenes. Today, remarkable 
improvements have been documented in many countries, where comprehensive drug policies 
incorporating scaled-up OST programmes with methadone and buprenorphine have been 
implemented (Hedrich and Pirona, 2017). Substantial progress has been made towards the 
elimination of new HIV infections among people who inject drugs, and high availability of OST 
has been instrumental in this achievement. Across the European Union, which in 2017 had over 
500 million citizens, just 1 046 newly reported HIV cases were attributed to drug injecting. In 
many cities, crime and public order problems related to drug use have also diminished 
substantially. OST has been a contributing factor in reducing the social cost of heroin use and 
improving the life expectancy of heroin users, and we are now observing ageing cohorts in their 
40s and 50s while, at the same time, the number of younger heroin-naive users is at an all-time 
low. These data provide some reassurance that Europe is currently not facing a similar opioid 
crisis as that recently observed in the United States. 

At the same time, the use of and harms associated with opioids other than heroin, primarily 
among experienced and older high-risk opioid users, are providing cause for concern. Signals 
from law enforcement agencies and health data indicate growing issues with tramadol and 
fentanyl and fentanyl derivatives, while data presented here reveal that the scale of domestic 
diversion and misuse of prescription OST medications is not negligible in several countries. 

5.1.  Addressing harms 

Currently, methadone remains the predominant medication prescribed for OST in two thirds of 
the EU Member States. It is therefore also the one most commonly mentioned among opioid-
related deaths involving OST medications. WHO guidance recommends that different opioid 
substitution medications be made available for treatment. Increasing the range of available 
buprenorphine-based OST medications, including the abuse-deterrent combination 
buprenorphine-naloxone, could reduce the risk of mortality associated with non-prescribed 
methadone. As a partial agonist, buprenorphine-based medications present a safer toxicological 
profile than methadone, which is a full agonist and increases the risk of overdose when used 
outside therapeutic guidance. A recent study in the United Kingdom examined the population-
wide overdose risk emerging from the prescription of methadone and buprenorphine for OST in 
England and Wales (Marteau et al., 2015). This analysis of the relative safety of buprenorphine 
and methadone for OST revealed that buprenorphine was six times safer than methadone with 
regard to the overdose risk among the general population. 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Unfortunately, the number of recent national studies on the nature and the health consequences 
of the misuse of prescription OST medications in Europe remains limited. Further national 
studies are necessary to gain a better understanding of the adverse consequences within a 
national context. In addition, it would be of particular interest to investigate which factors or 
determinants other than the pharmacological properties of the medication can explain the 
observed differences in terms of drug-related deaths involving OST medications between 
countries with large-scale misuse of buprenorphine medications, such as Finland (high 
mortality) and France and Czechia (low mortality). Study results could provide valuable 
information to develop tailored harm reduction responses (Box 4).  

Box 4. Similar problem, different outcomes: the cases of Czechia and Finland 

The scale of diversion and misuse of OST medications becomes particularly worrying when it 
reaches levels at which prescription OST medications become the drug of choice among the 
majority of high-risk opioid users in a country. In Finland, for example, a decrease in heroin 
supply resulted in a significant increase in diverted buprenorphine supply between 2000 and 
2004, which resulted in a sharp decrease in heroin-related deaths and an increase in death 
rates associated with the misuse of diverted prescription buprenorphine during the same period 
(Simojoki and Alho, 2013). That study showed that the use of diverted prescription 
buprenorphine was, for a large proportion of current Finnish high-risk opioid users, their first 
opioid experience. During the same time period, a decreasing rate of opioid-induced mortality 
was observed in Czechia when a significant shift occurred on the illicit market from heroin to 
diverted buprenorphine. Surprisingly, no fatalities associated with buprenorphine have been 
recorded in Czechia despite similar large-scale buprenorphine injecting among high-risk opioid 
users (Mravcik et al., 2018). These contrasting phenomena point to buprenorphine-related 
deaths being less of a function of the pharmacological properties of the medication and more a 
result of a variety of contextual factors. Social and drug-related contextual factors characterising 
the high-risk opioid user population in a country may include the extent and severity of polydrug 
use, especially involving alcohol and benzodiazepines, and the role of buprenorphine within this 
polydrug use pattern (Rönkä et al., 2015; Rönkä and Katainen, 2017). Users’ age, levels of 
marginalisation, the duration of their experience with opioids and their motives for using non-
prescribed buprenorphine are some of the factors to be investigated to understand and interpret 
the observed differences in fatalities between these two countries. 

5.2.  Implications for monitoring 

There are a range of implications for monitoring highlighted in this report. Monitoring of the 
diversion and misuse of pharmaceutical products, including prescription OST medications, 
remains a challenge owing to the large number of actors involved. These include the European 
and national medicines regulatory agencies; the producers, prescribers and retailers (e.g. 
pharmacies) of a legitimate pharmaceutical product; and reimbursement agencies. Access to 
commercial and medical data from the private sector is particularly difficult. In addition, the EU-
wide pharmacovigilance system coordinated by the European Medicines Agency does not cover 
the monitoring of diversion or misuse of medications; its primary role is to monitor adverse 
effects or other medicine-related problems. Current indicators of drug epidemiology, such as the 
treatment demand indicator and drug-related deaths data, provide some insight into the extent 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

of misuse of these products, while law enforcement agency data on drugs seizures provide 
information on trafficking and diversion at the wholesale and retail levels. 

To gain a more accurate understanding of the nature of and relationship between access to 
OST and the misuse and diversion of OST medications, current epidemiological tools require 
fine tuning, while their limitations must be acknowledged. For example, the source of the OST 
medication reported to be misused by clients entering treatment would be useful information to 
understand the provenance of the medication. This information would allow an understanding to 
be gained of whether the misuse involved legitimately prescribed OST medications or diverted 
OST medications. In addition, the duration of the problematic use of OST medications would 
provide useful information on the nature of the dependence associated with the misuse of these 
medications. 

In relation to drug-related deaths data, two main pieces of information would clarify the role and 
risks of non-prescribed OST medications. First, a clear definition would be needed about the 
main cause of death when prescription OST medications are detected in the post mortem 
toxicology, and it would need to be determined if the fatality could be attributed solely to the 
medication, if the medication was a contributing factor or if it was not implicated. Second, 
information on the treatment status of the deceased should be provided. These are important 
pieces of information that would clarify whether, when there are ‘mentions of OST medications’ 
in reported fatalities (or in emergency room mentions), the clients were in or out of treatment at 
the moment of death. This information would also clarify whether changes in the number of 
‘mentions’ of OST medications in opioid-related deaths are associated with growing diversion 
and misuse in the country or are a direct function of the number of people who are enrolled in 
legitimate OST. As mentioned earlier, as the number of patients in OST increases, so will the 
number of deaths in which prescribed OST medications are detected. Linkages between 
databases, like in Ireland, namely between the mortality register and the central OST register, 
can provide an indication of whether the deceased was prescribed the medication or whether it 
originated from diversion. 

Improvements in national and European instruments and mechanisms for monitoring the 
diversion and misuse of pharmaceutical products, including prescription OST medications, are 
therefore paramount for developing effective anti-diversion policies. 

6.  Conclusion 

The consequences of the diversion and misuse of prescription OST medications are a 
continuing public health concern and require heightened vigilance in light of the recent opioid 
epidemics in the United States. Another important concern presented here is the continued, and 
likely increased, involvement of OST medications in drug-related deaths in some countries. 
However, there is also a need to maintain focus on the importance of OST as an effective 
treatment option. In this context, encouraging the implementation of and adherence to evidence-
based guidance, such as WHO policy guidelines, will contribute to the prevention of diversion 
without hindering access for legitimate patients. 

It is also important that any policies and responses are in line with international conventions and 
treaties emphasising human rights and the right to health in the field of opioid dependence 
treatment. The international guiding principles for legislation and regulation of opioid agonist 
treatment (Pompidou Group, 2017) highlight that, from a normative point of view, anyone with a 
diagnosis of dependence syndrome must have access to treatment based on the latest scientific 
and medical knowledge, that obligations for physicians should be limited to what is strictly 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

necessary and proportionate to ensure the effectiveness of the treatment and its security to third 
parties, and that authorities should ensure that treatment is paid for and that healthcare 
professionals are duly remunerated. 

The implementation of effective anti-diversion strategies while maintaining adequate access to 
effective treatment requires accurate evaluation of the individual and systemic determinants of 
the phenomenon in each country. Importantly, some European countries still need to improve 
access to OST to those in need in order to achieve adequate coverage levels. The development 
of responses should include all stakeholders involved in the provision of OST and in the 
prevention of diversion and misuse, as well as patients, with the ultimate goal of reducing the 
harmful use of opioids, improving overall access to and the quality of OST, and reducing drug-
related deaths. 

Glossary 

Accessibility: the degree to which a medicine is obtainable for those who need it at the 
moment of need with the least possible regulatory, social or psychological barriers. 

Affordability: the degree to which a medicine is obtainable for those who need it at the moment 
of need at a cost that does not expose them to a risk of serious negative consequences, such 
as not being able to satisfy other basic human needs. 

Availability: the degree to which a medicine is present at distribution points in a defined area 
for the population living in that area at the moment of need. 

Benzodiazepine: a class of drugs that have a hypnotic and sedative action; they are prescribed 
mainly as tranquillisers to control symptoms of anxiety, but are also used for recreational 
purposes. 

Controlled medicines: medicines containing controlled substances, namely the substances 
listed in the international drug control conventions. 

Diacetylmorphine (the principal psychoactive constituent of heroin): a short-acting opiate 
agonist. Illicit (‘street’) heroin may be smoked or solubilised with a weak acid and injected. 

Diversion: the act of redirecting a prescription medication (e.g. an OST medication) from 
legitimate sources to illegitimate or illegal sources. 

Doctor shopping: the practice of visiting multiple physicians to obtain multiple prescriptions. 

Essential medicines: those medicines that are listed in the World Health Organization model 
list of essential medicines. This list presents a list of minimum medicine needs for a basic 
healthcare system, listing the most efficacious, safe and cost-effective medicines for priority 
conditions. 

Misuse of medications (including OST medications): the use medications outside legitimate 
therapeutic guidance. 

Morphine: a naturally occurring alkaloid extracted from opium; it is a powerful narcotic 
substance with a strong analgesic (painkilling) action and it has other significant effects on the 
central nervous system. 

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TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Opiate: one of a group of alkaloids derived from the opium poppy (Papaver somniferum) with 
the ability to induce analgesia, euphoria and, in higher doses, respiratory depression and coma. 
The term excludes synthetic opioids. 

Opioid: a generic term applied to alkaloids from the opium poppy (Papaver somniferum), their 
synthetic analogues and compounds synthesised in the body that interact with specific 
receptors in the brain and have the ability to induce analgesia, euphoria (a sense of well-being) 
and, in higher doses, respiratory depression and coma. 

Opioid agonist: any morphine-like substance that produces effects that mimic the action of the 
naturally occurring substance, including pain relief and respiratory depression. 

Opioid antagonist: a substance (e.g. naloxone and naltrexone) that blocks mu, kappa or delta 
opioid receptors, used primarily in the treatment of opioid-induced respiratory depression. 

Opioid substitution treatment (maintenance treatment): a treatment for opioid dependence 
that uses relatively stable doses of long-acting opioid agonists (usually methadone or 
buprenorphine) prescribed over prolonged periods of time (usually more than 6 months), which 
stabilises brain functions and prevents craving and withdrawal. 

Overdose: an accidental or intentional use of any drug in an amount that produces acute 
adverse physical or mental reactions — transient or lasting — or death; the lethal dose of a 
particular drug varies depending on the individual and the circumstances. 

Prescribed opioid medications (e.g. methadone and buprenorphine): medications that are 
prescribed by a licensed physician to a patient and dispensed by a pharmacy. 

Prescription (or prescribable) opioids: opioid medications that are intended to be prescribed 
as medicines and that can be diverted anywhere in the system without necessarily being 
prescribed. 

Withdrawal syndrome: the occurrence of a complex syndrome of uncomfortable symptoms or 
physiological changes caused by an abrupt discontinuation or a dosage decrease after repeated 
administration of a pharmacological agent. Withdrawal syndrome can also be caused by the 
administration of an antagonist. 

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how common is it?’, Journal of Addictive Diseases 28, pp. 269-278. 

Worley, J. and Thomas, S. P. (2014), ‘Women who doctor shop for prescription drugs’, Western Journal 

of Nursing Research 36, pp. 456-474. 

Wright, C. (1992), Medical Officer Briefing Package: The Houston Methadone Outbreak, Food and Drug 

Administration, Rockville. 

Wright, N., D’Agnone, O., Krajci, P., Littlewood, R., Alho, H., Reimer, J., Roncero, C., Somaini, L. and 

Maremmani, I. (2016), ‘Addressing misuse and diversion of opioid substitution medication: 
guidance based on systematic evidence review and real-world experience’, Journal of Public 
Health 38(3), pp. e368-e374. 

Yokell, M., Zaller, N., Green, T. and Rich, J. (2011), ‘Buprenorphine and buprenorphine/naloxone 

diversion, misuse, and Illicit use: an international review’, Current Drug Abuse Reviews 4(1), pp. 
28-41. 

Further reading 

Darke, S., Topp, L. and Ross, J. (2002), ‘The injection of methadone and benzodiazepines among 

Sydney injecting drug users 1996-2000: 5-year monitoring of trends from the illicit drug reporting 
system’, Drug and Alcohol Review 21(1), pp. 27-32. 

Kelleher, C. (2018), ‘Characteristics of methadone-related overdose deaths and comparisons between 

those dying on and off opioid agonist treatment’, Drugnet Ireland 64. 

Launonen, E., Alho, H., Kotovirta, E., Wallace, I. and Simojoki, K. (2015), ‘Diversion of opioid 

maintenance treatment medications and predictors for diversion among Finnish maintenance 
treatment patients’, International Journal of Drug Policy 26(9), pp. 875-882. 

Winstock, A., Lea, T. and Sheridan, J. (2008), ‘Prevalence of diversion and injection of methadone and 
buprenorphine among clients receiving opioid treatment at community pharmacies in New South 
Wales, Australia’, International Journal of Drug Policy 19(6), pp. 450-458. 

45 

 
 
 
 
TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Appendix 

Table A1. Year of introduction of opioid substitution treatment medications in the European Union 

Country 

Methadone  High-dosage 

buprenorphine 

Buprenorphine
-naloxone 
combination 

Diacetylmorphine 
(including pilots) 

Slow-release 
oral morphine 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

Germany 

Greece 

Hungary 

Ireland 

Italy 

Latvia 

Lithuania 

Luxembourg 

Malta 

Netherlands 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

United 
Kingdom 

1987 

1994 

1996 

1991 

NA 

1998 

1970 

2001 

1974 

1995 

1992 

1993 

1995 

1992 

1975 

1996 

1995 

1989 

1987 

1968 

1992 

1977 

1998 

1997 

1990 

1990 

1967 

1968 

1998 

2003 

NA 

2004 

2007 

2000 

1999 

(2003) 

1997 

1996 

2000 

2002 

NA 

(2002) 

1999 

2005 

2002 

2002 

2006 

1999 

2014 

1999 

(2007) 

(1999) 

2005 

(1996) 

1999 

1999 

2008 

2008 

(2008) 

2009 

2008 

2008 

NA 

NA 

2004 

2012 

2007 

2006 

2007 

(2006) 

2007 

NA 

NA 

NA 

NA 

NA 

2008 

NA 

2008 

2008 

2007 

NA 

NA 

2006 

NA 

2011 

NA 

NA 

NA 

NA 

2008 

NA 

NA 

NA 

2003 

NA 

NA 

NA 

NA 

NA 

NA 

NA 

NA 

1998 

NA 

NA 

NA 

NA 

NA 

2003 

NA 

1920s 

1998 

NA 

2006 

NA 

NA 

NA 

NA 

NA 

NA 

NA 

2015 

NA 

NA 

NA 

NA 

NA 

NA 

2006 

NA 

NA 

NA 

NA 

NA 

2005 

2005 

NA 

NA 

NA 

Note: Years in brackets indicate that the treatment substance was legally available in the country but there were no 
reported clients. NA stands for ‘not applicable’. 
Source: EMCDDA (2019c, dataset: opioid substitution treatment — year of introduction — OST). 

46 

 
 
TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Table A2. Total number of clients in opioid substitution treatment in European countries (1993-
2017) 

Country 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

Germany 

Greece 

Hungary 

Ireland 

Italy 

Latvia 

2017 

2016 

2015 

2014 

2013 

2012 

2011 

2010 

2009 

2008  2006 

2007 

18632  18222  17599  17272  16989  16892  16782  15798  14202  11551 

8656  10503 

16546  16560  16681  17026  17482  17351  17701  17622  16317 

– 

– 

– 

3247 

3338 

3423 

3404 

3568 

3445 

3452 

3012 

2930 

2315 

1124 

1378 

4792 

4256 

5061 

5180 

5238 

5311 

5127 

5035 

3812 

2296 

1951 

2016 

209 

229 

252 

178 

180 

239 

290 

294 

286 

50 

– 

71 

5000 

5000 

4000 

4000 

4000 

4000 

4500 

4500 

4300 

4000 

3700 

3800 

– 

– 

7050 

– 

– 

– 

– 

7515 

7384 

7418 

6012 

7327 

1186 

1248 

1116 

919 

1166 

1157 

1076 

1064 

1012 

1008 

– 

1044 

– 

– 

3329 

3000 

– 

– 

2439 

– 

1800 

1500 

1000 

1200 

178665  178560  167571  163922  165597  162406  160096  155944  150363  139945  124069  131607 

78800  78500  77200  77500  77300  75400  76200  77400  74600  72200  64500  68800 

9388 

9974  10201  10277 

9973 

9878 

6783 

6264 

5360 

5045 

3950 

– 

– 

– 

669 

745 

786 

672 

715 

1031 

992 

802 

– 

807 

10316  10087 

9917 

9764 

9640 

9419 

9243 

9266 

9047 

8718 

8089 

8429 

69642  62868  60047  75964  94376  97312  98636  103564  98493  93059  91503  95973 

669 

647 

609 

518 

Lithuania 

1136 

1231 

1393 

1036 

424 

592 

355 

452 

277 

513 

237 

676 

189 

562 

164 

512 

100 

381 

134 

395 

Luxembourg 

1142 

1085 

1078 

1121 

1126 

1254 

1128 

1248 

1212 

1050 

1044 

1092 

Malta 

Netherlands 

Norway 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

Turkey 

United  
Kingdom 

1025 

1030 

1026 

1013 

1078 

1094 

1107 

977 

977 

1046 

1094 

1087 

– 

– 

5241 

7421 

8292 

9148  10017  10147 

9918 

8592 

9818 

8968 

7622 

7554 

7445 

7433 

7055 

7038 

6640 

6015 

5383 

4913 

4166 

4542 

2685 

2601 

2564 

2586 

2455 

2213 

2181 

2129 

1951 

1525 

1221 

1230 

16888  16368  17011  16587  16858  24027 

–  29325  28708 

1530 

1480 

1268 

1457 

620 

642 

600 

660 

953 

408 

851 

459 

857 

484 

555 

610 

323 

700 

– 

60 

600 

534 

–  24312 

– 

639 

500 

– 

3042 

3261 

3190 

3282 

3427 

3490 

3526 

3324 

3332 

2689 

2957 

–  58749  59264  61859  61954  69111  76263  82372  77811  81390  78503  81706 

4468 

4136 

3679 

3502 

3425 

3697 

3708 

3574 

3454 

3150 

2600 

2898 

– 

– 

– 

– 

– 

–  12500 

2067 

– 

– 

– 

– 

149420  152823  142484  146327  148139  149000  152412  155801  150511  142322  116684  129680 

47 

 
 
 
TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Table A2 (continued) 

Country 

2006  2005  2004  2003  2002  2001  2000  1999  1998  1997  1996  1995  1994  1993 

8656 

7585 

6594  5718  4883  4303  3892  3311 

– 

– 

– 

– 

1124 

920 

670 

380 

1951 

995 

2944  1743 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

3700 

3200 

2700  1800 

900 

440 

210 

100 

20 

– 

– 

– 

– 

– 

0 

– 

– 

– 

– 

– 

0 

6012 

6589 

5887  5630  3378  2656  1919  1062 

764 

505 

284 

– 

500 

1000 

– 

253 

725 

60 

– 

– 

– 

550 

425 

225 

150 

124069 116143  102005 

– 

– 

Germany 

64500  61000  57700  52700  46000 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

3950 

3596 

3336  2293  1616  1146  1120 

966 

666 

304 

400 

– 

766 

– 

750 

– 

– 

– 

– 

– 

8089 

7756 

7270  6852  6609  5930  5039  4354  3689 

– 

– 

– 

– 

– 

– 

– 

– 

– 

0 

– 

– 

– 

– 

– 

0 

– 

– 

– 

– 

– 

– 

– 

0 

– 

– 

– 

– 

– 

0 

– 

– 

– 

– 

– 

– 

– 

50 

– 

– 

– 

– 

– 

0 

– 

– 

91503  83109  81277  84211  87796  83472  83873  80740  77776  74776  69618  66444  55161  47762 

100 

381 

91 

54 

67 

– 

88 

402 

436 

332 

322 

344 

Luxembourg 

1044 

1084 

1065  1056  1040 

Malta 

1094 

968 

807 

733 

Netherlands 

9818  10416  10199  9924 

– 

– 

– 

– 

94 

100 

107 

322 

1002 

– 

– 

90 

– 

– 

– 

– 

989 

– 

– 

4166 

3614 

3003  2431  1984  1503  1074 

719 

204 

1221 

750 

– 

– 

534 

– 

570 

525 

– 

– 

– 

448 

– 

400 

457 

700  1000 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

519 

443 

292 

171 

154 

19 

2689 

2401 

2128  1814  1559  1347  1348  1198  1034 

926 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

0 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

0 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

0 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

78503  83374  86017  88700  90488  84731  78806  72236  63030  55813  42230  28806  18027  15398 

2600 

– 

– 

– 

116684  99149 

858 

796 

750 

716 

636 

599 

581 

514 

480 

460 

432 

424 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

– 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

Greece 

Hungary 

Ireland 

Italy 

Latvia 

Lithuania 

Norway 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

Turkey 

United 
Kingdom 

Source: EMCDDA (2019c, dataset: opioid substitution treatment — clients — all clients). 
Note that ‘–’ corresponds to ‘no information available’ and ‘0’ to ‘no clients reported’.   
Czechia: until 2006, the estimates were based on the distributed volume of buprenorphine and average daily dose 
(3 mg) plus methadone clients in specialised centres. Later, the estimates are based on surveys among general 
practitioners and newly implemented annual aggregated reporting for general practitioners and psychiatrists. 
Germany: the data refer to clients in OST on a given day. 
Estonia: the data on clients in OST are estimated. 
France: the data on clients in OST are estimated based on the number in OST in prison (estimate), in OST on health 
insurance (estimate based on registry data) and in treatment centres (Centres de soins, d'accompagnement et de 
prévention en addictologie, registry data). 
Italy: the data on clients in OST before 2014 are estimated, so caution should be made when interpreting trends in 
OST clients in Italy. 
Latvia: point prevalence data (on 31 December of the respective year). 
Lithuania: the data before 2014 are not comparable with data from more recent years. 
Hungary: the methodology of OST data collection changed from 2010 to 2011. 

48 

 
 
TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

Netherlands: the data for 2015 are incomplete. 
Slovakia: the data on clients in OST are estimated. 
Finland: the data on clients in OST are estimated. 
Norway: the data on clients in OST are estimated. 
United Kingdom: all data are for England and Wales. 

Table A3. Total number of clients entering treatment for opioid-related problems in 2017 in 
European countries 

Country 

Year of 
treatment 

All 
opioids 

Heroin  Methadone  Buprenorphine  Fentanyl  Other 

opioids 

Austria 
Belgium (1) 
Bulgaria 
Croatia (2) 
Cyprus 

Czechia 

Denmark 

Estonia 
Finland (4) 
France 

Germany 

Greece 
Hungary (3) 
Ireland 

Italy 

Latvia 

2017 

2017 

2017 

2017 

2017 

2017 

2017 

2016 

2017 

2017 

2017 

2017 

2017 

2017 

2017 

2017 

2017 
Lithuania 
Luxembourg  2017 
2017 
Malta 
Netherlands  2015 
2017 
Norway 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 
Sweden (5) 
Turkey 

United 
Kingdom 

2017 

2017 

2017 

2017 

2017 

2016 

2017 

2017 

2017 

1 793 

2 493 

1 136 

5 773 

212 

799 

587 

271 

363 

12 899 

16 177 

2 593 

192 

3 837 

1 455 

2 082 

966 

5 292 

114 

443 

241 

10 

6 

8 674 

– 

2 342 

154 

3 241 

20 095 

19 265 

399 

1 448 

109 

1 274 

1 262 

973 

1 122 

1 247 

918 

760 

211 

300 

1 334 

104 

1 274 

949 

– 

831 

1 177 

865 

607 

183 

12 235 

10 807 

9 387 

6 817 

– 

6 738 

41 

129 

151 

169 

– 

32 

113 

29 

7 

1 049 

– 

4 

12 

88 

286 

12 

68 

5 

– 

139 

– 

27 

14 

25 

2 

4 

509 

– 

3 

57 

19 

0 

254 

1 

175 

27 

300 

1 263 

– 

112 

0 

1 

82 

14 

9 

– 

2 

– 

16 

10 

0 

3 

17 

18 

– 

31 

0 

12 

1 

1 

– 

9 

– 

226 

0 

66 

– 

0 

0 

2 

16 

0 

– 

1 

– 

13 

0 

13 

1 

70 

– 

5 

240 

144 

18 

57 

97 

140 

206 

6 

50 

1 847 

– 

135 

26 

505 

462 

57 

37 

– 

171 

– 

235 

46 

28 

135 

6 

831 

– 

40 

57 430 

48 360 

2 235 

2 505 

63 

4 267 

Note that ‘–‘ corresponds to ‘no information available’ and ‘0’ to ‘no clients reported’.   
(1) In the Belgian protocol, there is the possibility to choose an ‘Unknown’ category if the specific substance is not 
known; therefore, the number of clients for the category ‘All opioids’ is not equal to the sum of the specific 
substances. 
(2) All clients in treatment are considered for the data for all clients entering treatment; therefore, caution should be 
made when comparing Croatia with other countries for all clients entering treatment. 

49 

 
 
 
 
 
 
TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications  

(3) The data are in line with treatment demand indicator protocol 2.0. A new treatment demand indicator protocol was 
published in 2013, namely treatment demand indicator 3.0. For more information, see EMCDDA (undated). 
(4) Coverage of the Finnish Drug Treatment Information System is low. Reporting is voluntary for treatment units. 
There is no overall register of treatment units; therefore, the coverage is unknown. 
(5) The data for clients entering treatment refer only to hospital-based and specialised outpatient care facilities. 

50