While synthetic opioids have brought historically high levels of drug-related death to North America, Europe’s drug landscape is shaped by different cultural, political, and geographical factors that have—so far—limited harms. The opioid-related death rate in the United States is more than 10 times higher than in the European Union.

European approaches to drug policy include a role for law enforcement, but they have historically opted more than the USA for medical and harm reduction strategies than punitive measures. For example, Europe was quicker to adopt opioid agonist therapy (using methadone, buprenorphine, and—less frequently—heroin/diamorphine itself to treat opioid use disorders). However, concerning signs are emerging of a new wave of synthetic opioid deaths. The curbing of Afghan heroin supply may bring dramatic changes to European drug markets.

This paper seeks to:

• Suggest that there have been two waves of opioids in Europe; first heroin, and then its substitutes.
• Consider the general patterns of opioid use and harms in Europe, with a particular focus on the experience of northern European countries, which indicates that we may see a third wave involving synthetic opioids.
• Show how Europe’s social and policy contexts for the use of and response to opioids are characterized by stronger social protection and socialized health care, with less economic inequality and homelessness, and implications for opioid-related harms.
• Summarize what we know about the effects of European responses to opioid use. These include:
  • Law enforcement for supply reduction.
  • Opioid surveillance.
  • Treatment, including opioid agonist therapy.
  • Harm reduction, including overdose prevention centers, drug checking, and new developments in wearable technologies.
  • Decriminalization of drug possession.

The paper closes with recommendations for European countries, including:

• Monitor emerging synthetic opioids: Increase vigilance and data collection on the availability and use of potent synthetic opioids like fentanyls and nitazenes.
• Target law enforcement on synthetic opioids: It is more important to prevent the development of supply networks for potent synthetic opioids than to capture large numbers of dealers of other drugs.
• Expand and enhance treatment and harm reduction services: Get more people into opioid agonist therapy in countries that have lower coverage and expand services like overdose prevention centers and drug checking where they are needed.