Opioid crisis in Germany? Insights from a cross-sectional nationwide survey within the German drug scene.

Introduction: Synthetic opioids cause tens of thousands of deaths annually in North America and appear to be increasing in Europe. This study examined high-risk substance use in the German drug-using community with a particular focus on the synthetic opioids fentanyl and nitazenes. Methods: A cross-sectional online survey was conducted in the drug-using community in Germany (August-September 2025). The sample included 235 individuals aged 14 years or older (mean age=43.4 years; 57.9% male), recruited by peers in open drug-use scenes (79.6%) and in addiction clinics and opioid substitution services. The primary outcome was past 12-month substance use. Additional measures included opioid sources, forms, routes of administration, perceived changes in availability and price, risk perceptions, overdose experiences, and harm-reduction behavior. Results: 227 respondents reported substance use (mean: 6.2 substances). 73.1% (95% CI=67.0-78.5%) had used at least one opioid in the past year. Synthetic opioids were reported across regions and all age and gender groups. Among participants reporting a shortage of their primary opioid, 25.0% (95% CI=15.8-37.2%) used fentanyl as a substitute. 56.5% (95% CI=36.8-74.3%) of synthetic opioid users reported an overdose in the past 12 months. Most respondents perceived synthetic opioids as highly risky and feared contamination, but only 9.9% (95% CI=6.6-14.7%) use drug-checking services. Conclusions: Synthetic opioids have entered the German drug scene and are associated with high overdose rates and limited access to harm-reduction measures. These findings indicate an emerging synthetic opioid transition in Germany and highlight the need for expanded surveillance, naloxone distribution, and drug-checking services.