Within the last two decades there has been a shift from injection to inhalation of recreational opiates (heroin and crack cocaine) as this was perceived to be ‘safer’. However, there are little data as to the effect on lung function and diagnosis and treatment of airway disease. We recruited 145 current and past opiate users from a local community drug service and they completed questionnaires on demographics, drug use, symptoms and health status as well as spirometry. Lower limit of normal was used to define airflow obstruction in this young population. Of the 145 subjects 10 failed to produce adequate pre and post-bronchodilator (BD) spirometry and 26 subjects had injected but not smoked opiates. Of the remaining 109 subjects 36 (33%) had post-BD airflow obstruction with minor or no reversibility and so consistent with COPD. A further 6 subjects had marked reversibility suggesting asthma and 2 subjects had normal spirometry but had a secondary care diagnosis of bronchiectasis meaning a prevalence of airway disease of 40%. The 36 COPD subjects had smoked heroin for a mean 24 (SD 9) years, 34/36 had also smoked crack for 13 (9) years and 33/36 had smoked cannabis for 22 (11) years. All had been cigarette smokers; 24 (21) pack years. Their mean age was 44.7 (6.3) years and 25/36 (69%) were male. Post-BD FEV1 was 2.62 (0.92) L; 74.6 (23.8)% predicted and FEV1/FVC was 0.6 (0.13). Most subjects had mild to moderate COPD–GOLD stage I = 17, II = 13, III = 5 and IV = 1. Only 5 had ever been given a diagnosis of COPD but 21 had been told they had asthma. Mean CAT score was 20 (10) with 50% (18/36) having CAT scores of 20 or greater. Mean MRC score was 3 (1.6) with 53% (19/36) having MRC scores of 3–5. Despite this only 56% (20/36) were on any form of therapy and only 25% (9/36) were prescribed any long-acting bronchodilator. COPD is very common in an opiate smoking population with a third having irreversible airflow obstruction despite their young age. However, few have been diagnosed with COPD and despite a high level of symptoms and poor health status, treatment is far from optimal. The frequency and early development of lung disease related to opiate smoking represents an important public health message and better and earlier recognition and treatment could reduce healthcare utilisation and costs.