Background Existing incidence estimates of heroin use are usually based on one information source. This study aims to incorporate more sources to estimate heroin use incidence trends in Spain between 1971 and 2005. Methods A multi-state model was constructed, whereby the initial state “heroin consumer” is followed by transition to either “admitted to first treatment” or to “left heroin use” (i.e. permanent cessation or death). Heroin use incidence and probabilities of entering first treatment ever were estimated following a back-calculation approach. Results The highest heroin use incidence rates in Spain, around 1.5 per 1,000 inhabitants aged 10–44, occurred between 1985 and 1990; subdividing by route of administration reveals higher incidences of injection between 1980 and 1985 (a mean of 0.62 per 1.000) and a peak for non-injectors in 1990 (0.867 per 1,000). Conclusions A simple conceptual model for heroin users’ trajectories related to treatment admission, provided a broader view of the historical trend of heroin use incidence in Spain.