Harm reduction – the current situation in Europe (European Drug Report 2024)

cover of the European Drug Report 2024: Harm reduction

Harm reduction encompasses interventions, programmes and policies that seek to reduce the health, social and economic harms of drug use to individuals, communities and societies. On this page, you can find the latest analysis of harm reduction interventions in Europe, including key data on opioid agonist treatment, naloxone programmes, drug consumption rooms and more. 

This page is part of the European Drug Report 2024, the EMCDDA's annual overview of the drug situation in Europe.

Last update: 11 June 2024

Evolving drug problems pose a broader set of challenges for harm reduction

The use of illicit drugs is a recognised contributor to the global burden of disease. Interventions designed to reduce this burden include prevention activities, intended to reduce or slow the rate at which drug use may be initiated, and the offer of treatment to those who have developed drug problems. A complementary set of approaches goes under the general heading of harm reduction. Here the emphasis is on working non-judgementally with people who use drugs in order to reduce the risks associated with behaviours that are mostly associated with adverse health outcomes, and more generally to promote health and well-being. Probably the best known of these is the provision of sterile injecting equipment to people who inject drugs, with the aim of reducing the risk of contracting an infectious disease. Over time these sorts of approaches appear to have contributed to the relatively low rate, by international standards, of new HIV infections now associated with injecting drug use in Europe. Over the last decade, as patterns of drug use have changed and the characteristics of those who use drugs have also evolved, to some extent, harm reduction interventions have also needed to adapt to address a broader set of health outcomes and risk behaviours. Prominent among these are reducing the risk of drug overdose and addressing the often-considerable and complex health and social problems faced by people who use drugs in more marginalised and socially excluded populations.

A spectrum of responses is needed to reduce changing drug-related harms

Chronic and acute health problems are associated with the use of illicit drugs, and these can be compounded by factors such as the properties of the substances, the route of administration, individual vulnerability and the social context in which drugs are consumed. Chronic problems include dependence and drug-related infectious disease, while there is a range of acute harms, of which drug overdose is perhaps the best documented. Although relatively rare at the population level, the use of opioids still accounts for much of the morbidity and mortality associated with drug use. Injecting drug use also increases risks. Correspondingly, working with opioid users and those who inject drugs has been historically an important target for harm reduction interventions and also the area where service delivery models are most developed and evaluated.

Reflecting this, some harm reduction services have become increasingly integrated into the mainstream of healthcare provision for people who use drugs in Europe over the last three decades. Initially, the focus was on expanding access to opioid agonist treatment and needle and syringe programmes as a part of the response to high-risk drug use, primarily targeting injecting use of heroin and the HIV/AIDS epidemic. Recent joint EMCDDA-ECDC guidance on the prevention and control of infectious diseases among people who inject drugs recommends providing opioid agonist treatment to prevent hepatitis C and HIV, as well as to reduce injecting risk behaviours and injecting frequency, in both the community and prison settings. The guidelines also recommend the provision of sterile injecting equipment alongside opioid agonist treatment to maximise the coverage and effectiveness of the interventions among people who inject opioids.

In the last three decades, approaches to harm reduction have been broadened in some EU countries to encompass other responses, including drug consumption rooms and take-home naloxone programmes intended to reduce fatal overdoses (Figure 13.1). Interventions to reduce opioid-related deaths include those aimed at preventing overdoses from occurring and those aimed at preventing death when an overdose does occur (Figure 13.2).

Figure 13.1. Number of European countries implementing harm reduction interventions, up to 2023
 

Implementation at any level, including pilot projects, is included.

Figure 13.2. Interventions to prevent opioid-related deaths, by intended aim and evidence of benefit

  • Reducing fatal outcomes if overdose occurs
    • Naloxone administration*
    • Naloxone distribution and training* (specialist services and first responders, community)
    • Drug consumption facilities*
    • Fatal-overdose prevention apps
  • Reducing the risk of overdose occurring
    • Opioid agonist treatment, retention and continuity of care*
    • Targeted interventions at times of reduced tolerance (e.g. release from prison or interrupted treatment)
    • Overdose risk assessment, awareness raising and harm reduction
    • Overdose prevention strategies
    • Prevention of diversion of medicines
    • Drug checking and public health alerts
    • Supporting transition from injecting to smoking opioids
    • Targeted treatments (naltrexone treatment, heroin-assisted treatment)
  • Reducing vulnerability
    • Integrated care with mental health and generic health services
    • Interventions to improve access to social and health care
    • Housing programmes
    • Support to employment programmes
    • Interventions to reduce or prevent stigma

Note: Interventions where there is evidence of benefit and where we can have high or reasonable confidence in the available evidence are highlighted in bold and marked with an asterisk (*).

Note: Interventions where there is evidence of benefit and where we can have high or reasonable confidence in the available evidence are highlighted in a bolder frame. Much of the current evidence on interventions listed in this figure is either emerging or deemed insufficient, in part because of the practical and methodological difficulties of conducting research, especially in developing randomised controlled trials (see Spotlight on... Understanding and using evidence) and also because service delivery models often differ considerably.

In some countries, there are drug checking facilities, which have been established with the aim of enabling people to understand better what substances the illicit drugs they have bought contain. Tablets, for example, purchased as MDMA, may also contain adulterants and other drugs, such as synthetic cathinones. With many synthetic stimulants and new psychoactive substances now available on the illicit market in similar looking powders or pills, consumers may be increasingly at risk of being unaware of what particular stimulant or mixture of substances they may be consuming.

The increasing integration of the markets for new psychoactive substances and illicit drugs is creating new public health challenges, such as herbal cannabis mixed with synthetic cannabinoids, stimulants mixed with cathinones and ketamine or new synthetic opioids mixed with or mis-sold as heroin. As poisoning events can evolve rapidly, understanding what constitutes the delivery of effective of risk communication has become more important. Although the range of services provided may differ, all drug checking services undertake some form of health risk communication activity, often by issuing alerts on analysed drug products and sharing data with other stakeholders. The aim is to prevent or reduce harm at the level of the individual (the person submitting the substance for checking) and of the population (others who may be exposed to the same substance). Future steps in this field may include moves towards harmonisation and the building of consensus among European drug checking services on the determination of criteria and thresholds for when and how to issue alerts, as well as the adoption of evidence-based standard operating procedures for health risk communication. These issues are explored in a recent manual developed by the EMCDDA and the Trans-European Drug Information project on health risk communication strategies.

Some of these interventions remain controversial for reasons that include their legal status and the evolving nature of their evidence base. Coverage of these newer interventions therefore remains uneven within and between countries, and where they do exist, they are often most commonly found only in large cities. Overall, coverage and access to harm reduction services more generally, including those service models that are long-established and relatively well evidenced, varies considerably between EU countries, and in some countries remains inadequate in comparison to estimated needs.

Increasing preparedness to reduce the harm from potent synthetic drugs and unintentional consumption

Potent synthetic substances have a growing potential to cause drug-related harms in Europe, as inadvertent consumption of these substances in powders or mixtures sold as other drugs can lead to poisonings and deaths. This, together with more complex patterns of polydrug consumption, adds to the already considerable challenges of developing effective responses to reduce drug overdose deaths and drug-related poisonings. An example of this growing complexity, albeit currently on a relatively small scale, was seen in Estonia in 2022, where mixtures were identified containing new synthetic opioids and new benzodiazepines and also the tranquilliser xylazine. Known respectively as ‘benzo-dope’ and ‘tranq-dope’, these sorts of mixtures have been linked to increases in overdose deaths and other negative health-related outcomes in the United States and Canada. More recently, the highly potent benzimidazole opioids (nitazenes), which are more potent than fentanyl, have also been involved in localised poisoning outbreaks in parts of Europe (see also New psychoactive substances – the current situation in Europe).

During a recent outbreak in Ireland, a rapid risk communication exercise was undertaken, with the support of low-threshold services, which included leaflet drops to open drug scenes and distribution of information on social media and news platforms. This is an example of how services may need to respond both more rapidly and more intensively to outbreaks of drug poisoning than in the past (Figure 13.3). The presence of such mixtures and mis-sold substances on the market highlights the need to review current approaches to the delivery of some harm reduction interventions. For example, the distribution and administration of the opioid antagonist naloxone may need to be reviewed in the context of these mixtures and mis-sold substances. 

Figure 13.3. Example of a rapid risk communication issued in Ireland, 2024
An example of a rapid risk communication from Ireland

More generally, given possible developments in the synthetic opioid market, it would be prudent to review current plans to prepare for and respond to any possible increase in the availability and use of synthetic opioids or in the harm associated with these substances. This could include enhancing toxicological analysis capabilities, alert messaging and frontline responder preparedness. Where drug consumption rooms are operational, the possible benefits and risks from also providing drug checking services may be an issue for consideration. Most drug consumption rooms in Canada, for example, offer drug checking for fentanyl. This is currently uncommon in the European Union, but a consumption room in Copenhagen has recently started providing this service, and other pilot projects are reported to be in development elsewhere in Europe.

Stimulant-related harms linked to different patterns of use

Reducing the risks associated with injecting drug use has always been an important target for harm reduction interventions, and the service models are relatively well developed and evidenced. However, even in this area, changes in drug consumption are creating new challenges for effective service delivery. In the last decade, there have been HIV outbreaks associated with the injection of illicit synthetic stimulants in 7 European cities, across 6 EU countries. A potentially increased frequency of injection is associated with stimulant use compared with heroin use, while crushing and dissolving crack cocaine and other tablets for injection also brings with it additional health risks. These consumption patterns raise questions regarding, for example, the type and adequacy of needles and syringes provided to people in street-based open drug scenes, which now are typically characterised by polydrug use. An additional concern exists that service restrictions during COVID-19 lockdowns adversely impacted on testing for drug-related infections, such as HIV and HCV, and on conduits to care among more vulnerable and marginalised populations of people who use drugs, including those experiencing homelessness.

Synthetic stimulants and various other substances are consumed to facilitate and enhance sex in the context of sexualised drug use by various groups, but mainly among men who have sex with men, when it is known as ‘chemsex’. While this definition is imprecise, it is usually used to refer to settings or events where both high-risk drug taking and high-risk sexual behaviour may occur. The drugs involved can range from stimulants, such as methamphetamine, cocaine and synthetic cathinones, to alcohol, depressants such as GHB/GBL and dissociatives such as ketamine. While it is difficult to estimate the prevalence of chemsex, information from research studies suggests it is an issue that is present, albeit at a small scale and among specific subgroups of people who use drugs, across Europe. Engaging with and providing effective harm reduction responses for people engaged in these forms of high-risk behaviours remains a challenge, and the development of tailored harm-reduction interventions is likely to be needed. Also likely to be needed in this area are strong multi-agency partnerships between those providing sexual health services and those services providing drug-related harm reduction.

New challenges and opportunities to reduce harm

Despite cannabis being Europe’s most commonly consumed illicit drug, an argument can be made that it is also an area in which harm reduction advice and interventions are often lacking. Cannabis users in Europe commonly smoke the drug with tobacco, and an undeveloped area for the development of harm reduction approaches is the consideration of what might constitute effective inventions to reduce smoking-related harm in this group. More generally, as the types and forms of cannabis products available in Europe continue to change, so too have considerations about the implications this has for harm reduction responses. Overall, cannabis products, both resin and herbal, are now of a higher potency – they contain more THC – than they were historically, and high-potency cannabis products are associated with more acute and chronic harms. In addition, the diversity of product types has expanded, with edibles, e-liquids and extracts all now available. These changes create new potential challenges to identify what constitutes effective harm reduction interventions and opportunities to implement them to reduce harm. 

Cannabis is not the only area in which harm reduction approaches have the potential to play a greater role. As noted elsewhere in this year’s European Drug Report, there are also signs of increasing consumer interest in less commonly known substances, including dissociative drugs and psychedelics such as nitrous oxide and ketamine. These substances do have the potential to cause possible harm, and some patterns of use are likely to increase the risk of adverse consequences occurring, creating potential opportunities for harm reduction approaches.

While some harm reduction responses remain controversial in some countries in Europe, the overall concept that evidence-based measures to reduce harm are an important component of balanced drug policies is largely accepted. The contexts within which harm reduction services operate, the evidence base that supports them, and what constitutes standards for quality of care in this area therefore remain key areas for further development and policy consideration. Looking forward, the evolving threats to public health arising from Europe’s dynamic illicit drugs markets highlight the growing need to evaluate new and evolving models of service provision that may be needed to protect the health of people at risk of adverse outcomes arising from more complex consumption patterns, new substances and mixtures, or associated with particular subgroups or settings.

The EMCDDA’s Health and Social Responses to Drug Problems: A European Guide contains detailed information for those wanting to find out more about the evidence that exists for the relative effectiveness of harm reduction and other forms of intervention.

Key data and trends

Needle and syringe programmes

  • Needle and syringe programmes are also a widely available and standard component of harm reduction services. In 2022, all EU Member States and Norway had needle and syringe programmes in place. Needle and syringe coverage and access remain a challenge, with only 5 of the 17 EU countries with available data reaching the WHO service provision targets in 2022 (Figure 13.4).

Figure 13.4. Needle and syringe distribution and opioid agonist treatment coverage in relation to WHO 2020 targets, 2022 or latest available estimate

The coverage is based on the latest national estimates of injecting drug use and high-risk opioid use matched by harm reduction activity data (within a maximum of 2 years). The estimate of coverage of opioid agonist treatment for Belgium is derived from a subnational study conducted in 2019.

Opioid agonist treatment

  • Opioid agonist treatment can be considered as an effective form of drug treatment and also as a service delivery model that addresses some harm reduction objectives. Opioid agonist treatment is a well-established intervention that is implemented in all European countries and is acknowledged as a protective factor against overdose deaths. A range of opioid agonist medications are prescribed in treatment clinics in Europe, but methadone is the most widely used, with about 56 % of opioid agonist clients receiving it, while another 35 % are treated with buprenorphine-based medications.

Take-home naloxone programmes

  • Up to 2022, 16 European countries have reported the implementation of take-home naloxone programmes, which includes pilot projects, to prevent overdose deaths and 10 countries report having opened at least one drug consumption room, intended to facilitate safer use and prevent various health problems (Figure 13.5).

Figure 13.5. Availability of take-home naloxone in Europe
 

Data for EU Member States, Türkiye and Norway in 2023 or most recent year.

Drug checking services

  • Twelve European countries report the existence of some type of drug checking service. These services aim to prevent harms by allowing people to find out what chemicals are in the illicit substances they have bought, and, in some cases, provide access to counselling or brief interventions. The analytical techniques used by services range from sophisticated technology that can provide information on strength and content of a wide variety of substances, to methods that simply show the presence or absence of a particular drug (Figure 13.6).

Figure 13.6. An illustration of the range of drug checking technologies available and their relative accuracy and reliability

Drug checking technologies ranked in order of increasing accuracy and reliability of results:

  • Multiple methods
    (most accurate and reliable)
  • High-performance liquid chromatography
  • Fourier transform spectroscopy
  • Thin-layer chromatography
  • Reagent test kit
    (least accurate and reliable)

Drug consumption rooms

  • While drug consumption rooms have become a more accepted harm reduction response, establishing them remains problematic in some countries. In 2023, 10 EU countries and Norway had operational facilities (Figure 13.7). Where multicultural and new immigrant populations are present, increased own-language harm reduction messaging is desirable for people engaged in high-risk drug use.

Figure 13.7. Location and number of drug consumption facilities throughout Europe, 2023
 

Source: European Network of Drug Consumption Rooms (ENDCR) and Correlation – European Harm Reduction Network (C-EHRN).

Please note that all geographical coordinates used here are approximate only.

Interventions in prisons

  • EMCDDA data on harm reduction and treatment interventions available in prisons in 2022 show that continuity of opioid agonist treatment was available in all EU Member States, apart from Slovakia, as well as in Türkiye. Initiation of opioid agonist treatment in prison was not allowed in 2 countries (Bulgaria, Slovakia). Needle and syringe programmes were available in prisons in 3 countries: in all prisons in Spain and Luxembourg (2 prisons), and in one female prison in Germany. Take-home naloxone was available in 7 countries (Germany, Estonia, Ireland, France, Italy, Lithuania, Norway) (Figure 13.8).

Figure 13.8. Availability of drug-related and other health and social care interventions targeting people who use drugs and are in prison, Europe, 2022
Number of countries reporting the formal availability of interventions in prison

European situation by type of intervention in prison

 

Source: Prison and drugs in Europe: current and future challenges (EMCDDA, 2021), updated with recent data from 2023 prison workbooks, EMCDDA national focal points

Source data

The data used to generate infographics and charts on this page may be found below.


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