Health and social responses: provision of harm reduction equipment for high-risk drug use

Introduction

This page provides an overview of key issues related to the provision of harm reduction equipment for high-risk drug use, including service delivery, guidance and evidence, and considerations for implementation. It also considers implications for policy and practice.

Last update: 25 July 2025.

Basics

Harm reduction approaches

Harm reduction approaches seek to reduce the health, social and economic harms of drug use to individuals, communities and societies. A core principle is the development of pragmatic interventions, programmes and policies to minimise health-related harms associated with ongoing drug use without requiring abstinence.

Potential targets for interventions in this area include preventing overdose, reducing the risk of transmission of HIV or viral hepatitis and other infections among people who inject drugs, and encouraging people who use drugs to adopt less risky behaviours. Common harm reduction responses include the provision of opioid agonist treatment, needle and syringe programmes, outreach work, health promotion and education, and the distribution of harm reduction equipment.

Provision of harm reduction equipment

Harm reduction equipment is typically provided to people who are not able or willing to quit the use of illicit substances and who engage in high-risk drug use and may have limited or no access to hygienic supplies for injection, smoking or inhalation. Harm reduction equipment may also be provided to people who use drugs in recreational settings, however this is not the focus here.

The provision of harm reduction equipment typically involves the distribution of sterile materials intended to reduce harms associated with continued drug use. It is generally part of larger integrated harm reduction programmes, usually low-threshold services, and seldom a standalone intervention. Materials are often distributed free of charge.

Harm reduction equipment (also referred to as harm reduction supplies or paraphernalia) includes items used to prepare drugs for consumption (e.g. filters, cookers, water), to administer drugs (e.g. needles and syringes, pipes, foil), or to prevent harms related to drug use such as bacterial infections from injecting (e.g. wound care kits) and overdose (naloxone kits).

Alongside the distribution of equipment, guidance is usually provided on the correct use of the items, how to safely dispose of them after use and options for transition to less risky routes of administration.

Why is it important?

Providing fit-for-purpose harm reduction supplies that meet local needs enables people who use drugs to reduce the risk of contracting blood-borne infections and to lower their likelihood of experiencing injection-related injury and fatal overdose. In the absence of fit-for-purpose supplies, people may turn to repurposed and unsterile materials, increasing their risk of additional harms such as skin and soft tissue infections, sepsis and infective endocarditis – complications that are common among people who inject drugs and can be severely life-limiting (Larney et al., 2017; McGowan et al., 2020; Wright et al., 2020).

In addition, observational studies suggest that the expansion of programmes providing harm reduction equipment may increase contact and engagement with harm reduction services, including access to treatment (Boucher et al., 2017; McGowan et al., 2013).

Equipment and supplies distributed to reduce harms associated with high-risk drug use

Historically, the harm reduction equipment distributed in Europe has mainly been sterile needles and syringes and the paraphernalia associated with the injection of illicit drugs. More recently, the range of materials distributed by low-threshold services has expanded to reflect new challenges and patterns of use. The materials distributed can be loosely grouped into equipment associated with drug preparation, equipment associated with drug administration and equipment associated with client care and prevention interventions.

Supplies for drug preparation

Supplies for drug preparation include a range of materials to prepare drugs for consumption, such as:

• Acidifiers, such as sterile citric acid and ascorbic acid (vitamin C), used to prepare brown heroin and crack cocaine for injection. People who inject drugs may resort to the use of harmful alternatives if they are unable to access sterile acidifiers.
• Bleach and chlorine tablets for rinsing needles and syringes for reuse. Although likely safer than other household cleaning products, bleach can damage needles and syringes. It should only be provided in emergency situations and high-risk settings where sterile needles and syringes are not provided.
• Cookers, which are containers that may be used for heating mixtures of drugs and water to produce an injectable solution.
• Filters to remove impurities from drug solutions, such as particles, adulterants and pharmaceutical fillers, which may cause vein damage; they may also (depending on the pore size) protect against some bacterial and fungal infections.
• Sterile water for dissolving drugs into an injectable solution. Pharmaceutical-grade water is sterile, while tap water and bottled water may be contaminated.
• Other items may include chopsticks to avoid burns when handling drugs on hot inhalation material or to compact and recover the resin that accumulates on the inside of a pipe, cutting cards to divide powder drugs for sniffing (e.g. cocaine), glass snappers to open glass ampoules, pill crushers to pulverise pills into powder so that they may be dissolved for injection and single-use soda bicarbonate to reduce exposure to ammonia and associated harms.

Supplies for drug administration

Supplies for drug administration include a range of materials for drug administration, such as:

• Sterile syringes and hypodermic needles to inject drugs. Needles and syringes come in various sizes and vary in terms of capacity. The size of the needle must be appropriate for the area of the body that will be punctured.
• Foil to construct tubes for inhaling and as ‘chasing foil’ on which a substance – usually brown heroin – is placed so that it can be heated from below.
• Pipes, typically made from glass, for smoking crack or crystal meth. They are distributed with a mouthpiece to avoid burns and may be used with pipe screens to prevent clogging. To reduce the risk of respiratory tract burns, the length of the pipe must be appropriate to the substance being used.
• Other supplies include capsules made of gelatine to allow methamphetamine to be consumed orally as an alternative to injection; tourniquets, which aid in the location of suitable veins for injection by applying pressure to a limb and making veins more visible; safer sniffer tubes that reduce the risks of cuts and bleeding when sniffing powder; and lighters/blowtorches with optimal flame to reduce finger injuries.

Supplies for care and prevention

Supplies for care and prevention include a range of materials to care for and prevent harms related to drug use, such as:

• Naloxone kits to prevent opioid-related deaths. Naloxone is an opioid antagonist medication that can reverse opioid overdoses. Naloxone kits typically include two doses of naloxone, two nasal misters or syringes, and information on how to appropriately administer the naloxone. They may also include a single-use cardiopulmonary resuscitation (CPR) shield and protective gloves.
• Fentanyl test strips to test drugs before consumption and thereby reduce the risk of fatal overdose.
• Wound care kits containing necessary first aid supplies for initial wound and abscess care.
• Other supplies include chewing gum to stimulate the production of saliva for people who use stimulants and those who smoke/inhale drugs; disinfectant wipes (e.g. alcohol wipes) to clean the injection site before injection; dry wipes to stop blood flow after injection; lip balm to moisturise the dry, cracked lips associated with repeated exposure to heat from smoking crack or other substances; sharps bins for the safe collection and proper disposal of syringes after use; and marquis reagent tests, which are on-the-spot tests to identify compounds present in a particular substance, including MDMA, amphetamine, methamphetamine and opioids.

Service delivery

Typically, the distribution of harm reduction material is integrated into broader low-threshold services. It is seldom a standalone intervention.

Low-threshold services are easily accessible social and health services that aim to remove many of the barriers to care that may be encountered in traditional healthcare systems. Important concepts for these services include taking a non-judgemental and trauma-informed approach and minimising the formal demands made on clients, such as requiring identification or that they remain abstinent or be in treatment. They generally provide a comprehensive set of integrated services, including opioid agonist treatment, infectious disease testing and vaccination, provision of harm reduction equipment, health promotion and education, referral to other services (e.g. healthcare and addiction treatment, housing, social care), counselling, primary medical care and safe disposal of used equipment.

Various models exist for the distribution of harm reduction equipment. It may be available in fixed sites (e.g. harm reduction service facilities, healthcare facilities and shelters), mobile sites (e.g. mobile opioid agonist treatment and harm reduction units) and other locations such as pharmacies, prisons, peer-based outreach sites and vending machines. These sites may be managed and funded by civil society organisations, municipalities and national or regional health services.

Some delivery models are tailored to the needs of particular populations, such as sex workers, women, people experiencing homelessness, migrants and people engaging in chemsex. For example, HaRePo (harm reduction by post), established in France in 2011 by the NGO SAFE, provides harm reduction counselling by phone and email and sends harm reduction equipment through the French postal service. The programme is free and confidential, and has been successful in reaching people who use drugs and are not familiar with low-threshold services, including a high number of men who have sex with men and who practise chemsex (Torres-Leguizamon et al., 2020).

Typically, guidance is provided at the point of delivery, with information on the correct use of materials, the benefits of each type of equipment and options for transitioning to less risky routes of administration. Guidance may also be provided on the safe disposal of used items to prevent them from being left on the street.

Equipment is often provided free of charge, although, in some countries, some items may require payment. Some harm reduction services limit the number of items distributed or only supply items for onsite use, but there is often no set limit on the number of items provided per person per visit. Allowing sufficient resources for secondary distribution (i.e. when a person who uses drugs obtains equipment for its distribution to others) may increase the use of harm reduction equipment by those who cannot, or do not wish to, access the services. Ensuring a reliable and plentiful supply of equipment is important, and options for removing limits on its distribution and supporting peer networks for its dispensing may be considered (Boucher et al., 2017).

Considerations for implementation

The provision of harm reduction equipment should be adapted to local needs and priorities (EMCDDA, 2021a). Fit-for-purpose drug consumption supplies are produced by various manufacturers, but some items may not be suitable (given drug availability, properties or quality), acceptable (owing to ease of use or user preference) or accessible (due to legal restrictions, cost or lack of availability)

The selection of harm reduction items and decisions on their distribution will need to be guided by the following:

• compliance with national and regional legal frameworks
• identification of target population needs, and expected outcomes
• assessment of scientific evidence
• stakeholder engagement
• availability of resources.

Compliance with national and regional legal frameworks

The distribution of harm reduction supplies must comply with existing national and regional legal frameworks. While many of the items provided are not subject to restrictions, their distribution may, in some cases, face practical and regulatory hurdles. For example, naloxone is a medication included in the pharmacopoeia of all European countries, but a medical prescription is generally considered a requirement. Understanding the national legal framework will therefore be an important factor to consider in the development and implementation of new distribution programmes.

Assessment of scientific evidence

An evidence-informed approach to decision-making integrates the best available scientific evidence with a balanced consideration of possible benefits, costs and harms. This approach takes into account the opinions of experts and professionals working in the field, as well as the values and preferences of the targeted population, community, frontline workers and policymakers (see Spotlight on… Understanding and using evidence) (EMCDDA, 2021a).

Existing evidence on the effectiveness of the provision of harm reduction equipment is limited and, with the exception of needle and syringe programmes and take-home naloxone programmes, there is a paucity of data for most items. However, observational studies suggest that providing harm reduction equipment can serve as a point of contact for broader engagement, including access to treatment. This may be particularly important for population groups that have less accessibility to healthcare services (e.g. women, LGBTIQ+ and migrants).

Notably, a lack of evidence, or a body of low-quality evidence, does not necessarily mean that an intervention does not work. It merely shows that the intervention has not yet been adequately studied and that there is still a high degree of uncertainty when interpreting the results obtained by studies. More research and evaluation are needed.

Identification of local needs and emerging trends

An effective approach to decision-making will involve careful consideration of local circumstances, including local drug markets and patterns of drug use. Important to consider too are the emerging trends in drug supply or proliferation of new routes of administration, and how these might impact the provision of harm reduction services in the short-to-medium term (see Action framework for developing and implementing health and social responses to drug problems).

People who use drugs will need to be consulted as they may express preferences for certain items; their participation enables them to make the best choices for their circumstances. A choice of items (e.g. providing various sizes of syringes and needles, as well as both citric acid and vitamin C) may also encourage access to services. However, it is important that choices are informed by clear information on the advantages and disadvantages of each item.

Stakeholder engagement

Establishing functional and stable communication mechanisms between people who use drugs and public health decision-makers can facilitate a regular, two-way flow of information. Service providers can act as a knowledge transfer bridge to policymakers, in addition to offering an early warning function. This is important because drug supply and preferences in terms of substances and routes of administration may be subject to sudden shifts (EMCDDA, 2021a).

The provision of harm reduction equipment may be supported by education and instructional materials developed through a continuous cycle of knowledge sharing between service providers and people who use drugs, ensuring that changing local needs are consistently met. It is also important to engage service providers, people who use drugs and the local community when efforts are made to adjust or scale up service provision, including staffing and referral capacity.

People who use drugs may also be involved in the design and evaluation of the supplies that will be dispensed.

Availability of resources

The provision of some harm reduction items has been shown to be, or potentially be, cost-effective, despite its high cost. Research on needle and syringe programmes shows that the distribution of sterile injecting supplies reduces injecting risk behaviour and contributes to the prevention of the transmission of blood-borne viruses among people who use drugs (ECDC and EMCDDA, 2011; Hancock et al., 2020; National Institute for Health and Care Excellence, 2014; Sweeney et al., 2019). Studies also suggest that take-home naloxone is cost-effective, even when conservative estimates are built into the cost-effectiveness model (Cherrier et al., 2022; Coffin and Sullivan, 2013; Langham et al., 2018). Although there are few data on the cost-effectiveness of the provision of other harm reduction supplies, many items are relatively inexpensive.

In addition, the cost of harm reduction supplies must be considered relative to the social and economic costs of long-term treatment and support for illnesses (e.g. hepatitis B virus/hepatitis C virus (HBV/HCV) infections and HIV/AIDS), repeated hospital admissions for recurring skin and soft tissue infections and other complications (e.g. deep vein thrombosis, sepsis and acute respiratory syndromes), and opioid-related overdose (EMCDDA, 2021a; FRA, 2015; Hope et al., 2008; Tookes et al., 2015).

Given that resources are limited, there may be many factors to consider when determining priorities. For example, basic wound care kits (including bandages, tape, sterile wipes, sterile pads and a disposal bag) can be a cost-effective intervention because injecting site infections represent a significant burden of disease in this population, with costs for the healthcare system. However, the kits are expensive, and their distribution may not be a priority where professional healthcare and wound management is widely available in harm reduction services with specialised nurses. In this example, the distribution of wound care kits is likely more important in locations where access to professional healthcare is less prominent or where the integration of low-threshold services and other parts of the health system is weak.

Guidance and evidence

International guidance by the World Health Organization (WHO) addresses the safety of injection to prevent medically acquired infections in healthcare settings as well as the community management of opioid overdose, including through take-home naloxone kits (WHO, 2014; WHO, 2016).

Generic guidance regarding the provision of syringes and other sterile injecting supplies also exists at the European Union (EU) level (ECDC and EMCDDA, 2011; ECDC and EMCDDA, 2023). In 2003, the Council of the European Union passed a recommendation on the prevention and reduction of health-related harm associated with drug dependence. This recommendation urged Member States to adopt various policies and interventions to tackle the health-related issues linked to drug dependence. In 2007, the European Commission reaffirmed the prevention and reduction of drug-related harm as a public health objective in all member countries.

In 2023, as part of a combined multi-component approach to infection prevention, embedded within harm reduction, counselling and treatment programmes, the European Monitoring Centre for Drugs and Drug Addiction, EMCDDA (now the European Union Drugs Agency, EUDA) and the European Centre for Disease Prevention and Control produced guidance on the prevention and control of infectious diseases among people who inject drugs. The guidance recommends that the provision of, and legal access to, sterile drug injection supplies (sterile needles and syringes, cookers, filters and water for injection) be implemented throughout Europe (ECDC and EMCDDA, 2023). In addition to needles/syringes, cookers, filters and water ampoules, the guidance recommends that services provide a minimum set of essential equipment that includes acidifiers, alcohol/disinfectant swabs and dry swabs, foil, sharps bins and naloxone (for overdose prevention and management).

At the national level, generic guidance remains uncommon and, except for needles and syringes, there are no clear recommendations about the use of specific types of harm reduction equipment.

Evidence

In comparison with other health interventions addressing substance use (such as pharmacological treatment), there is a paucity of data on the effectiveness of distributing harm reduction equipment other than needle and syringe programmes and, to some extent, take-home naloxone programmes. However, observational studies suggest that expanding equipment provision may lead to increased contact and engagement with harm reduction services, including access to treatment (McGowan et al., 2013).

Results from available studies evaluating the provision of harm reduction equipment are often difficult to interpret and apply to different settings, as they are typically context-specific, with most conducted in Australia, North America and the United Kingdom.

High-quality evidence to support the effectiveness of these interventions in reducing harm is also limited due to a lack of robust evaluations and adequate evidence synthesis. The lack of high-quality evidence does not necessarily mean that an intervention is not effective. Rather, it indicates that the intervention has not been adequately studied and that there is a high degree of uncertainty in the existing findings (see Spotlight on… Understanding and using evidence). Where high-level evidence is lacking, decisions on which responses to implement may be informed by integrating existing findings with expert opinion, the local drug policy context, the potential impact on patients/clients and relevant clinical factors.

Needles and syringes

There is evidence that needle and syringe programmes are effective for the prevention of HCV and HIV transmission and in reducing injecting risk behaviour among people who inject drugs (Aspinall et al., 2013; ECDC and EMCDDA, 2011; ECDC and EMCDDA, 2023; Palmateer et al., 2022; Platt et al., 2017; van Santen et al., 2021). However, to have a significant impact on the rates of HCV and HIV transmission in this population, needle and syringe programmes must be provided at a sufficiently large scale and in combination with other responses, such as treatment (ECDC and EMCDDA, 2023; Palmateer et al., 2022; Platt et al., 2017) (see Drug-related infectious diseases: health and social responses).

Naloxone and naloxone distribution programmes

Evidence supports the role of take-home naloxone programmes in reducing drug-related deaths (EMCDDA, 2015; Razaghizad et al., 2021). Naloxone is an opioid antagonist that can reverse the effect of opioid overdoses (Abdulrahim et al., 2018; Chou et al., 2017; Razaghizad et al., 2021; Yousefifard et al., 2020). In 2014, the World Health Organization recommended that naloxone be made available in emergency rooms and to anyone likely to witness an opioid overdose (Behar et al., 2015; Crocker et al., 2019; Giglio et al., 2015; Jones et al., 2014; WHO, 2014), particularly first responders, such as police and ambulance staff.

Naloxone can be administered through injection (with naloxone provided in glass ampoules or pre-filled syringes) or nasal spray. Studies of the pre-hospital management of opioid overdose have demonstrated that intranasal naloxone is as effective as injectable naloxone (Avetian et al., 2018; Chou et al., 2017; Kerr et al., 2009; McDonald et al., 2018; Skulberg et al., 2019). While more often requiring an additional ‘rescue’ dose, nasal sprays may become the preferred alternative to injectable naloxone in take-home and peer-to-peer programmes for lay people because they are easier to handle and can facilitate the use of the antidote by a wider range of people (see Opioid-related deaths: health and social responses).

People recently released from prison may particularly benefit from access to naloxone (EMCDDA, 2016; Horton et al., 2017; Parmar et al., 2017). An evaluation of a Scottish programme to distribute naloxone to people on release found that it was associated with significantly fewer opioid-related deaths within a month of prison leaving (Bird et al., 2016).

Overview of the evidence on … provision of harm reduction supplies

Evidence effect key:
Beneficial: Evidence of benefit in the intended direction. Unclear: It is not clear whether the intervention produces the intended benefit. Potential harm: Evidence of potential harm, or evidence that the intervention has the opposite effect to that intended (e.g. increasing rather than decreasing drug use).

Evidence quality key:
High: We can have a high level of confidence in the evidence available. Moderate: We have reasonable confidence in the evidence available. Low: We have limited confidence in the evidence available. Very low: The evidence available is currently insufficient and therefore considerable uncertainty exists as to whether the intervention will produce the intended outcome.

European picture

The distribution of hygienic and fit-for-purpose injecting equipment to prevent the transmission of drug-related infectious diseases among people who inject drugs has a long history in Europe, starting in the Netherlands and Germany in the early 1980s. Today, it is a core component of harm reduction activity across Europe, where the provision of, and legal access to, sterile harm reduction equipment has been recommended (ECDC and EMCDDA, 2023).

National drug policies increasingly reflect the harm reduction objectives defined in the EU drugs strategy, and there is broad agreement within Europe on the importance of reducing harms, particularly the spread of infectious diseases and overdose-related morbidity and mortality. Accordingly, EU Member States are committed to common multi-annual European drug strategies that count among their objectives the prevention and reduction of the negative consequences of the use of drugs on individual and public health – in particular the transmission of blood-borne infections and the reduction of overdose deaths (see Opioids: health and social responses). As part of this commitment, countries provide a range of interventions, including the distribution of needles, syringes and other preventive items and materials to minimise drug-related harms.

However, the lack of practical guidance about the provision of harm reduction equipment in many EU Member States and at the European level complicates both policy and programme decision-making. Some efforts have been made in this regard in countries such as France (Ministère des Solidarités et de la Santé, 2020) and Germany (Schäffer and Sweers, 2018), but more guidance is needed.

While drugs and health services across Europe currently distribute a variety of harm reduction items to enable people who use drugs to do so hygienically, availability and coverage vary at national and local levels. An EMCDDA survey, conducted in Europe among harm reduction agencies, public health agencies, drug treatment services, advocacy groups and research organisations, suggests that harm reduction equipment priorities in Europe include needles and syringes, disinfectant wipes/swabs, naloxone, sterile water, sterile filters, acidifiers, sharps bins, sterile cookers, dry wipes, foil and low dead-space needles and syringes. Variations at the national level suggest that differences in local drug markets and the preferences of people who use drugs call for the region-specific provision of essential harm reduction supplies.

Needles and syringes

Most countries monitored by the EUDA provide sterile injecting equipment free of charge via specialised outlets integrated into larger harm reduction services. There are considerable differences among countries in the geographical distribution of provision sites and the proportion of people who inject drugs covered by needle and syringe programmes, with only a few reporting a level of coverage above the 2025 target of 200 syringes per person who injects drugs.

Naloxone and naloxone distribution programmes

Over a third of European countries offer naloxone training and distribution programmes in some form. As new legal pathways have been identified at the national level, Europe has seen an increase in the community-level distribution of naloxone to people who use opioids and their partners, peers and families, along with training in overdose recognition and response. New naloxone products, including pre-filled syringes and nasal sprays, have come on the market. The over-the-counter sale of naloxone products is permitted in some countries, while, in others, naloxone access is facilitated by programmes run by drug services. Peer-to-peer naloxone programmes have been piloted in a small number of European countries.

Implications for policy and practice

Basics

• Harm reduction equipment consists of hygienic and appropriate tools and other items used to reduce harms associated with continued drug use. In particular, it seeks to prevent the transmission of blood-borne viruses, skin and soft tissue infections, and overdose.
• The distribution of harm reduction supplies is generally part of larger integrated harm reduction programmes, usually low-threshold services. It is seldom a standalone intervention.
• Expanding the provision of harm reduction supplies is encouraged, and strategies to overcome constraints to provision expansion can be developed, including active and meaningful engagement with service providers and people who use drugs in order to ensure the most appropriate use of resources.

Opportunities

• Research suggests that people who use drugs readily take advantage of opportunities to avoid the negative consequences of substance use.
• Developments in the field of information technology and mobile applications provide new opportunities for improving the reach and effectiveness of harm reduction interventions.

Gaps

• There are some specific evidence gaps that need to be addressed, particularly regarding the effectiveness and impact of the intervention, as well as the acceptability of items other than needles and syringes.
• Also required are studies assessing the cost-effectiveness of the provision of different items and of different service models.
• There is little meaningful engagement with service providers or people who use drugs in the design of the research or the interpretation of the results assessing the provision of harm reduction supplies.
• Service models tailored to the needs of vulnerable groups, such as women, migrants and men who have sex with men, including chemsex users, need to be developed and expanded.

Further resources

EUDA

• Harm reduction topics page.
• Prevention and control of infectious diseases among people who inject drugs – 2023 update.
• Increase access to hepatitis C (HCV) testing and care in drug services – a toolkit.
• Take-home naloxone (topic overview).
• Spotlight on… Drug consumption rooms.
• Monitoring the elimination of viral hepatitis as a public health threat among people who inject drugs in Europe, 2019.

Other resources

• Federal Ministry for Economic Cooperation and Development (Germany), Integrated Strategy for HIV, Hepatitis B and C and Other Sexually Transmitted Infections.
• Ministère des Solidarités et de la Santé, ‘Liste Des Matériels de Prévention Pour Les Services de Réduction Des Risques‘, 2020.
• Schäffer, D. and Sweers, H., ‘Empfehlungen für die Vergabe von Drogenkonsumutensilien‘, 2018.
• World Health Organization, Action plan for the health sector response to viral hepatitis in the WHO European Region, 2017.
• World Health Organization, WHO guideline on the use of safety-engineered syringes for intramuscular, intradermal and subcutaneous injections in health care settings, 2016.
• World Health Organization, Combating hepatitis B and C to reach elimination by 2030, 2016.
• World Health Organization, Community management of opioid overdose, 2014.

References

Abdulrahim, D., Bowden-Jones, O. and behalf of the NEPTUNE group (2018), ‘The misuse of synthetic opioids: harms and clinical management of fentanyl, fentanyl analogues and other novel synthetic opioids. Information for clinicians’, NEPTUNE, London.

Aspinall, E. J., Nambiar, D., Goldberg, D. J., Hickman, M., Weir, A., Van Velzen, E., Palmateer, N., Doyle, J. S., et al. (2013), ‘Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis’, International Journal of Epidemiology 43(1), pp. 235-248, doi:10.1093/ije/dyt243.

Avetian, G. K., Fiuty, P., Mazzella, S., Koppa, D., Heye, V. and Hebbar, P. (2018), ‘Use of naloxone nasal spray 4 mg in the community setting: a survey of use by community organizations’, Current Medical Research and Opinion 34(4), pp. 573-576, doi:10.1080/03007995.2017.1334637.

Behar, E., Santos, G. M., Wheeler, E., Rowe, C. and Coffin, P. O. (2015), ‘Brief overdose education is sufficient for naloxone distribution to opioid users’, Drug and Alcohol Dependence 148, pp. 209-212, doi:10.1016/j.drugalcdep.2014.12.009.

Bird, S. M., McAuley, A., Perry, S. and Hunter, C. (2016), ‘Effectiveness of Scotland’s national naloxone programme for reducing opioid‐related deaths: a before (2006-10) versus after (2011-13) comparison’, Addiction 111(5), pp. 883-891, doi:10.1111/add.13265.

Boucher, L. M., Marshall, Z., Martin, A., Larose-Hébert, K., Flynn, J. V., Lalonde, C., Pineau, D., Bigelow, J., et al. (2017), ‘Expanding conceptualizations of harm reduction: results from a qualitative community-based participatory research study with people who inject drugs’, Harm Reduction Journal 14(1), p. 18, doi:10.1186/s12954-017-0145-2.

Cherrier, N., Kearon, J., Tetreault, R., Garasia, S. and Guindon, E. (2022), ‘Community distribution of naloxone: a systematic review of economic evaluations’, PharmacoEconomics - Open 6(3), pp. 329-342, doi:10.1007/s41669-021-00309-z.

Chou, R., Korthuis, P. T., McCarty, D., Coffin, P. O., Griffin, J. C., Davis-O’Reilly, C., Grusing, S. and Daya, M. (2017), ‘Management of suspected opioid overdose with naloxone in out-of-hospital settings: a systematic review’, Annals of Internal Medicine 167(12), pp. 867-875, doi:10.7326/m17-2224.

Coffin, P. O. and Sullivan, S. D. (2013), ‘Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal in Russian cities’, Journal of Medical Economics 16(8), pp. 1051-1060, doi:10.3111/13696998.2013.811080.

Crocker, A., Bloodworth, L., Ballou, J., Liles, A. M. and Fleming, L. (2019), ‘First responder knowledge, perception and confidence in administering naloxone: impact of a pharmacist-provided educational program in rural Mississippi’, Journal of the American Pharmacists Association, doi:10.1016/j.japh.2019.04.011.

ECDC (European Centre for Disease Prevention and Control) and EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) (2011), Prevention and control of infectious diseases among people who inject drugs, ECDC, Stockholm.

ECDC and EMCDDA (2023), Prevention and control of infectious diseases among people who inject drugs: first update 2023, ECDC, Stockholm.

EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) (2015), Preventing fatal overdoses: a systematic review of the effectiveness of take-home naloxone, EMCDDA Papers, Publications Office of the European Union, Luxembourg.

EMCDDA (2016), Preventing opioid overdose deaths with take-home naloxone, Insights, Publications Office of the European Union, Luxembourg.

EMCDDA (2021a), Action framework for developing and implementing health and social responses to drug problems, Health and social responses to drug problems: a European guide.

EMCDDA (2021b), Impact of COVID-19 on drug markets, use, harms and drug services in the community and prisons: results from an EMCDDA trendspotter study, Publications Office of the European Union, Luxembourg.

FRA (2015), Cost of exclusion from healthcare: the case of migrants in an irregular situation, European Union Agency for Fundamental Human Rights, Vienna.

Giglio, R. E., Li, G. and DiMaggio, C. J. (2015), ‘Effectiveness of bystander naloxone administration and overdose education programs: a meta-analysis’, Injury Epidemiology 2(1), p. 10, doi:10.1186/s40621-015-0041-8.

Hancock, E., Ward, Z., Ayres, R., Neale, J., Hussey, D., Kesten, J. M., Hickman, M. and Vickerman, P. (2020), ‘Detachable low dead space syringes for the prevention of hepatitis C among people who inject drugs in Bristol, UK: an economic evaluation’, Addiction 115(4), pp. 702-713, doi:10.1111/add.14849.

Hope, V., Kimber, J., Vickerman, P., Hickman, M. and Ncube, F. (2008), ‘Frequency, factors and costs associated with injection site infections: findings from a national multi-site survey of injecting drug users in England’, BMC Infectious Diseases 8, p. 120, doi:10.1186/1471-2334-8-120.

Horton, M., McDonald, R., Green, T. C., Nielsen, S., Strang, J., Degenhardt, L. and Larney, S. (2017), ‘A mapping review of take-home naloxone for people released from correctional settings’, International Journal of Drug Policy 46, pp. 7-16, doi:10.1016/j.drugpo.2017.05.015.

Jones, J. D., Roux, P., Stancliff, S., Matthews, W. and Comer, S. D. (2014), ‘Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users’, International Journal of Drug Policy 25(1), pp. 166-170, doi:10.1016/j.drugpo.2013.05.006.

Kerr, D., Kelly, A.-M., Dietze, P., Jolley, D. and Barger, B. (2009), ‘Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose’, Addiction 104(12), pp. 2067-2074, doi:10.1111/j.1360-0443.2009.02724.x.

Langham, S., Wright, A., Kenworthy, J., Grieve, R. and Dunlop, W. C. N. (2018), ‘Cost-effectiveness of take-home naloxone for the prevention of overdose fatalities among heroin users in the United Kingdom’, Value Health 21(4), pp. 407-415, doi:10.1016/j.jval.2017.07.014.

Larney, S., Peacock, A., Mathers, B. M., Hickman, M. and Degenhardt, L. (2017), ‘A systematic review of injecting-related injury and disease among people who inject drugs’, Drug and Alcohol Dependence 171, pp. 39-49, doi:10.1016/j.drugalcdep.2016.11.029.

McDonald, R., Lorch, U., Woodward, J., Bosse, B., Dooner, H., Mundin, G., Smith, K. and Strang, J. (2018), ‘Pharmacokinetics of concentrated naloxone nasal spray for opioid overdose reversal: phase I healthy volunteer study’, Addiction 113(3), pp. 484-493, doi:10.1111/add.14033.

McGowan, C., Harris, M. and Rhodes, T. (2013), ‘Hepatitis C avoidance in injection drug users: a typology of possible protective practices’, PloS One 8(10), pp. e77038-e77038, doi:10.1371/journal.pone.0077038.

McGowan, C. R., Wright, T., Nitsch, D., Lewer, D., Brathwaite, R., Scott, J., Hope, V., Ciccarone, D., et al. (2020), ‘High prevalence of albuminuria amongst people who inject drugs: a cross-sectional study’, Scientific Reports 10(1), p. 7059, doi:10.1038/s41598-020-63748-4.

Ministère des Solidarités et de la Santé (2020), ‘Liste des matériels de prévention pour les services de réduction des risques’, République Française, Paris.

National Institute for Health and Care Excellence (2014), ‘Costing statement: needle and syringe programmes implementing the NICE guidance on needle and syringe programmes (PH52)’, Putting NICE guidance into practice, NICE, London.

Palmateer, N., Hamill, V., Bergenstrom, A., Bloomfield, H., Gordon, L., Stone, J., Fraser, H., Seyler, T., et al. (2022), ‘Interventions to prevent HIV and hepatitis C among people who inject drugs: latest evidence of effectiveness from a systematic review (2011 to 2020)’, International Journal of Drug Policy 109, p. 103872, doi:10.1016/j.drugpo.2022.103872.

Parmar, M. K. B., Strang, J., Choo, L., Meade, A. M. and Bird, S. M. (2017), ‘Randomized controlled pilot trial of naloxone‐on‐release to prevent post‐prison opioid overdose deaths’, Addiction 112(3), pp. 502-515, doi:10.1111/add.13668.

Platt, L., Minozzi, S., Reed, J., Vickerman, P., Hagan, H., French, C., Jordan, A., Degenhardt, L., et al. (2017), ‘Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs’, Cochrane Database Syst Rev 9(9), p. Cd012021, doi:10.1002/14651858.CD012021.pub2.

Razaghizad, A., Windle, S. B., Filion, K. B., Gore, G., Kudrina, I., Paraskevopoulos, E., Kimmelman, J., Martel, M. O. and Eisenberg, M. J. (2021), ‘The effect of overdose education and naloxone distribution: an umbrella review of systematic reviews’, American Journal of Public Health 111(8), pp. e1-e12, doi:10.2105/AJPH.2021.306306.

Schäffer, D. and Sweers, H. (2018), ‘Empfehlungen für die Vergabe von Drogenkonsumutensilien’, Deutsche Aidshilfe, Berlin.

Skulberg, A. K., Asberg, A., Khiabani, H. Z., Rostad, H., Tylleskar, I. and Dale, O. (2019), ‘Pharmacokinetics of a novel, approved, 1.4-mg intranasal naloxone formulation for reversal of opioid overdose-a randomized controlled trial’, Addiction, doi:10.1111/add.14552.

Sweeney, S., Ward, Z., Platt, L., Guinness, L., Hickman, M., Hope, V., Maher, L., Iversen, J., et al. (2019), ‘Evaluating the cost-effectiveness of existing needle and syringe programmes in preventing hepatitis C transmission in people who inject drugs’, Addiction 114(3), pp. 560-570, doi:10.1111/add.14519.

Tookes, H., Diaz, C., Li, H., Khalid, R. and Doblecki-Lewis, S. (2015), ‘A cost analysis of hospitalizations for infections related to injection drug use at a county safety-net hospital in Miami, Florida’, PLoS One 10(6), p. e0129360, doi:10.1371/journal.pone.0129360.

Torres-Leguizamon, M., Reynaud, E. G., Néfau, T. and Duplessy, C. (2020), ‘HaRePo (harm reduction by post): an innovative and effective harm reduction programme for people who use drugs using email, telephone, and post service’, Harm Reduction Journal 17(1), p. 59, doi:10.1186/s12954-020-00403-1.

van Santen, D. K., Coutinho, R. A., van den Hoek, A., van Brussel, G., Buster, M. and Prins, M. (2021), ‘Lessons learned from the Amsterdam Cohort Studies among people who use drugs: a historical perspective’, Harm Reduction Journal 18(1), p. 2, doi:10.1186/s12954-020-00444-6.

WHO (World Health Organization) (2014), Community management of opioid overdose, WHO, Geneva.

WHO (2016), WHO guideline on the use of safety-engineered syringes for intramuscular, intradermal and subcutaneous injections in health care settings, WHO, Geneva.

Wright, T., Hope, V., Ciccarone, D., Lewer, D., Scott, J. and Harris, M. (2020), ‘Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK’, PLoS One 15(7), p. e0235350, doi:10.1371/journal.pone.0235350.

Yousefifard, M., Vazirizadeh-Mahabadi, M. H., Neishaboori, A. M., Alavi, S. N. R., Amiri, M., Baratloo, A. and Saberian, P. (2020), ‘Intranasal versus intramuscular/intravenous naloxone for pre-hospital opioid overdose: a systematic review and meta-analysis’, Advanced Journal of Emergency Medicine 4(2), p. e27, doi:10.22114/ajem.v0i0.279.

About this miniguide

This miniguide is one of a larger set, which together comprise Health and social responses to drug problems: a European guide. 

Recommended citation: European Union Drugs Agency (2025), Health and social responses: provision of harm reduction equipment for high-risk drug use, https://www.euda.europa.eu/publications/mini-guides/publications/mini-guides/provision-harm-reduction-equipment-high-risk-drug-use

Identifiers

HTML: TD-01-25-005-EN-Q
ISBN: 978-92-9408-067-7
DOI: 10.2810/3522934

Source data

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