Harm reduction – the current situation in Europe (European Drug Report 2023)

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 2023, the EMCDDA's annual overview of the drug situation in Europe.

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Last update: 16 June 2023

Europe's changing drug situation creates new challenges for harm reduction interventions

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-judgmentally 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 needed to adapt to address a broader set of health outcomes. Among these are reducing the risk of drug overdose and addressing the often-considerable health and social problems faced by more marginalised populations.

Chronic and acute health problems are associated with the use of illicit drugs, and these are compounded by factors that include 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 the best documented. Although relatively rare, 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 probably 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 two 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. In the last two decades, approaches to harm reduction have been broadened in some EU countries to encompass other responses, including supervised drug consumption rooms and take-home naloxone programmes intended to reduce fatal overdoses. In some countries, there are also drug checking facilities, set up to enable 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 what particular stimulant or mixture of substances they may be consuming.

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.

Some indicators now suggest that synthetic opioids and synthetic stimulants 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, comes from Estonia where mixtures have been 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. The presence on the market of such mixtures highlights the need to review current approaches to the delivery of some harm reduction interventions. For example, these mixtures may need consideration to be given to reviewing distribution and administration of the opioid antagonist naloxone.

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 6 major European cities, across 5 EU countries. A potentially increased frequency of injection is associated with stimulant use compared to heroin use, while crushing and dissolving crack cocaine and other tablets for injection also brings 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, 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.

The use of illicit stimulants and other drugs to facilitate group sexual encounters, sometimes of an extended duration, among men who have sex with men is known as chemsex. This high-risk sexual practice can involve participants having multiple sexual partners, with whom they engage in unprotected sexual activity, placing them at risk of sexually transmitted infections. Group chemsex sessions can be associated with the use of social media apps, where access to illicit drugs and group sex may be combined by some organisers. 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. High-risk consumption of some of these drugs, including injecting drug use, places people at risk of infectious diseases such as HIV and HCV, as well as acute drug toxicity, fatal overdose, acute psychiatric complications, substance use disorder and other psychiatric problems such as anxiety and depression. In 2022, a monkeypox outbreak was documented for the first time in Europe. Descriptive studies showing a potential association between monkeypox infection and specific exposures (chemsex, tattooing) have raised questions on the implications and specific harm reduction needs of some groups of people who use drugs. While it is difficult to estimate the prevalence of chemsex, information from research studies and treatment centres suggest it is an issue that is present, albeit at a small scale and among specific subgroups of people who use drugs, across Europe. It must be noted that this group of people are generally not present as clients in drug treatment clinics. Providing effective harm reduction responses for people engaged in these high-risk behaviours remains a challenge and the development of tailored harm-reduction interventions is needed. In Europe, treatment services for drug and sexual health problems are usually funded separately, have different eligibility criteria and are rarely co-located. This makes it difficult to provide integrated care for people exposed to the dual risks of unprotected sex and high-risk drug use in a chemsex context. Ongoing research is aimed at identifying the most appropriate service model to engage clients, such as integrating drug services into existing sexual health services for men who have sex with men.

Cannabis users in Europe often 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. For example, natural cannabis products sprayed with potent synthetic cannabinoids, but mis-sold as natural cannabis, place consumers at risk of health complications. Generally, cannabis products, both resin and herb, are now of a higher potency than they were historically, while the diversity of product types has expanded, with edibles, e-liquids and extracts all now available. The semi-synthetic cannabinoid hexahydrocannabinol (HHC) has recently become commercially marketed in some EU Member States and sold as a ‘legal’ alternative to cannabis. The newness of these cannabis forms raises issues around consumer safety, particularly where little information exists about their impact on human health and creates a complex harm reduction messaging challenge.

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. Among these are substances such as nitrous oxide and ketamine. While these drugs are associated with episodic or recreational use in specific contexts, such as nightlife or entertainment settings, they are linked with a range of possible health harms, of which the people using them may not be aware.

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 policy consideration. Looking forward, the evolving threats to 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.

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 2021.

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 supervised drug consumption room, intended to facilitate safer use and prevent various health problems.

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.

Supervised drug consumption rooms

• While supervised drug consumption rooms have become a more accepted harm reduction response, establishing them remains problematic in some countries. In 2022, 9 EU countries and Norway had operational facilities. Where multicultural and new immigrant populations are present, increased own-language harm reduction messaging is desirable for people engaged in high-risk drug use.

Interventions in prisons

• EMCDDA data on harm reduction and treatment interventions available in prisons in 2021 show that continuity of opioid agonist treatment was available in all EU Member States, apart from Slovakia, as well as in Türkiye and Norway. Initiation of agonist treatment in prison was not allowed in 6 countries. Needle and syringe programmes were available in prisons in 3 countries and take-home naloxone was available in 4 countries.