Europe must continue to lead on harm reduction

Abstract

Europe has been at the forefront of harm reduction since its inception. These important early steps were in large part a response to the dramatically expanding HIV epidemic, and investing in these innovative interventions early and robustly had a transformative effect. This brought about not just pioneering services but also pioneering policy changes. However, while Western Europe and Member States in the European Union often have been at the vanguard of harm reduction innovation and vocal advocates for public health and human rights-based drug policy reform, the situation has been much different in the “wider” WHO European region, which also includes Eastern and Southeastern Europe as well as Central Asia. This is a result not just of limited budgets for health, but also of punitive laws and policies and persistent stigma and discrimination. Even as harm reduction has demonstrated huge successes in Europe, there is a need to move forward a wider array of services to respond to an evolving and increasingly complex drug situation in Europe. Instead, it is a lack of political will and of political courage that is holding back the establishment, expansion, and deepening of these essential, lifesaving interventions. Responding proactively and effectively to this changing drug situation will require redoubled investment in public health and harm reduction approaches.

Introduction

Europe has been at the forefront of harm reduction since its inception. From the first needle and syringe programs (NSPs) operating in the in the Netherlands in the early 1980s [1], to the world’s first overdose prevention centre (OPC) opening in Switzerland in 1986 [2], Europe has been a pioneer in shaping responses to drugs grounded in compassion, dignity, health and rights. These important early steps were in large part a response to the dramatically expanding HIV epidemic, and investing in these innovative interventions early and robustly had a transformative effect – reducing HIV transmission among people who use drugs in these countries to nearly zero [3].

This brought about not just pioneering services but also pioneering policy changes. The decriminalization model adopted in Portugal in 2000 [4], seeking to respond to HIV and overdoses among people who inject drugs, continues to be a great example of what can be achieved for public health and human rights when drug policies are reformed to focus on health, support, and harm reduction. Similar policies in the Czech Republic likely prevented the country from experiencing an unsafe injection-linked HIV epidemic at all [5].

However, appraising progress on harm reduction in Europe depends on how one defines “Europe”. While Western Europe and Member States in the European Union often have been at the vanguard of harm reduction innovation and vocal advocates for public health and human rights-based drug policy reform, the situation has been much different in the “wider” WHO European region, which also includes Eastern and Southeastern Europe as well as Central Asia alongside the EU-EEA countries.

Eastern Europe has the fastest-growing HIV epidemic in the world, with new infections among people who inject drugs (PWID) as a key factor, while the highest HIV prevalence in the region is among PWID [6]. Interventions that make up the baseline WHO definition of harm reduction – NSPs, opioid agonist maintenance therapy (OAMT) and community distribution of naloxone for overdose management – are lagging much further behind in this region [6].

This is a result not just of limited budgets for health, but also of punitive laws and policies and persistent stigma and discrimination. A microcosm of this can be seen in Russia and Ukraine. In Russia, where OAMT is illegal [7], NSPs are dwindling [8], and harm reduction service providers are subject to repression and criminalization through foreign agent laws [9], HIV remains rampant among people who inject drugs [10]. Ukraine, on the other hand, had begun to make considerable progress in reducing HIV transmission and addressing drug use through a health lens in recent years, with some of the best practices in the region in establishing and maintaining harm reduction interventions [11] – even in the face of war and humanitarian crises that have placed grave challenges on reaching clients and providing services [12]. Sadly, beginning with Crimea in 2014 [13] and now in other regions of eastern Ukraine since 2022, Ukrainian regions currently under Russian control have seen catastrophic increases in new HIV infections [14] and overdoses among people who inject drugs, as the sudden change in de facto laws in those regions and impacts on health systems across the country have abruptly cut off access to harm reduction and treatment for those who need it [15].

The limited availability to opioid agonist medications in Eastern Europe and Central Asia constrains the effectiveness of efforts to treat opioid dependence in the region. Beyond just being an effective harm reduction measure, OAMT is the gold standard of treatment for opioid use disorder. Methadone and buprenorphine are both included on the WHO’s Model List of Essential Medicines [16]. Stepping up access to these medications is not just about improving harm reduction provision – it is crucial to achieving health equity and universal health coverage.

Even as harm reduction has demonstrated huge successes in Europe, there is a need to move forward a wider array of services to respond to an evolving and increasingly complex drug situation in Europe. While European countries have been among the earliest and widest adopters of overdose prevention centres, it nevertheless remains the case that far more of these centres are needed in more European countries. This is especially the case in areas [17] that have already begun to see the potential early signs of a shift in the illicit drug supply from plant-based drugs to synthetics [18] – it will take a bold, proactive, and robust action for European cities and countries to avoid an overdose crisis like the one that is still heavily impacting North America.

The lack of progress in moving harm reduction into the 21st century has not been for a lack of scientific evidence. Needle and syringe programmes have decades of evidence behind them [19], and are among the most cost-effective public health interventions in the world [20]. The evidence base behind OAMT makes it the most effective treatment for opioid use disorder [21], and maintaining clients on treatment also greatly reduces their risk of overdose or of contracting HIV, viral hepatitis, or other bloodborne infections [22]. Putting naloxone in the hands of those most likely to witness an overdose has proven time and again to be more effective than only allowing it to be accessed by prescription, medical personnel, or law enforcement [23]. And there has never been an overdose in any overdose prevention centre in the nearly 40 years that such sites have been in existence – while these sites also provide crucial connections to other health and social services for people who use drugs [24].

Instead, it is a lack of political will and of political courage that is holding back the establishment, expansion, and deepening of these essential, lifesaving interventions. 2024 will be one of the most consequential years for elections in global history, with more than half of Europe’s and the world’s population going to the polls. In the context of a geopolitically fraught state of global politics, marked by war, climate emergencies, humanitarian disasters, and increasing attacks on and pressure against human rights, harm reduction and drug policy reform risk being crowded out of the political agenda. Furthermore, shifts to the right both at the European Parliament level and in many European countries threaten to herald a return to more punitive approaches to drugs, and even in contexts where left-of-center parties remain strong or are gaining ground, like in the UK, urgently-needed reforms may sit on the political backburner [25].

This is particularly concerning, as new developments in drug markets and production across the global threaten to unleash new drug-related crises in Europe. While Europe has seen an increase in drug-related deaths in recent years [26], as well as record use of cocaine [27] and other stimulants, its illicit opioid supply is thus far still largely made up of heroin originating from Afghanistan, and has as such largely been spared the levels of fatal overdoses that have been seen in North America since fentanyl and other synthetic opioids and adulterants began to dominant the street drug supply [28]. However, the Taliban’s recent ban on opium cultivation has cut harvests of the opium poppy used to produce heroin by over 90% [29], and while stock from previous harvests has continued to supply the market for the time being, these stocks are rapidly dwindling. Demand for opioids is rather inelastic, and it is highly likely that this gap in supply will be filled by synthetic alternatives [30] – and indeed, Europe has already begun to see clusters of overdoses caused by nitazenes, synthetic opioids that can be many magnitudes more potent than fentanyl [31].

Responding proactively and effectively to this changing drug situation will require redoubled investment in public health and harm reduction approaches. And furthermore, we will also need to rely not just on the interventions that formed the core of the response to HIV among people who inject drugs in the 1980s and 1990s, but also expand our toolkit to encompass overdose prevention centres, drug checking services, and safer supply initiatives such as heroin-assisted treatment, tailoring a revamped harm reduction approach to respond to the challenges we face today.

Progressive action has made Europe a leader in harm reduction and public health-based drug policies on the international stage for a generation. To respond to the drug situation of the next generation, it must continue to act and innovate to promote a harm reduction approach fit for the future.