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.