Harm reduction and its monitoring in Europe, from EMCDDA to EUDA

Abstract

Background

Harm Reduction, conceptualized by Russell Newcombe in the late 1980s, has revolutionized how drug use, individuals who use drugs, and drug policies are understood globally. Emerging from the HIV/AIDS crisis, Harm Reduction sought to address the dire rates of drug-related infections and the overwhelming burden on healthcare providers. Early initiatives, such as Opioid Substitution Treatment (OST) and needle exchange programs, were met with resistance but gradually established new standards of care, transforming attitudes toward people who use drugs and prioritizing human-centered, rather than solely medical, approaches.

Main body

This paper explores the evolution and expansion of Harm Reduction from an HIV/AIDS prevention strategy to a broader framework adopted across Europe. Although ideological barriers initially slowed adoption, Harm Reduction principles have gained acceptance, notably through EU policies promoting drug-related harm reduction and the United Nations’ 2024 resolution. Through initiatives such as OST, needle exchange programs, drug consumption rooms, and drug-checking services, the European Union has demonstrated progressive success in reducing drug-related deaths and infectious diseases. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has supported this evolution by providing extensive data, scientific evidence, and policy recommendations that guide national approaches. More recently, advancements in hepatitis C treatment have created opportunities for improved health outcomes among individuals who use drugs, fostering their role as active partners in healthcare processes.

Conclusion

Today’s increasingly complex drug landscape, characterized by high substance availability, poly-drug use, and drug-related violence, necessitates a redefined approach to Harm Reduction. With the transformation of the EMCDDA into the European Union Drug Agency (EUDA), the agency’s mandate now includes a proactive focus on anticipating, alerting, responding to, and learning from emerging drug-related challenges. Strengthening collaboration with civil society will be crucial in evolving Harm Reduction to meet future needs, ensuring that EU drug policies remain inclusive, adaptive, and aligned with the diverse realities faced by individuals who use drugs.

The concept of Harm Reduction, as invented by Russel Newcombe1 at the end of the eighties, has been at the origin of a conceptual revolution that has not finished impacting our representation of drug use, of people who are using drugs, and of drug policies in Europe and in the entire world.

For many of us, it all started with the AIDS epidemic and the critical numbers of drug- related HIV infections and AIDS cases in many countries. I remember as if it was yesterday the burden for the teams working in drug treatment facilities of having to provide care to their HIV-infected patients and assist them in their final moments when dying of AIDS. They were not prepared nor trained to provide that kind of care and assistance, and they were desperate to find something to offer to people using drugs to reduce their risk of infection and to provide treatment to people living with AIDS at a time when a fatal prognosis was almost unavoidable.

I remember, in particular, talking with the staff from the first Opioid Substitution Treatment (OST) programmes in Madrid and other European cities, frontline workers who were often close to burnout and found themselves in a rather hopeless situation at this time. There had been such opposition to OST programmes and when they finally opened the admission criteria were so restrictive that the conditions for access were almost impossible to meet.

For the young clinical psychologist and psychotherapist that I was, it was a kind of revelation to see how the death of the clients was perceived and experienced differently by the medical teams, depending on whether it was because of an overdose or because of AIDS (and later on because of HCV and liver cancer or any other health problem). Suddenly, the loss of life among people who used drugs was viewed in another way, less technical or medical and more human, simply human. And this was, to some extent, confronting us with our radical humanity and mortality; we were all human, all the same. This experience is, for me, the essence of Harm Reduction as we saw it evolving in the last 35 years, and it is this essence that we need to re-discover or re-invent for it to become the Harm Reduction Spirit of the future.

Therefore, it is not surprising that the concept and principles of Harm Reduction have been evolving from HIV/AIDS prevention to a broader concept and spreading throughout Europe responding to the spread of drug-related blood-borne diseases.

This evolution has been relatively rapid in some countries, but in most of our countries, there have been many ideological obstacles to adopting this "new" approach.

We cannot forget that we had to wait until 2024, to get a resolution at the Commission on Narcotic Drugs at the United Nations that explicitly mentions Harm Reduction.2 In the meantime, there has been an enormous cost of lives lost or wasted.

Despite this, we have made good progress in the European Union, as reflected by the progressive increase in the availability of OST/OAT services and needle exchange programmes3 and the dramatic impact in terms of reducing drug-related deaths, HIV, HCV and other infections,4 to mention just the most significant achievements. More recently, new progress in the treatment of hepatitis C5 created new opportunities to treat and cure this disease in substance users, giving them new hopes and new futures. This also led to their being considered as partners in the process.

Later, new interventions and services were experimented with and implemented, such as drug consumption rooms and drug checking programmes, which are increasingly being adopted by many countries. However, they have yet to be mainstream.

As reflected in many EMCDDA publications since the early years and in particular in its Insight on "Harm reduction: evidence, impact and challenges" published in 2010,6 the EU's approach and policy on drugs has seen a steady and continuous evolution towards more convergence, and more consensus, in particular since 2000. For instance, in June 2003, the Council of the European Union adopted a "Recommendation on the Prevention and the Reduction of Health-Related Harm Associated with Drug Dependence",7 and the EMCDDA reported a few years later on the follow-up of the Recommendation in the EU Member States.

This culminated with the adoption of the European Union Common Position on UNGASS 20168 by all EU Member States without exception, making for the first time an explicit reference to Harm Reduction, the respect for the Human Rights of people using drugs and the role of civil society in global drug policy.

Over the years, Harm Reduction has also been regularly mentioned among the principles and objectives of the European Drug Strategies and Action Plans, culminating in the fact that the reduction of drug-related harm was included as a key pillar of the strategy for the first time in the 2021-2025 policy document.9

The EU approach to drugs is based on consensus and dialogue and, when relevant and possible, on the scientific evidence presented by our Agency, noting that drug policy remains largely the competence of the Member States. This approach was the only one that would allow progressively build convergence without imposing any harmonisation that was not considered desirable. In the end, the important thing is that we agreed on a shared portfolio of interventions.

At the end of this long journey, despite a considerable variation of the situation among the European Union countries, the participation of people who are using drugs ("Nothing about us without us"), and the adoption or promotion of policies that aim at helping and protecting people with an addiction problem ("Support, don't punish"), have made substantial progress. For instance, the creation of a consultative European Civil Society Forum on Drugs10 by the European Commission in 2007 has produced positive results. It is placing the European Union in a more advanced position than other regions worldwide.

In parallel with this evolution, since 1993, the European Union has created the European Monitoring Centre for Drug and Drug Addiction (EMCDDA), which opened its doors in Lisbon in January 1995.

Since the first publications on topics directly or indirectly related to Harm Reduction in 1999–2000, the EMCDDA has been at the forefront of exploring, studying, gathering scientific evidence and documenting service provision as well as new and innovative approaches, such as the first report on Drug Consumption Rooms in Europe, another on Drug Checking, or publications about Naloxone.

Over the years, we have built a corpus of scientific and evidence-based publications on a broad range of Harm Reduction interventions. We have provided ad hoc analyses upon request from our key stakeholders, which have contributed to developing a comprehensive set of tools that the EU and its Member States use according to their needs and political priorities. Almost every week, we are requested to provide briefings, explanations, and analyses to national authorities, national parliaments, and other local authorities.

In recent years, we have also changed our approach to partnerships with civil society. After one or two decades of trying to find ways to complement and improve our European drug information system, we have moved towards more co-production and developing projects of shared interest.

Where are we today with the drug situation, and what will change with the transformation of the EMCDDA into the new European Union Drug Agency11 (EUDA)?

Today, the recent changes in the drug situation, characterised by an all-time extremely high availability of any substances, the pressure from the drug market to find new customers and to increase existing users' consumption, the further spread of poly-drug or poly-substance use, and the emergence of drug-related violence, have paved the ground for an upscale of our Agency and for broadening its mandate.12

Our new mission is to contribute to EU preparedness on drugs through four main actions: anticipate, alert, respond, and learn.

Anticipation means combining our extensive data collection and new methods for near real-time information and exploring possible future scenarios and their potential consequences for the EU and its citizens.

The Alert action aims to create a new European Drug Alert System to ensure that medical professionals and emergency services receive timely information about new substances, how to detect and identify them, their risks and necessary antidotes.

Together with a new European Threat Assessment System, it will complement and boost how the EU prepares for emerging or potential health and security threats. The objective is to save lives and ensure that all the knowledge collected or produced is available for the field actors.

The Response component focuses on our ability to assess and coordinate with Member States to address those emerging issues and threats, ensuring they have the necessary decision-making support and capabilities.

Finally, Learning involves:

• Assessing the effectiveness of our actions.

• Evaluating our crisis management decisions.

• Updating our best practices and quality standards accordingly.

Through our support of capacity development across Member States, we will ensure we remain at the forefront of drug policy and responses.

The evolution of the drug situation and our Agency's new mandate are also opportunities to redefine and revitalise the harm reduction concept and adapt it to emerging challenges.

Indeed, it is time for us in Europe to change our implicit theories, which are still shaped and influenced by the heroin epidemic that has been the problem since the seventies. Today, we need to include in our analysis the impact of the high availability and diversity of substances and poly-drug use, as well as the causes and results of the increased violence spreading everywhere.

We will promote this through closer cooperation with civil society, as foreseen by our new mandate, and more co-production with our different partners.

A very symbolic sign of our commitment towards a closer relationship with civil society is the fact that we invited the Chair of the European Civil Society Forum on Drugs to attend the launch of the new Agency in Lisbon and to address the members of our Management Board for the first time in 32 years.

For us, the commitment to go further with the change initiated a few years ago, to work closely with civil society and to ultimately be more helpful to people using drugs is unconditional, and it starts now.

Author contribution

AG wrote the main manuscript text.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.