In the context of Europe, harm reduction represents an interesting case among public health and drug policies because of its long and challenging journey towards acknowledgement and acceptance. As a grassroots phenomenon, originating from people who use drugs, harm reduction has had to navigate complex political and social circumstances to shift the logic of drug policies from criminal justice towards public health [1]. Initial ignorance about HIV and AIDS, as well as stigma surrounding drug use, resulted in delayed and initially inadequate responses. With improving medical knowledge and activism of disproportionately affected communities, pragmatic interventions aimed at reducing HIV transmission among people who inject drugs - while also mitigating a public health threat to society - became part of official policies. So far, this has brought many good things. However, in this commentary, we argue that it is high time to transform harm reduction and help move it forward from the current clinical focus on reducing harms towards holistically improving the well-being of individuals and communities while acknowledging the benefits of using drugs, and helping people who use drugs sit at the decision-makers’ table.

Today, there are several countries in the European Union (EU) that have established themselves as vanguards of harm reduction, building experience over decades since the first institutionalised needle exchange programmes were launched in the early 1980s. Their current commitment is a result of a slow process of harm reduction mainstreaming, supported by intensive advocacy, grassroots engagement and rigorous scientific endeavours.

The Netherlands has been among the pioneers in the harm reduction field, with the first low-threshold drop-in centre with needle exchange, space for drug consumption and a range of auxiliary services being opened in Amsterdam as early as 1974 [2]. A decade later, advocacy efforts of the unions of people who use drugs led to the establishment of the first local government-operated needle exchange programme in Amsterdam in 1984 [3]. Today, The Netherlands has one of the most well-developed networks of harm reduction services in Europe, with two dozen specialised drug consumption rooms [4, 5] and more consumption spaces integrated into assisted living facilities, and drug checking that already started in late 1980s [6]. It is also one of the few countries that implements heroin-assisted treatment (HAT). Still, this long and intimate relationship with harm reduction has not made the topic undisputed. The Dutch government, for example, seems less eager to convey harm reduction principles publicly and remains hesitant to ensure the availability of naloxone to the broader community^{Footnote 1}, likely due to the low rates of overdose deaths in the country.

Meanwhile, in the United Kingdom (UK), a group of key stakeholders established an informal alliance in 1985 to address the sharply increasing heroin use among youth, laying groundwork for something that would become known as the Mersey Model of Harm Reduction [8]. Following the principles of inclusiveness, widespread outreach and focus on health and prevention of communicable diseases, policymakers decided to integrate services like Needle and Syringe Programmes (NSP) and Opioid Agonist Treatment (OAT) into national health policies. Ever since, harm reduction in the UK has been subject to changes in the political landscape, where a mainly abstinence-recovery focus dominated UK’s drug policy since the 2010s, leaving the introduction of harm reduction interventions such as drug consumption rooms lagging behind for many years [9]. Long overdue, the first official Drug Consumption Room (DCR) was opened in Glasgow on January 13, 2025, following a ten months-long unsanctioned operation of a mobile service by a community activist in 2020–2021 [10].

In Switzerland, open drug scenes combined with high prevalence of HIV/AIDS among people who inject drugs triggered an early drastic change in its drug policy in the 1980s. The Swiss started with attempts to address widespread public drug use in larger cities like Zurich, by allowing people who use drugs to gather in ‘Needle park’ where they could also access medical and harm reduction services. Switzerland has since become one of the champions in harm reduction. They developed a balanced four-pillar drug policy approach, integrating law enforcement, prevention, treatment, and harm reduction in the law since 2008. Over the years, the country developed one of the most comprehensive networks of harm reduction services in Europe, including drug consumption rooms and drug checking services, as well as heroin-assisted treatment [11, 12].

Over the following decades, a few other countries made significant progress developing and scaling up harm reduction responses. Portugal became globally known for its decriminalisation and dissuasion policy and development of a comprehensive, person-centred care model. A wide range of interventions is also available in Spain and Germany, however, accessibility remains uneven. In Spain, for example, most harm reduction services are concentrated in Barcelona, Catalonia [13]. Some more conservative German Bundesländer have hardly any harm reduction services available. Drug consumption rooms are concentrated in the Northern-Eastern part of the country, while in the Southeast they remain completely absent [14].

Despite some successes in the 1980s and − 90s, harm reduction interventions and policies remained entrenched in the political rhetoric of ‘good’ or ‘bad’ policies. For its proponents, harm reduction was a pragmatic and humane response to the public health crisis. Opponents, on the other hand, argued that it encouraged drug use because of its ‘permissive’ and ‘enabling’ character, conveying a more moral standpoint that any drug use is ‘bad’.

As a result, one could see striking contrasts between European countries regarding whether and how to support people who use drugs. Similar motives (e.g. wanting to reduce drug-related problems) led to completely different approaches. While Germany or Spain developed harm reduction services, for example, the Swedish invested in strict abstinence-based treatment with a rather repressive character [15]. In many countries, the discussion on harm reduction was largely fuelled by ideology and political interests, rather than informed by existing evidence. The different views on drug policy and particularly harm reduction principles also affected relationships between countries. France pressured the Netherlands, for example, by naming it a ‘narcostate’ in the mid-1990s because of the ‘permissive’ character of Dutch drug policy [16].

In the context of broader developments in policy and public administration, the 1980s and 1990s were marked by a shift from the traditional Weberian bureaucracy to New Public Management (NPM), based on the ideas of neo-liberalism and neo-managerialism [17]. This new approach focused on effectiveness and efficiency, introducing ideas such as performance measurement, auditing and accountability, strategic management, and policy analysis and evaluation [18], requiring reliable data to inform decision-making. With the establishment of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) in 1993, extensive data collection and monitoring of the drug situation in Europe began, and the drug policy discourse increasingly shifted away from ideology toward scientific discussions. The EMCDDA further helped enhance the debate around harm reduction by promoting evidence as a basis for better understanding of its effectiveness, benefits and limitations, and by collecting and sharing good practices from the field in EU member states and beyond [19].

Harm reduction researchers were able to show its effectiveness. A multitude of research around OAT and NSPs showed clear evidence: NSPs are effective in reducing the risk of blood-borne infection transmission [18,19,20,21], and OAT in addition helps to reduce the risk of overdose and mortality among people injecting opioids [24,25,26]. There is also abundant and growing evidence supporting the effectiveness of less well-established harm reduction services. Drug consumption rooms, for example, have been found to reduce drug-related deaths and HIV infections [27], reduce unsafe practices or behaviours (also outside the service) [28,29,30], and facilitate treatment uptake [31], among other other benefits [32, 33].

The scientific battle for acknowledgement of harm reduction has been fought parallel to the policy-political battle. Since the beginning, harm reduction in Europe underwent a serious evolution, representing one of the elements of a more general policy shift from punitive measures associated with the criminal justice field, towards approaches centering public health. This included alternatives to incarceration, which were implemented to varying degrees, with positive but inconclusive evidence for success in most EU countries [34]. In 2018, the Council of the EU consolidated these efforts by publishing its Conclusions on Promoting the use of alternatives to coercive sanctions for drug using offenders, calling for implementation of alternatives to coercive sanctions in all Member States [35]. Results of this transformation are clear. In Europe, approximately 34 persons per 100 000 inhabitants are incarcerated for drug offences. To compare, the US incarcerates around 106 persons per 100 000 [36,37,38,39]. This shift away from the criminal justice approach, however, has not been steady, nor uniform, contributing to the varying degree of harm reduction adoption across Europe.

Still, harm reduction gained broader recognition in Western European countries by the mid-1990s. By the year 2000, almost all European countries (as defined by the European Union Drugs Agency, EUDA; formerly: EMCDDA) reported implementation of NSPs and OAT [19]. The long struggle for recognition seems to have paid off in other areas as well. At a supra-national level, a significant milestone came in 2005, when the EU officially recognised the importance of harm reduction in the EU Drugs Strategy [40]. This marked a turning point, as the EU Drug Strategy provided a framework for member states to implement harm reduction measures as part of their national drug policies. Following this, the EU Action Plan on Drugs 2009–2012 [41] and EU Drugs Strategy 2013–2020 [42] further embraced harm reduction in a balanced approach, which has since become a hallmark of the EU policy on drugs, both domestically and internationally. This includes active engagement in the annual sessions of the UN Commission on Narcotic Drugs (CND) and intersessional meetings, contributing to the formulation and implementation of global drug policies, and consistently advocating for harm reduction measures, such as NSPs, OAT, and overdose prevention initiatives.

The most recent EU Drugs Strategy 2021–2025, which was coined ‘one of the most progressive drug strategies in the world’ [43], recognised harm reduction as a separate pillar of drug policy for the first time. This extraction of harm reduction from the category of demand reduction, thereby acknowledging the fundamentally different logic and goals of the two, has been strongly advocated by the Civil Society Forum on Drugs [44].

Finally, the recent opioid crisis and the rise of overdose deaths in North America may have fundamentally changed the US’s (and, hence, international) opposition to harm reduction. In 2024, the push from the US and its allies at the 67th session of the Commission on Narcotic Drugs for harm reduction led to a historical moment of breaking - after more than 70 years - the so-called ‘Vienna consensus’, and adopting a resolution via voting and not unanimous decision. As a result, the term ‘harm reduction’ was included in a UN resolution for the first time in history.

In sum, it would seem that both scientific and political battle for the acknowledgement of harm reduction has been won, in Europe and beyond. However, in the following, we argue that the implementation of harm reduction is still lagging behind in important ways.

Considering the developments and evolution of harm reduction discussed above, one could claim that the struggle for recognition of harm reduction has been largely won. At the same time, however, reality shows otherwise. While the development of harm reduction in Western European countries is - in a global perspective - advanced, most European countries still lag behind Canada, the US or Australia [45]. Data show, for example, that there are great disparities between Western and Eastern parts of Europe in terms of the range of services available. While most countries have implemented OAT and NSP, services such as drug checking and drug consumption rooms are particularly absent in most European countries [45, 46]. Embracing harm reduction principles, including a compassionate and supportive stance towards people who use drugs, is mostly lacking completely. This limited adoption of harm reduction has also led to criticism frequently raised among harm reduction professionals regarding the excessive medicalisation of harm reduction in Europe, which we discuss in more detail below. Furthermore, whereas harm reduction interventions addressing risk and harm related to injecting opioid use (i.e., the transmission of blood-borne infections) have been more established and accepted, there are considerably fewer harm reduction services and interventions to support people who use other substances, use in specific setting or contexts (like nightlife setting or chemsex), and those who do not inject [46].

Another category of shortcomings is the uneven coverage of and access to services. The variance in coverage and access, can be observed both between and within countries. With respect to the latter, harm reduction services are usually concentrated in large cities, and close to nonexistent in rural areas. Moreover, since responsibility for the implementation of drug-related services, including harm reduction, very often lies within regional or local governments, we can also see large differences between regions. As we mentioned earlier, in Spain, for example, harm reduction has been much more developed in Catalonia than in other regions of the country. In Italy, the network of harm reduction services is much more developed in the North compared to the South. In Germany, drug consumption rooms are concentrated in Bundeslaender in the West and the North. In Slovakia, harm reduction services do not exist in the eastern part of the country. There are significant differences in accessibility and coverage also between countries. The total number of fixed sites offering needle and syringe programmes, for example, varies from 1945 in Portugal (one per seven estimated PWID) and 847 in Spain (one per eight estimated PWID) to 743 in France (one per 146 estimated PWID) to nine in Lithuania (one per 985 PWID) and a single one in Bulgaria (per estimated 9783 PWID) [47, 48].

Additionally, since 2017, harm reduction organisations are calling out a funding crisis, signalling austerity, international donor retreat and weak political support [49, 50]. In other words, while some interventions of harm reduction seem to have become a mainstream part of drug policies in the EU formally (at the Union and individual member states levels), the actual implementation falls short and is characterised by clear disparities, lack of progress, and dependence on project-based funding and philanthropy.

We see that the political recognition of harm reduction in EU policy documents has not been translated into support for the implementation of harm reduction policies and services. Despite the intentions expressed in the EU Drug Strategy 2021–2025, the EU has increasingly turned towards a securitisation approach in recent years, through programmes focusing on increasing detection, border control and law enforcement. Harm reduction and demand reduction activities are not financially supported by the European Commission (EC), and the Drugs Policy Initiatives Justice Programme has been discontinued in 2020, further drying up the funding for civil society organisations, including those providing services. Another significant manifestation of this shift at the EU level was the transfer of the drugs portfolio from the European Commission’s Justice Department to the Directorate-General for Migration and Home Affairs (DG HOME) in 2016, which put drug policy more in the space of security and border control issues.

The EU's departure from a health-oriented paradigm, has been also visible in language. High-level politicians use hostile discourse, framing drugs as one of the major societal threats, stigmatising people who use drugs by holding them responsible for acts of violence committed by organised crime [51]. EU institutions also associate organised crime with drug use in official documents [52, 53]. In doing so, European drug policy seems to be moving in a direction away from the core principles of harm reduction, and instead aiming to eliminate drug use from society altogether.

In fact, the featuring ‘balanced approach’ principle of the EU Drug Strategy has become questionable in the current Strategy, as supply reduction measures dominate other aspects of drug policy. Recently, the European Commission also proposed a new EU roadmap to intensify the fight against drug trafficking and criminal networks. At the same time, health aspects of the drugs domain are expected to be covered by the national health policies and the EC refrains from involvement or support in national responses on harm reduction, leaving it in the hands of the individual member states. This is a reminder that the EU Drug Strategy is merely a political declaration without any binding power. As it turns out, leaving governments to take up and scale up harm reduction services is unrealistic.

In the following section, we explore some reasons that may explain some of the deficits of harm reduction implementation outlined above.

Evolving needs and challenges

The drug landscape in Europe keeps evolving, with increasing complexity and variation in consumption patterns and drug markets. Seizures of methamphetamine and amphetamine-type stimulants have increased significantly in the last decade, both in terms of number of seizures and the quantity [54, 55]. Cocaine has reached unprecedented levels of purity and availability, while the cultivation of coca in South America is booming [56]. Polysubstance use, the rise of new (mostly synthetic) psychoactive substances (NPS), in party scenes as well as in marginalised communities, increasingly pose challenges for harm reduction services. While harm reduction services addressing injecting heroin use are now relatively well established, services aimed at stimulants and NPS have just recently started developing [57].

Furthermore, under the Taliban’s ban, opium production dropped dramatically in Afghanistan in 2023, only slightly picking up recently [58, 59]. While this has not yet led to dramatic changes in the heroin supply in Europe, potential shortages could catalyse the rise of extremely potent and relatively risky synthetic opioids (e.g. fentanyls and nitazenes). Rises in availability, use and most likely more incidents and fatal overdoses, as a result from an unpredictable supply market, could pose a huge challenge for harm reduction and other health services. Particularly if use of synthetic opioids is picked up by (younger and novice) populations, who are unfamiliar with harm reduction services. Some European countries have already witnessed the emergence of populations who either look for these strong sedatives or who have encountered them through adulterations in fake-medications for stress and anxiety relief, self medication or other forms of non-prescribed use [60].

Taking a look at a broader context, socioeconomic inequality has been rising since the 1980s in Europe, despite it remaining one of the most economically equal regions in the world [61]. The young generation is especially at increased risk of falling into the poverty trap [62]. In addition, poor mental health is on the agenda, with an estimated more than 84 million Europeans struggling with mental health problems [63]. The link between socioeconomic deprivation, mental health problems and high-risk drug use is well established. This evolving situation requires expansion and perhaps different qualities of harm reduction services, including more person-centred and holistic support aimed at empowerment and resilience.

Stigma

Although harm reduction has been - at least at the declarative level - accepted, we argue that this acceptance is only superficial. Harm reduction is widely accepted as a pragmatic measure reducing the transmission of blood-borne infections. At the same time, we see that the underlying principles of harm reduction, such as respect, compassion, and empowerment have not made their way - with some notable exceptions - into the hearts of people and policies.

On the social and public opinion front, the same happens due to cultural and moral opposition. Stigmatisation of people who use drugs remains a significant barrier to the acceptance of harm reduction. Indeed, according to the least favourite neighbour survey, people who use drugs (along ‘heavy drinkers’) are by far the most stigmatised group in Northern (more than 60% of respondents do not want them as neighbours), Western (nearly 60%) and Southern Europe (over 50%), and in Eastern Europe they are slightly more favoured to ‘heavy drinkers’ (not tolerated by over 70% respondents) [64].

Public opinion is often shaped by stereotypes and misconceptions about drug use and stigma towards people who use drugs is extrapolated to harm reduction services as well, as they are claimed to encourage or endorse morally undesired behaviours and to support people who are seen as a threat to society. In the context of various drug services, but especially harm reduction, public opinion generally exhibits ‘not in my backyard’ attitudes [65,66,67,68,69]. This, again, is an example of the declarative and superficial support for harm reduction which results in significant difficulties in establishing new services and scaling up the existing ones.

Return to moralistic-criminal approaches

Harm reduction makes the most sense if one accepts that a drug-free society is not possible. Unfortunately, not all of society is willing to accept this and some people see drug use as something inherently and morally evil that needs to be eradicated. Such sentiments, making a moral appeal to reject what is ‘wrong’, have been present in European societies for as long as we can remember. People who use drugs are a ‘suitable enemy’^{Footnote 2} [70], who can easily be portrayed as threatening public safety and moral standards, and exploited for political gains.

While there was a period characterised by the acceptance and implementation of evidence-based policies and measures around the drug phenomenon, in recent years, more morally- and ideologically-driven drug policy discourse gained support in Europe. The problem of drug-related organised crime, the extreme cases of violence in producer countries and some high profile incidents have turned the tide in the past decade or so.

The Netherlands, for example, was recently coined a narcostate (again), after a series of high-profile murders by an organised crime group that was also involved in drug trade. Some Dutch politicians argue that people who use drugs fuel organised crime and therefore contribute to death and destruction. Two Christian conservative parties even proposed prosecuting people who use drugs [71]. Rotterdam, whose huge international port forms a major drug trade hub, launched a public campaign in 2024, featuring posters of blood-stained ecstasy tablets and a cocaine cross, with the message: “Your pill [or line], his assassination.” The Netherlands’ once pragmatic approach to drug use is increasingly shifting towards a more intolerant, morally judgmental stance.

Similar shifts can be seen in other countries as well. In France, fixed fines for cannabis use were introduced in 2018, while the government has been clearly expressing its preference for law enforcement over harm reduction to address drug use, with politicians often using moralistic and blaming rhetoric. In the UK, a 10-years drug strategy from 2021 [72] and a 2022 white paper [73] suggested higher penalties for drug trafficking and distribution, but also ‘swift, certain and tough’ punishment for recreational drug use through a three-tier penalty framework for drug possession. These drug policy documents from the Johnson Conservative government period are filled with moral panic and threat-focused narrative, but were never implemented due to changes in Home Secretary, the Prime Minister, and then of the governing party. Despite the UK’s strong history of providing harm reduction, attention has shifted to crime, abstinence-based recovery and austerity [74]. Worrying developments can also be seen in Italy, where the right-wing government of Meloni applies a moralistic approach targeting drug use at rave parties, as they are seen to undermine traditional values. Portugal, praised for many years for its health-oriented drug policy model involving decriminalisation, has effectively re-criminalised drug use in 2008 by implementing threshold quantities for possession, which was followed by a sharp increase in implemented sanctions, including fines and imprisonment particularly for those with patterns of heavy use [75].

Crisis of the welfare state

One could argue that the development of harm reduction in Europe has become an element of the modern welfare state, where the government takes responsibility to promote the health and wellbeing of all citizens, including those marginalised, deprived or disenfranchised. Harm reduction along similar lines aims to support everyone in need, with no judgement, prerequisites or imposed requirements regarding drug use. However, the concept and practical implementation of the welfare state policies have not been steady, and with a recent rise of political polycrises and populism, they are increasingly challenged.

The concept and practice of the welfare state were dominant in European policy for several decades following World War II, when economic security became a ‘right’ for every citizen. However, the aftermath of the 1970s oil crisis revealed cracks in some of its fundamental principles and questioned the affordability of such policies. This gave way for a new period of neoliberal economics characterised by budget discipline and welfare retrenchment. The welfare state was thought to have unrealistic expectations towards governments and citizens who would not want to fund welfare through taxes [76]. Originating in English-speaking countries, these ideas also gained ground in most countries in Europe from the mid 1980s. However, by the late 1990s, growing disillusionment with neoliberal policies led to electoral victories for centre-left parties in Europe. Newly elected social democratic leaders such as Tony Blair, Gerhard Schröder, Wim Kok, and Poul Nyrup Rasmussen were convinced that European welfare states needed to shift from passive benefit systems to active, capacity-building, social investment states [77]. A new wave countered the view that social policy provisions have negative economic effects and that it can actually be a productive factor, making them investments rather than an expense.

Another conceptual change in thinking that accompanied this new wave was the adoption of a life-course perspective in welfare provision [78]. According to this view, poverty and other socioeconomic problems do not just happen by chance. They are outcomes of issues that arise early in people’s lives. Narrating this complex connection helped justify welfare like childcare and support for marginalised groups, including harm reduction for people who use drugs. However, the 2007–2010 financial crisis has led to critical interrogation of the assumptions of this social investment perspective. Furthermore, the social investment theory emphasises that economic sustainability depends on the size and productivity of the workforce. This workfare paradigm and policies, emphasising the conditionality of support making it high-threshold, do not align well with the low-threshold principle of harm reduction.

As we highlighted above, there are many reasons that may (have) contribute(d) to harm reduction stalling in Europe. In the next section, we will focus more on how the current conceptualisation of harm reduction as an approach to deal with drug use has not been able to sustainably change persistent views on drugs as something inherently immoral. We do this by loosely borrowing from an approach of critical theory. This means that we aim to reveal some of the assumptions underlying the current concept of harm reduction and explore how we may come to alternative views.

So, what exactly are we talking about when discussing harm reduction, anyway? Harm reduction has been historically defined as “a social policy which prioritises the aim of decreasing the negative effects of drug use” [79]. Emerging as an alternative to abstinence-oriented paradigm originating in punitive criminal justice approaches, it emphasises human rights and puts public health in the centre of attention. Focusing on practical approaches, it seeks to reduce the negative health and social impacts of substance use rather than trying to eradicate the use itself [80]. However, this definition is increasingly critised. One of the main problems, starts with the terminology used, which implies a strong focus on ‘limiting’ and ‘negative consequences’ of some behaviour or action [81].

Focus on negative consequences

The concept of harm reduction inevitably draws the attention to negative consequences (‘harms’) that are supposed to be minimised. This focus can inadvertently perpetuate stigma against people who use drugs. By emphasising the harms associated with drug use, negative stereotypes are reinforced.

In recent years, however, there have been an increasing number of voices highlighting not (only) the negative impact of drug use, but that of punitive (drug) policies. Those voices come mostly from activists, retired politicians and other civil society actors (see, for example: [82,83,84,85]. An exception was the recent launch of the Amsterdam Manifesto Dealing with Drugs, initiated by the acting Mayor of Amsterdam Femke Helsma and signed by several other mayors. Still, the mainstream policy making arena uses the concept of harm reduction almost exclusively in the context of drug use.

This is further illustrated by pragmatic utilitarian arguments which are often employed to justify harm reduction and to counter morally driven anti-drug sentiments. It is argued, for example, that harm reduction should be implemented because it is cost-effective and that it is ‘better than doing nothing’. At the same time, harm reduction services are rarely implemented in a purely utilitarian spirit and usually are rooted in strong moral frameworks, driven by social justice, human rights, and compassionate care. The clinical focus on reducing harms is paradoxically undermining the underlying forces that drive promoters of harm reduction who want to increase well-being, empowerment and autonomy of people who use drugs.

Medicalisation

The inherent focus on negative health consequences also contributes to the medicalisation of harm reduction. An expression of this is that measures such as NSP and OAT are often preferred over interventions that address broader social determinants of health and underlying issues, such as poverty, social isolation, marginalisation or trauma. While these issues remain overlooked, and high-risk drug use or drug dependency are perceived as the problem instead of as a response to a problem, harm reduction tends to be used as short-term ‘band-aid’.

Another phenomenon that contributes to the medicalisation is the prevalent addiction-as-(brain-)disease model [86], which frames high-risk substance use and dependency as chronic medical conditions. The disease model has long been internationally praised as a progressive stance on (high-risk) drug use and dependency, as it offers an alternative and less stigmatising approach to those entrenched in morality and criminal justice. Still, this health and pathology-focused approach has its own problems.

First and foremost, while such medical paradigms have resulted in increased legitimacy, funding, and integration of harm reduction interventions into healthcare, they also brought depoliticisation of dependency and have limited attention for social and structural determinants. The disease model individualises dependency by emphasising neurobiological mechanisms while overlooking factors such as poverty, trauma, social inequality and criminalisation of drug use [87].

The medicalisation of harm reduction means that interventions such as NSPs, DCRs and naloxone distribution are increasingly being delivered in clinical settings and managed by medical practitioners. While these programmes started within community-based, grassroots movements, they have been incorporated into healthcare systems, reinforcing the belief that high-risk drug use is best addressed through medical expertise. OAT also aligns with a dominantly medicalised approach, by treating opioid dependence as a chronic, relapsing condition that requires long-term pharmacological intervention. This reflects a medicalised shift where harm reduction is no longer seen as a public health or social justice effort but rather as an extension of clinical addiction medicine.

Service providers also emphasise the health aspects of harm reduction interventions because health interventions are (politically) favoured, and are awarded abundant resources disproportionally compared to other interventions. Examples from many European countries (but also EU funds) show the general highest public expenditure on law enforcement and drug supply reduction, followed by treatment, and with only marginal funds for harm reduction.

In such a context, harm reduction practices that emphasise peer-led interventions and lived experience tend to be marginalised. For example, community-run needle and syringe programmes may lose autonomy when integrated into hospital-based programmes, reducing accessibility for people who distrust medical institutions. In practice, community-based and community-led low threshold services, including programmes addressing housing, employment and income generation, are usually struggling with inadequate funding and capacity and sustainability problems.

While meant to reduce it, framing people who use drugs as suffering from disease also reinforces stigma, as it portrays them as powerless victims in need of curative attention. It implies a hegemonic model of care where the medical professionals ultimately hold the power, which results in paternalistic relationships with service users, clearly conflicting with harm reduction principles with high regard for autonomy, self-determination and empowerment. In other words, it is in conflict with treating people who use drugs as individuals capable of making informed decisions about their life and health.

Finally, the principles of harm reduction are not widely accepted and integrated into medical settings when it comes to people who use drugs and other marginalised groups. The above mentioned top-down relationships between service providers and service users are often focused on compliance and control, disregarding the principle of meaningful participation [88]. Anecdotal evidence from harm reduction service providers also highlights negative attitudes of medical professionals towards people who use drugs, impeding the efforts to ensure the continuity of care; reports of people in vulnerable situations being discriminated against, stigmatised or even denied care are not an exception. The terminology used in addiction science and policies with respect to some sub-groups of people who use drugs - e.g. “hard-to-reach populations” - further shows the lack of willingness and capacity of the health care systems to reach out to people and meet them where they are. Instead, it shifts the responsibility towards people who use drugs, expecting them to adjust to the strict conditions and rules that govern public services. However, the recent shift in discourse from ‘hard-to-reach populations’ to ‘hard-to-access services’ allows for cautious optimism regarding the future direction of service delivery development.

Instrumentalisation

Another issue with the current conceptualisation of harm reduction is how certain aspects of harm reduction are instrumentalised for narrow goals. In the sections above, we have shown how medicalisation has led to an instrumentalisation of harm reduction as something that serves to merely address the prevalence of communicable diseases, for example, ignoring the fact that harm reduction services also benefit their users in broader ways.

Another crucial way in which harm reduction has been instrumentalised, is the idea that its goal is to protect the general population against public nuisance and crime [89]. OAT, for example, has gained popularity not only because it reduced the risk of transmission of blood-borne infections and overdose, but also because it was highly effective in reducing drug-related offences and drug use in public spaces. Safety concerns seem to currently be one of the main discussion points in European cities where establishment of drug consumption rooms is being negotiated. It seems that it is not compassion that convinces the decision-makers but getting people who use drugs out of sight of local communities. Such a view of harm reduction represents broader gentrification processes, aligning with neoliberal urban policies. Such an approach to policy, based on ‘punishing the poor’ through effectively criminalising poverty and marginalised communities, results in increased inequalities, displacement, and social control of residents with lower incomes for the purpose of enhancing the comfort and lifestyle of the middle class [90].

Finally, there are also economic considerations related to instrumentalisation of harm reduction. Research shows that harm reduction services lead to saving significant costs in health care of communicable diseases, for example [91, 92]. The economic arguments very clearly focus on the benefits of harm reduction for the society at large, completely removing people who use drugs and their needs from the picture.

Overall, policies prioritising public health and safety, and economic outcomes may overlook the specific needs of people who use drugs, and focus (mainly) on making them less visible and ‘burdensome’ for the broader society.

Our critique of the situation of harm reduction in Europe may not be earth-shattering. We are aware that some of these arguments have been voiced before, and that in some cases, modest progress has been made to address them. Our intention here, is to bring together the discussions and arguments that have been floating around in the harm reduction space over the last years, hoping we can help move from discussion towards more action. Thus, if - as we have argued above - the acceptance and implementation of harm reduction is stalling for various circumstantial and substantial (conceptualisation) reasons, how do we move forward as a field? How can we look at and think about harm reduction in different ways?

Outside the context of drugs, individuals routinely take measures aimed at preventing harm and improving health and safety. Such activities include getting enough and regular sleep, exercising, and maintaining a balanced, nutritious diet. Such practices can be viewed as harm reduction strategies for navigating the challenges of modern life, though we rarely call them that. There is a prevalent belief that continuous efforts are required to mitigate all the negative influences of our lifestyle on our physical and mental well-being. For instance, prolonged sitting has been widely compared to smoking in terms of harm [93], excessive screen time has detrimental effects on our sleep, stress and well-being [94], not to mention the long list of negative impacts that social media [95] and overeating fat, sugar and salt have on people’s bodies and minds [96].

Modern capitalism has led to proliferation of businesses that are very successful in targeting our limbic system [97] and that exploit the brain’s reward system for generating profit, while sacrificing public health [98]. Paradoxically, a whole other universe of businesses capitalise on protecting people from those harms with wellness and health-oriented products, phone applications to practise mindfulness and subscriptions to content from yoga and meditation influencers. In other words, harm reduction as a philosophy is already interwoven with many aspects of modern life. This begs the question then: what makes the drug field special?

For many individuals, drug use is a similar - albeit not equally socially accepted - form of coping with the challenges of modern life. This need for a coping mechanism can be heightened by trauma, stress, or other mental health challenges. In the long run, this coping mechanism may escalate, even into dependency - in a similar way that shopping or exercising can become compulsive or excessive when used as a distraction or a way to regulate emotions. What makes a difference here is whether the practice is stigmatised or socially accepted - no one condemns a person who went for a run or bought a pair of shoes to treat themselves and elevate their mood. We rarely even think of them as harmful practices that need to be controlled.

As we discussed earlier, harm reduction in Europe has traditionally focused on reducing the health and social risks associated with drug use, having health considerations (e.g., HIV and other communicable diseases) and public nuisance (e.g. open drug scenes) as the point of reference. With a substantial portion of such problems now being largely contained and addressed in Europe, including in international guidelines and national policy documents, what harm reduction really needs at the moment is a fresh start. A recognition that it must look beyond just the harms. To move forward, we need to face the true spirit of harm reduction origins and evolve from a place of compassion to address broader aspects of well-being for people who use drugs. This does not mean that medical or physical health aspects should be disregarded. Indeed, we need to keep reminding policymakers of the successes which can be attributed to harm reduction services, and why services such as needle and syringe programmes should still be scaled up and made more accessible.

What this means is, that in order to ‘reinvent’ harm reduction for the years to come, the field needs to recognise that drug use has (very specific and tangible) benefits and that people use drugs because drugs bring a positive experience, such as helping to achieve psychological balance, pleasure, fun, social fulfilment [99], decreasing anxiety, pain and stress, or improving attention [100] among other benefits [101]. When such positive experiences can be recognised, and acknowledged as valid reasons for using mind-altering substances, we can shift the focus from a deficit-perspective characterised by harms, towards a benefit-oriented perspective aimed at maximising well-being [102,103,104].

To get there, we propose three main pathways for the field. First, a new approach could focus on endorsing a different language, including terms such as ‘mindful consumption’ and ‘benefit maximisation’, which promotes empowerment and safer use practices without merely focusing on harms as the central aspect of drug use.

Second, acknowledging the benefits of drug use alongside related risk should result in a revision of the international drug control system, moving towards reforms including decriminalisation of all controlled substances, responsible regulation and safe supply alongside expanded service offer.

Third, we need to put people who use drugs at the heart and centre of the discussion, including those typically underserved (even within the harm reduction field) - ethnic minorities and migrants, women, youth, diverse and non-conforming SOGIESC^{Footnote 3}, and others experiencing intersecting vulnerabilities. The reconceptualisation or reinvention of harm reduction should put more emphasis on the inclusion of people who use drugs and their leadership in designing, implementing and evaluating services and policies. This should include lived and living experiences, especially facilitating initiatives that can help expand the current understanding of functions of harm reduction, such as providing space where people feel they belong to a larger community, moral support, positive social interactions and breaking social isolation, etc [102]. Following the ‘nothing about us without us’-principle, acknowledging experiential knowledge as valid evidence, well-being maximisation services should be founded on what people who use drugs consider as improving their quality of life. The linkages with other areas of life, including social determinants of health, inequalities and discrimination, should be improved, and the impact of (international) politics on the lives of individuals and communities should not be anymore underrated.

Fourth, and final, in order to deal with parallel or competing social innovations, the field needs to engage and link more with other domains and find common grounds. Harm reduction can sometimes be too isolated and get caught up in its own discussions, themes, voices and public: preaching for the choir. In order to gain a more sustainable basis, harm reduction needs to engage with and relate itself to other fields, including those of justice, mental health, recovery, welfare and other societal issues. In a broader sense, harm reduction needs a more holistic and truly balanced perspective on how drug use fits in modern societies and on the diversity of motives for the use of (illegal) substances and drivers of positive change.