Foreword

It is with great pleasure that I introduce the EMCDDA´s latest Scientific monograph, which provides a state-of-the-art review of the role of harm reduction strategies and interventions. Harm reduction has become an integral part of the European policy debate on drugs, but this was not always the case. Although harm reduction approaches have a long history in the addictions field and in general medicine, our modern concept of harm reduction has its roots in the challenges posed by the rapid spread of HIV infection among drug injectors in the mid-1980s. Initially, there was considerable controversy surrounding the notion that preventing the spread of HIV was of paramount importance and required immediate and effective action, even if this meant that abstinence as a therapeutic goal had to take second place.

In Europe today, that controversy has to a large extent been replaced by consensus. This reflects not only a general agreement on the value of the approach but also recognition that national differences in interpretation and emphasis exist. Harm reduction as a concept is now accepted as part of a balanced approach, an integral element of a comprehensive strategy that includes prevention, treatment, social rehabilitation and supply reduction measures. This, I would argue, is a strong endorsement of the pragmatic and evidence-based approach that European drug policies have come to embrace.

It would be wrong to overstate this position; the drug debate remains an ideological as well as a scientific one. Nonetheless, the evidence that needle exchange and substitution treatment can be effective elements in a strategy to reduce HIV infection among injectors, and importantly that these interventions do not lead to greater harms in the wider community, has had a significant impact on European drug policies and actions. Although it would be wrong to minimise the continuing problem that we face, when comparing Europe to many other parts of the world it is clear that overall our pragmatic approach has borne fruit. Arguments may still exist about the relative role played by different types of interventions, but most informed commentators would now agree that harm reduction approaches have been influential in addressing the risks posed by drug injecting in Europe over the last 20 years.

This is, then, an appropriate moment to take stock of existing scientific evidence on harm reduction and consider the issues that we will need to tackle in the future. The evidence for some harm reduction interventions is relatively robust. For others, methodological difficulties make generating a solid evidence base difficult, and the current scientific bases for guiding policymaking need to be strengthened.

The assertion that the concept of harm reduction is an accepted part of the European drug policy landscape does not mean that all interventions that fall under this heading are either widely supported or endorsed. Many areas of controversy remain, and one purpose of this monograph is to chart where the current fault lines now lie, with the hope that future studies will provide a sounder basis for informed actions. Moreover, and perhaps more importantly, the drug problems and issues we face in Europe today are very different to those we struggled with in the past. HIV remains an important issue, but it is no longer the predominant one. From a quantitative public health point of view, drug overdose, HCV infection, and other psychiatric and physical co-morbidities are becoming of equal or even greater importance. In addition, drug injecting levels appear to be falling and patterns of drug taking are become more complex and are increasingly characterised by the consumption of multiple substances, both licit and illicit.

What role will harm reduction have within this new landscape? This monograph begins to explore that question, as we consider how harm reduction strategies may be a useful component of our approach to the challenges that drug use in twenty-first century Europe will bring. I strongly believe that in taking drug policy forward we have a duty to learn from the past, and that ideological positions should not stand in the way of a cool-headed analysis of the evidence. In the future this is likely to become imperative both to those who instinctively support harm reduction approaches, and to those who instinctively oppose them. This monograph makes an important contribution to the debate by highlighting where we are now, and considering how we have got here. It also draws our attention to some of the challenges that lie ahead, if we are to understand the role and possible limits of harm reduction approaches to future European drug policies.

Wolfgang Götz
Director, EMCDDA