Countries in Western Europe were among the first to adopt harm reduction services. This long tradition puts harm reduction in a favourable position, both in terms of policy inclusion and funding, compared to other regions around the globe. Core harm reduction services, including needle and syringe programmes (NSP) and opioid agonist therapy (OAT), are available in most Western European countries. However, according to the latest available data, only Luxembourg, Norway, and Spain meet the World Health Organization (WHO) 2020 targets for Hepatitis C elimination of providing at least 200 syringes per person who injects drugs per year and having 40% of the population of opioid users on OAT. In Western Europe, one of the most prevalent barriers to accessing harm reduction services in general, is uneven distribution of services within countries. People who use drugs living in rural areas are particularly underserved in many countries across the region. This is a problem, for example, in Belgium, Germany, Ireland, Italy, Portugal, Scotland, Spain, Sweden, Switzerland, and the United Kingdom. Unfortunately, there were no changes in this regard since our 2020 report.

The number of countries in Western Europe in which NSPs operate remains unchanged since the Global State of Harm Reduction 2020, with services available in 20 countries: all countries in the region except Turkey (and no data on Andorra, Liechtenstein, Monaco, and San Marino). Although the first months of the COVID-19 pandemic brought serious disruption to harm reduction services in the region, most countries in Western Europe were able to maintain NSP services during COVID19. Between 2019 and 2020, in relation to the COVID-19 measures introduced, the number of syringes distributed fell by more than 10% in five countries (Greece, Ireland, Malta, Portugal, and the United Kingdom), while there was a slight increase in Austria, Norway, and Sweden, and no change in other countries in the region.

However, COVID-19-related disruptions in harm reduction services had adverse effects on the health of people who use drugs. Pandemic-related restrictions reduced outreach activities and low threshold harm reduction service capacities in general, leading to reduced HIV and hepatitis C testing availability in the region. User groups providing peer-to-peer NSP and outreach services were essential in bridging the gap in harm reduction service coverage during COVID-19.

Though COVID-19 still affects harm reduction services, in 2021, some cities (Copenhagen, London, Paris, and Rome) reported that daily practices of harm reduction services were no longer affected by the pandemic and, overall, there were fewer reductions in service provision after 2020. Nevertheless, reduced opening hours and other limitations in NSPs’ capacity reduced access to harm reduction commodities like syringes, and harm reduction services had to be adapted through various means to counter COVID-19-related disruptions. For example, the expansion of peer-to-peer syringe distribution (with more peer-to-peer NSP services) or the implementation of mail delivery of injecting equipment in at least four countries (Austria, Belgium, Italy, and the United Kingdom).

Switzerland is among the few countries across the globe where most harm reduction services are available, from NSP, OAT, and drug checking, to heroin assisted treatment in and out of prison. Professionals working in the field of harm reduction and substance use were unanimous in their opinion that all harm reduction services available in the country should also be accessible for young people who use drugs. However, access to harm reduction services in the country for young people who use drugs under the age of 18 is limited, with lower coverage across harm reduction services compared to adults in general. For example, DCRs are strictly for people who use drugs over the age of 18. Anonymity and self-declared age put NSPs in a grey zone with regional differences. Experts working in the field of harm reduction highlighted that this limited availability is rooted in local policies and the lack of political will, as the Swiss law regulating drug use and addiction related services at the federal level impose age related restrictions only on HAT, where the admission criteria is being at least 18 years old. Though federal laws set the framework, cantons have great autonomy due to the fact that they have their own constitutions and laws, and run their own educational systems, social services, and police. Therefore, implementation, policies, and funding of services can differ greatly from canton to canton. For example, drug checking services are available in six cities (Basel, Bern, Geneva, Lucerne, Olten, Zurich), while only one drug checking service in Zurich is available officially for people under 18.

Another aspect of Swiss drug policy important to the issue of harm reduction for young people who use drugs, is the concept of early detection (Früherkennung). This policy regulates the role and responsibility of people working in education, social care, the health system, and law enforcement when drug use-related problems are suspected in children and young people. Though harm reduction is included in the policy as one of the interventions that can be offered depending on the situational assessment, harm reduction services should be explicit about their role in early detection to avoid undermining the trust of their clients. For example, drug checking services developed guidance to integrate early detection into their work and defined the possible actions for clients under the age of 18: providing information about the risks of drug use under 18 and about the related youth protection regulations. However, the guidance also clarifies that early detection can be integrated to drug checking services insofar as it does not endanger the relationships with their clients.

Nevertheless, in practice, young people who use drugs might access harm reduction services in Switzerland because most services are anonymous. For example, DILU, a drug checking service in Lucerne, is an anonymous service where age is self-declared, so anyone using the service can access sterile syringes at the premises. A similar situation was reported in Bern, as the NSP is anonymous and, in theory, accessible for all. The contradiction between anonymity and age restriction can lead to inconsistencies. For example, in Vaud, young people who inject drugs can access sterile injection equipment, but they are not allowed to use the local DCR. They therefore cannot inject under professional supervision, unlike people who inject drugs over 18 years of age.

ACCESS TO NSPS

Young people who use drugs accessing NSPs is a grey zone, with substantial differences between cantons. For example, young people who inject drugs in Lucerne can access syringe dispensing machines, but not the NSP.
Reports indicate that young people cannot access NSPs in Basel, and they have to ask older people who inject drugs for equipment. The situation is similar in Solothurn, where under 18s are not admitted to NSPs. In Bern, NSPs are open for young people who inject drugs, though it is not clear to what extent this age group uses the service. In addition to general barriers, such as uneven geographical distribution of services with difficult access for people living in rural areas, lack of political will and appropriate funding for NSPs for young people is hindering access.

ACCESS TO OAT

Access to OAT seems to be an area where the difference between adults and young people who use drugs is smaller compared to other harm reduction services. This relatively good coverage can be attributed to the perceived low demand for this programme among young people. According to expert opinions, cases where OAT is needed in this age group are very rare, though the issue of data availability was also raised. In general, access to OAT for young people is not automatic. For example, in Grisons, cantonal guidelines allow OAT only for adults (over 18), but exceptions can be made if OAT is needed, with training for general practitioners also available. In Vaud, only those over 18 can access OAT, but the cantonal doctor can authorise OAT from the age of 16. Scepticism and reluctance among professionals in prescribing OAT medications to young people was mentioned as a specific barrier in access to OAT.

ACCESS TO DCRS

Young people cannot access DCRs in Switzerland. There are no regional differences, as age limits prevent access in all ten cities where DCRs are available in the country without exception.

ACCESS TO SAFER SMOKING EQUIPMENT

Generally, safer smoking equipment (SSE) is available at DCRs, meaning that age restriction is a serious barrier for young people who use drugs in accessing such harm reduction commodities. Outside of DCRs, access is possible: young people can buy SSE at specialised shops and may have access at festivals if SSE is distributed there.

ACCESS TO DRUG CHECKING

Young people who use drugs can access the drug checking service in Zurich but, elsewhere, people under 18 are not formally permitted to use the service. However, experts highlighted that drug checking services are anonymous, and age is selfdeclared. The first step in using drug checking services is an interview where proof of identity is not necessary: the interview is based on mutual trust, and the staff won’t check the information provided. This is a pragmatic practice, prioritising the need for the service and building trust in the community over age restrictions. Besides age restrictions, young people who use drug checking services face the same barriers as others: uneven geographical coverage of drug checking services (they are available only in big cities), and funding issues regarding available testing capacities. A lack of funding creates a significant barrier to access and, in particular, service availability. For example, in Basel, the drug checking service can take ten samples every 2 weeks, which is not adequate for the need for drug checking in the city. A recent analysis of client questionnaires highlighted the underrepresentation of young people among people who use drug checking services in Switzerland: of the 564 respondents, only 29 were under 18. Age disaggregated data shows higher rates of recreational use of benzodiazepines and prescription opioids, and higher rates of combined use of alcohol and benzodiazepines among under 18s compared to over 18s. Finally, the report emphasised the need for access to cannabis drug checking for young people who use drugs, as cannabis is the most frequently used substance in this population.

Young people who use drugs are a vulnerable sub-population of people who use drugs, and unrestricted access to appropriate harm reduction services is therefore crucial. Swiss experts consulted for this report unanimously agreed on the importance of providing young people access to available harm reduction services without age restrictions. The most important issues hindering the implementation of harm reduction for young people were the lack of political will and funding for young person-oriented harm reduction services, and the bias towards offering prevention and treatment to under 18s when drug use is suspected. Disparate policies for young people under 18 is also a significant issue.
Bureaucratic burdens like requiring case-by-case authorisation to gain access to services, or restricting young people’s access to harm reduction commodities, lead to higher barriers compared to adults, thereby creating a more unsafe environment for young people who use drugs. Additionally, different local polices can further complicate the implementation of services and can lead to geographical inequalities in availability of services.

The most important issue regarding access to harm reduction for young people who use drugs is the availability of specialised services tailored specifically to this age group. Both professional opinion and literature are unequivocal: all available harm reduction services should be available to all people who need it, young people included.

However, there is an important caveat: existing harm reduction services designed and implemented focusing on adults who use drugs are not appropriate for young people who use drugs. We should develop new harm reduction services that ensure that young people are meaningfully involved throughout all aspects of programme design, implementation, and evaluation, giving young people agency and autonomy over decision-making processes.