1 A. Context Harm reduction has been widely introduced as a public health policy concept in the 1980s in the context of the HIV epidemic and has been utilized constructively in the context of global responses to preventing the transmission of HIV and other bloodborne diseases among people who inject drugs. Over the past three decades, measures under the umbrella of harm reduction have expanded. Today, these measures go beyond the scope of HIV prevention and care and beyond merely reducing harms associated with injecting drug use. Many governments have incorporated a range of interventions into their respective national drug strategies. Already in its 2009 discussion paper, UNODC pointed to the fact that harm reduction is often made an unnecessarily controversial issue as if there was a contradiction between prevention and treatment on one hand and reducing the adverse health and social consequences of drug use on the other.1 Ideological leanings, corporate mandates, intended use, national situation and priorities have all played a role. The controversy has been exacerbated by the linking of the term harm reduction with legalization in some instances. UNODC has been working with Member States and partner organizations for over two decades to develop and improve national health responses to non-medical use of controlled substances. The response includes evidence-based drug prevention programmes, drug treatment and care services and harm reduction interventions. Within its mandate, UNODC’s harm reduction work focuses on minimizing the adverse health and social consequences of drug use2 such as substances use disorders, HIV/AIDS, hepatitis, other infectious diseases, and overdose. Harm reduction can be contextualized. This paper notes harm reduction as an integral part of a comprehensive health response to non-medical use of controlled substances, embedded in a recovery-oriented continuum of care. In that context, and within the scope of applicable international legal framework on drugs, harm reduction measures save lives and improve health outcomes for the individuals, families, and population at large. As such, the full recovery-oriented continuum of care should be evidence-based, available, accessible, and affordable to all people who use drugs and with drug use disorders. B. Harm reduction and international drug policy commitments State Parties to the Single Convention of 1961 as amended and those to the 1971 Convention are required to give special attention to and take all practicable measures for the prevention of abuse of narcotic drugs and psychotropic substances and for the early identification, treatment, education, after-care, rehabilitation, and social reintegration.3 Harm Reduction Policy Note November 2024 2 Since 2009, governments have agreed on commitments to work towards reducing harms associated with drug abuse in all major policy documents. In the 2009 Political Declaration, Member States’s action was to develop, review and strengthen comprehensive and integrated demand reduction policies and programmes, aimed at promoting health and social well- being among individuals, communities and families and reducing the adverse consequences of drug abuse for individuals and a society as a whole.4 This commitment was reaffirmed in the outcome document of the 2016 UN General Assembly special session on the world drug problem and subsequently in the 2019 Ministerial Declaration5 as well as the high- level declaration on the 2024 midterm review6. The need to scale up public health actions to improve access to and quality of treatment has been included also in the 2030 Agenda for Sustainable Development. Target 3.5 of UN sustainable development goal 3 sets out a commitment by governments to strengthen the prevention and treatment of substance abuse, in addition to target 3.3 referring to ending the AIDS epidemic and combating viral hepatitis, target 3.4 on preventing and treating non-communicable diseases and promoting mental health, target 3.8 on achieving universal health coverage and target 3b with its reference to providing access to affordable essential medicines.7 In the United Nations system common position supporting the implementation of the international drug control policy through effective inter-agency collaboration commits to stepping up joint efforts and supporting each other in the promotion of ‘increased investment in measures aimed at minimizing the adverse public health consequences of drug abuse, sometimes referred to as harm reduction, which reduce new HIV infections, improve health outcomes and deliver broader social benefits by reducing pressure on health-care and criminal justice systems’.8 The term “harm reduction” was used for the first time in a parliamentary document in resolution 67/4 entitled “Preventing and responding to drug overdose through prevention, treatment, care and recovery measures, as well as other public health interventions, to address the harms associated with illicit drug use as part of a balanced, comprehensive, scientific evidence- based approach” which was adopted by vote at the 67th session of the CND in March 2024. “Harm reduction” was used in the context of encouraging innovative approaches and measures aimed at minimizing the adverse public health and social consequences of the non-medical use of drugs, including the prevention and response to drug overdoses. C. Risk of harms associated with drug use The three international drug conventions have been concluded out of concern of the international community for the health and welfare of humankind, and for the public health and social problems that result from the non-medical use of controlled substances, while being cognizant of the importance these substances play in medical and scientific fields. It is with that in mind that the World Health Organization has been mandated by the conventions to review narcotic drugs and psychotropic substances for their potential to cause harm to one’s health, with the ultimate decision-making power on the control status of each substance vested in governments who are members of the Commission on Narcotic Drugs.9 The use of narcotic drugs and psychotropic substances outside of the medical context and/or without medical supervision is associated with significant risks of health- related harms. According to the 2024 World Drug Report, 1 in 18 people worldwide are estimated to have used a drug at least once in 2022. That same year, 1 in 81 people worldwide were suffering from a drug use disorder and out of those, only about 1 in 11 received drug treatment globally. Single or infrequent use bears the risk of adverse or fatal outcomes, including due to adverse reaction to the substance or its adulterants, overdose, or accidents. At the same time, it is estimated that at least 8% of 3 individuals who start using drugs will develop a drug use disorder over time10. Drug use disorders include harmful pattern of use and drug dependence, which has been recognized as a complex multifactorial health disorder that often takes the course of a chronic and relapsing disorder11. When left untreated, drug use disorders increase morbidity and mortality risks for individuals and can trigger or increase existing substantial suffering and impairment in personal, family, social, educational, occupational or other important areas of functioning. They are associated with significant costs to society due to premature mortality, increased health care and social welfare expenditure, lost productivity, and costs related to criminal justice. There is an increased risk of fatal overdose, but also cardiovascular and liver problems, mental health disorders co-morbidities, violence and suicides.12 In addition, people who inject drugs are exposed to additional series of risks, including, but not limited to, blood-borne infections such as HIV or hepatitis C virus (e.g. due to the sharing of blood- contaminated injection equipment).13 In 2022, out of all people who used drugs, an estimated 4.7 per cent injected drugs (13.9 million), with 2 per cent living with hepatitis C (6.8 million) and 0.6 per cent with HIV (1.6 million). Preventing drug use As described above, any internationally controlled substance used outside of medical setting in any form or way carries the risk of health-related harms and other negative consequences. The most effective way to avoid any risk of harm associated with non-medical use of controlled substances is to prevent or delay initiation and consumption of drugs in the first place. In broader terms, drug use prevention aims to ensure the healthy and safe development of children and youth and the health and wellbeing of adults. Effective prevention contributes significantly to the positive engagement with their families and in their schools, workplaces and communities. Drug use prevention, when based on evidence, is effective and represents a long- term investment in the overall health and wellbeing of peoples of all ages, respecting, protecting and promoting their human rights and overall welfare. However, in view of the complexities of the world drug problem, and as in the case of any health disorder, no effective prevention intervention, policy or system can be developed or implemented in isolation. Subsequently, local and national prevention systems should be embedded and integrated in a comprehensive, balanced and health-centred system, which includes also recovery-oriented treatment of drug use disorders, while at the same time making effort to reduce harms associated with non- medical use of controlled substances, and includes law enforcement and supply reduction.14 D. Responding to drug use and reducing harms The international drug conventions do not use the term “harm reduction”. Instead, the 1988 Convention obliges State Parties to adopt appropriate measures aimed at eliminating or reducing illicit demand for narcotic drugs and psychotropic substances, with a view to reducing human suffering […] 15 Drug use prevention focuses on people who have not initiated drug use. Addressing harmful drug use or dependence for those who have already initiated the use of drugs is the primary goal of treatment of drug use disorders in a continuum of care. Because drug use disorders often take the course of a chronic and relapsing disorder, services need to be prepared to work with patients over the long term – often, but not always, for years and sometimes during a patient’s entire life – maintaining contact, offering crisis interventions and support when needed and at different levels of intensity16, yet always with a view to the highest 4 attainable standards of health and patient autonomy. Under the recovery-oriented continuum of care, harm reduction measures are needed for people who use drugs who for various reasons are currently not able to stop the use of drugs, despite being exposed to the various risks of health-related harms. Such measures may include a range of non-conditional, low- threshold and evidence-based interventions, for example access to clean needles for people injecting drugs, access to emergency overdose management (including through take home naloxone programmes) and provide an important link with evidence-based treatment of drug use disorders, including opioid agonist treatment for people with opioid use disorders. Sustainable recovery is possible. Recovery is the ultimate goal at every stage of the treatment continuum, at every stage of the disorder and across a variety of settings: from low threshold outreach services to intensive inpatient or residential treatment. UNODC/WHO International Standards for the Treatment of Drug Use Disorders, 2020 Implementing a ‘no wrong door’ principle means that people who use drugs and people with drug use disorders receive relevant and non-judgemental support and access to comprehensive therapeutic interventions regardless of their entry point in the health or social system17 and regardless of the initial health and social needs that bring them in contact with the support system. In other words, and at its core, harm reduction, while protecting people who use drugs and their families from infectious diseases and other adverse health and social consequences through targeted interventions, can support a crucial voluntary step in the direction of improved health – with a view to recovery – offering timely access to evidence- based and person-centred drug dependence treatment as well as medical care and rehabilitation.18 Additionally, harm reduction interventions, along with and part of the continuum of care and treatment services, when connected appropriately to the health care system, may be cost-effective and can provide early identification, data and knowledge of the patterns of drug use and availability of drugs on the local illicit market. The International Narcotics Control Board, an independent body mandated by the international drug conventions to monitor compliance of State Parties with the treaties, acknowledged already in 1993 the importance of certain aspects of harm reduction as part of a comprehensive drug demand reduction strategy, but such programmes should not be carried out at the expense of other important activities to reduce the demand for drugs, such as prevention.19 E. Examples of harm reduction services There are various measures that have been implemented in different regions and countries and found to be effective in reducing harms associated with the non- medical use of drugs, including saving lives of people who use drugs, especially when adapted to national and local situations priorities and cultures, while not increasing use. For example, in some countries where opioid use disorders are the most prevalent, health systems have implemented psychosocially assisted pharmacological treatment of opioid use disorders, such as opioid agonist maintenance treatment. Opioid agonist maintenance treatment (OAMT) programs using methadone and/or buprenorphine have been found to be effective not only to reduce drug use and promote recovery, but also to decrease injection and decrease mortality both, from natural causes and opioid overdoses, while at the same time reducing public health costs. OAMT is a key intervention recommended by both the UNODC/WHO International Standards for the Treatment of Drug Use Disorders, and by the UNODC/WHO/UNAIDS publications on preventing HIV/AIDS and other infectious diseases among people who use drugs20. 5 Needle syringe exchange programmes have been found in scientific literature to be an effective tool to address transmission of HIV infections, hepatitis C and other blood-borne infections among people who inject drugs, while not increasing drug use. Additionally, the WHO-UNODC-UNAIDS Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users outlines a comprehensive package of nine interventions specifically aimed at the prevention, treatment and care of HIV infections among people who inject drugs. Finally, countries have been implementing take-home naloxone programmes which are proven to be effective in the management of overdoses and have been recommended by WHO, while not increasing drug use and with demonstrated feasibility including in low- and middle-income countries.21 Additionally, some countries have also developed naloxone dispensing programs in community settings, extending beyond home use. In many places, the delivery of harm reduction services is undertaken in community-based settings and by civil society organizations, including peer-led organizations. F. Conclusion Evidence-based drug use prevention in line with international standards and consistent with international law is the most effective way to avoid any harm associated with drugs in the first place. A comprehensive health response requires a full continuum of care. Harm reduction interventions encompass measures for people who use drugs and people with drug use disorders that have been found by scientific evidence to effectively prevent, reduce or minimize the adverse public health consequences of drug use, as part of a people-centred and recovery-oriented continuum of care, thereby reducing drug- related mortality and morbidity. Ensuring access to such measures when tailored to national needs, resources and priorities as part of a recovery-oriented continuum of care, can save and improve the lives of people who use drugs and people with drug use disorders and can contribute to the overall health and security of communities at large. When prioritising and implementing any such measures, Governments must be cognizant of their commitments pursuant to existing international drug conventions, which require limiting the use of controlled drugs to medical and scientific purposes only. The world drug problem is complex, and challenges posed by drugs have wide-ranging adverse impacts on security, human rights and development. The multifaceted nature of the problem requires a comprehensive and balanced approach that includes efforts promoting health, human rights, including equality and non-discrimination, law enforcement efforts ensuring people’s security and sustainable development. UNODC will continue providing legislative, policy and technical assistance to implement strategies that address all the various challenges associated with drugs. From a health perspective, UNODC remains committed to assisting Member States, upon request, to implement an evidence-based drug use prevention strategy and put in place a larger comprehensive and holistic recovery- oriented continuum of treatment and care services for people who use drugs and people with drug use disorders, including harm reduction measures tailored to specific circumstances, in line with international law.