Drug Checking – European Harm Reduction Network

Last week our Head of Policy, Roberto Perez Gayo, participated in the Congress organised by UNAD ‘La red de atención a las adicciones’ in Oviedo, Asturias, to reflect on current developments and challenges in the provision of care and support to people who use drugs in Spain.

Under the banner “A journey through the pathways to addiction care with a gender perspective”, the Congress dedicated an important space to examine the public health challenge posed by synthetic opioids. Together Mireia Ventura, director of Energy Control -ABD‘s Analysis Services, and Roberto Perez Gayo participated in the panel “Nitazenes and other synthetic drugs: a rigorous analysis for drug dependence care professionals”.

In their presentation, the pair of speakers demonstrated how scientific evidence dismantles the media alarm about some substances, such as fentanyl. Nitazenes, on the other hand, were highlighted as a reality already present in some countries, where synthetic substances are beginning to be used as adulterants of other drugs, considerably increasing the risk of overdose due to their consumption. Faced with such risks, both Perez Gayo & Ventura highlighted the role of harm reduction, and more specifically of supervised consumption rooms and drug checking services to identify emerging trends in the drug market and increase care and protection for marginalised and underserved people who use drugs.

The event was also attended by different institutional representatives such as the Government Delegate for the National Plan on Drugs, Joan Ramón Villalbí Hereter, and the General Director of Public Health and Mental Health Care of the Health Service of the Principality of Asturias, Ángel José López Díaz. During his speech, the Government Delegate for the National Plan on Drugs referred to the first responses that were given to addictions, recognising that they came “from civil society” in the form of the first organisations of family members of people who use drugs. Villalbí praised the role of those first organisations, which “started their work to find each other” and “helped public administrations not to make mistakes and to do better” in the face of the consequences of drug consumption.

Following the event, Perez Gayo & Ventura gave an interview to Agencia EFE, a leading news agency in Spanish, which gained coverage in several news platforms including infobae and deia.

Photo credit: UNAD

The video is the recording of the webinar organised to celebrate the core publications for the C-EHRN Civil Society-led Monitoring of Harm Reduction in Europe that took place on the 7th of March.

The event brought together four volumes of the 2023 Data Report:

Moderator: Rafaela Rigoni (C-EHRN)

Speakers:
Iga Jeziorska (C-EHRN) – Essential Harm Reduction Services
Tuukka Tammi (THL) – Eliminating Hepatitis C in Europe
Daan van der Gouwe (Trimbos) – New Drug Trends
Guy Jones (TEDI) – Drug Checking Observations and European Drug Checking Trends via TEDI

Following a new format, Correlation – European Harm Reduction Network’s Civil Society-led Monitoring of Harm Reduction in Europe 2023 Data Report is launched in 6 volumes: Hepatitis C Care, Essential Harm Reduction Services, New Drug Trends, Mental Health of Harm Reduction Staff, TEDI Reports and City Reports (Warsaw, Bălţi, Esch-sur-Alzette, London, Amsterdam). The Executive Summary can be accessed here.

In 2023, C-EHRN and its members assessed the state of essential harm reduction services in European cities for the fourth time as part of the Civil Society-led Monitoring of Harm Reduction In Europe, with 35 cities responding to our survey in 30 countries. You can now download the resulting publication, Essential Harm Reduction Services: Report on Policy Implementation for People Who Use Drugs, and read the interview with Iga Jeziorska, C-EHRN’s Senior Research Officer and the primary author below.

Which type of harm reduction services are most lacking in the cities that contributed to the report?

The ones that are not that well established are those not related to the prevention of infectious diseases as closely as needle and syringe programmes and are not aiming to minimise injecting use like opioid substitution treatment does. Namely, drug consumption rooms and drug checking are lacking in Europe overall the most. This underdevelopment of DRCs and drug checking may become a serious problem, especially in the context of the opioid crisis that we might be facing very soon.

Another problematic issue is harm reduction services in prison. Except for opioid agonist treatment (OAT), this is also an area where there are very big gaps in the service provision in terms of harm reduction. OAT is officially available in prison in most cities, but that doesn’t mean that it is easily accessible everywhere. We know that in Budapest, Hungary, for example, it is theoretically available, but there are no records of people using the service, and definitely not because there are no people who use opioids in prisons.

What would you highlight regarding the barriers in the outreach of harm reduction services based on the findings?

Funding, lack of political will and lack of or insufficient involvement of people who use drugs in services were reported as the main barriers to reaching out to specific subgroups of people who use drugs. Of course, all of these aspects are related to one another. Funding is an evergreen topic which is always there, and the lack of or insufficient funding is a direct consequence of the lack of political will. If there was political support for harm reduction, there would have been funding as well.

Are there any main differences in the availability, accessibility and quality of the services between the cities of the focal points?

On the one hand, we have opioid agonist treatment, needle distribution programs and all of the infectious diseases-related services, such as testing and treatment. These are well-developed in general in terms of availability, accessibility and quality.

On the other hand, there are some more innovative services that maybe, as I said before, are not that much connected, at least in the minds of the general public and the policymakers, with direct prevention of infectious diseases. These services that go beyond the ‘traditional’ harm reduction and focus primarily (but not exclusively) on overdose prevention are the drug consumption rooms (DCRs) and drug checking. These are in general more available in Western European countries. Snorting kits, kits for smoking, and fentanyl strips are also less available and accessible.

There are no DCRs in Central-Eastern Europe and Western Balkans. They are quite well developed as a network in Germany, Switzerland, Spain and maybe two other countries. In some countries, such as Greece or Portugal, there are one or two services. Drug checking is similar. There is a clear division between Central-Eastern Europe and Western Balkans on the one hand and Western Europe on the other, in terms of service scope, service accessibility, low versus high threshold of various services, and the very service existence in the first place.

Harm reduction is chronically underfunded everywhere, but that means something different in the West and in Eastern-Central Europe and Western Balkans. In the East and Southeast, underfunded means that an insufficient number of services are operating or – in extreme cases – they are not funded for several months in a year because there are gaps between grants. Underfunded in the West seems to mean mostly that services don’t have enough funds to develop the offer, scale up activities and broaden their scope. We can also see that in the West, in general, services are more integrated into the health and social care systems, and in the East, they are more standing alone. One of the worrying phenomena that we observed this year, however, is the extremely low availability and accessibility of social integration services, such as housing, income generation and employment, and legal support. Furthermore, for the two latter types of services, we’ve observed significant deterioration in availability over the last couple of years.

We also know from the previous Monitoring edition that there are divisions between the urban and rural areas. Services are focused and concentrated in big cities, and they are lacking in the countryside. The question is also to what extent they are needed in the rural areas, as we also know that the concentration of people who use drugs is also in bigger cities. Some level of services is necessary in rural areas, but what level of availability and accessibility is necessary is something that would require additional assessment.

How do you think that harm reduction organizations can use the report?

We are trying to follow the requests of the Focal Points in terms of the focus and to make our assessments address the topics that are important to people at any given moment.

When it comes to using the report in advocacy efforts, harm reduction organisations can use it to highlight cities and countries that can serve as good practice examples, like Bern or Amsterdam, with holistic, integrated services. The report is a general overview of the situation in Europe, and it can serve as a starting point in orienting oneself in what’s happening in different cities.

In the context of talking to policymakers, the report – in conjunction, for example, with the European Drug Strategy, which calls for scaling up harm reduction services – can help to showcase the gaps in harm reduction services at the city level compared to what is declared by a country or a city in official policy documents. This can potentially be quite a powerful tool in helping organisations in their advocacy efforts.

What do you think is the added value of civil society-led monitoring in comparison with other types of monitoring done by major agencies?

One of the added values is trust and the hands-on experience of our Focal Points, and the related kind and detail of the information collected. Civil society organisations are close to people who use drugs, and people who use drugs trust them enough to share honest information. For example, from the point of view of drug checking, this means that we can have very detailed information on how people use drugs, what drugs they use, in what contexts, etc. This is in sharp contrast, for example, to wastewater analysis that can tell us how much cocaine is in the wastewater but cannot provide information about the people who used it and the circumstances, if they used it at all.

For our monitoring, we collect data in a way that is contextualised. This is quite different from data collected, for example, by the national Reitox focal points that focus on the existence of services and perhaps the number of services.

On the other hand, when we ask to what extent particular types of services are available to specific communities and to what extent they are accessible, we implicitly include the element of the needs. That is this contextualisation of data that I mentioned, which includes additional information. For example, seven services existing in one city can mean something completely different than the same number of services in another city because the needs are different, and this is what we address with our monitoring. This is one of the main values of C-EHRN monitoring compared to other data.

Another point is focus on the city level. Most data is collected by European agencies and country governments is collected at the national level. Our data is collected at the city level, which is important primarily because the implementation of drug policies is done mostly at the local level in European countries.

We are also quite timely with our data. We are now at the beginning of 2024, and we are reporting on the data between 2022 and June 2023, a bit over one year of delay in reporting. This is also something that makes us different, less bureaucracy and resulting quicker data processing give us the possibility of being quicker with our reporting.

Would you pick one graph that you find significant and explain why it is relevant?

All of them are significant in their own way. What I would suggest is Figure 9 on service delivery for ageing people who use drugs, a category that we introduced last year. Ageing people who use drugs are becoming a more and more significant group among the clients of harm reduction services all over Europe. The people for whom the first harm reduction services were established in the 1980s are ageing, and there is an increasingly recognised need for developing and adjusting services to their needs, which significantly differ from those of the other subgroups, and there hasn’t been sufficient focus on them so far.

Another question that we asked last year for the first time is the extent of involvement of people who use drugs in service governance, service implementation and evaluation. There are very few cities where people with living and lived experience are involved in the governance of services. They are involved in implementation and, to some lesser extent, in evaluation but not really in the governance of organisations and services. This is something that we need to keep monitoring. The debate about community involvement, community empowerment and community-led services is very lively across the continent, but we are still not there yet in terms of practice of harm reduction services functioning. We should keep a close eye on this and possibly combine the monitoring with capacity-building efforts to improve the involvement of people with lived and living experiences in services.

To monitor new drug trends in Europe and complement the information gained through focus group discussions, C-EHRN’s 2023 Civil Society-led Monitoring of Harm Reduction in Europe includes two reports via the Trans European Drug Information Network (TEDI), drawing from data collected from drug checking services.

The snapshot report contains information from the first two quarters of 2023 for each drug where significant drug checking data exists in Europe. These are amphetamine, cocaine, ketamine, MDMA, methamphetamine, heroin, and general pages for benzodiazepine sedatives, novel stimulants and novel opioids. The multi-year report contains data since 2018 and aims to show the changes in drug markets over time.

Download the snapshot report and the multi-year report and read the interview with Guy Jones, TEDI’s data manager and the primary author below!

How do you see the role of drug-checking services?

Drug checking services are an invaluable tool that are able to both monitor trends while also responding in real-time to mitigate the health impacts that emerging trends may have. They have unique insight into new trends as they can talk directly to service users to understand the real drivers of new consumption patterns and understand whether people are deliberately seeking out a new drug or if it is simply being added by manufacturers.

What are the main adulterants and risk trends in the European drug market based on the data you

analysed from 2023?

2023 has seen the market recover to pre-COVID trends of increasing strength of some drugs, presenting a significant risk that service users regularly underestimate.

Alongside this, there is major concern about the potential for changes in the heroin supply from Afghanistan and whether this could lead to a move to synthetic opioids as was seen in North America over the last decade.

Would you highlight any differences in drug preferences in the past year between European countries based on the findings?

Not really. Europe has a fairly consistent supply throughout the continent, however, there are consumption patterns that exist more in certain countries, such as a slightly higher prevalence of amphetamine in Eastern Europe.

Based on the data you analysed, what are the most significant changes in the drug markets over time?

When I first started working in the field, I never expected that we would find ourselves in a position where the major threat in the cocaine supply was because it was so strong and unadulterated.

How do you think harm reduction organisations can use the reports?

The reports are often extremely interesting to service users and they can serve as an invaluable starting point for discussions about risk from adulteration but also about the role that tolerance plays in a service user’s experience of a drug.

How do you think data from drug-checking services can be combined with other kinds of research, such as the data from insights from focus group discussions conducted as part of C-EHRN’s 2023 Civil Society-led Monitoring of Harm Reduction in Europe?

Data is extremely useful for “calibrating” qualitative observations to help us understand whether they are accurate reflections of reality and tuning how we collect qualitative data to get more accurate information, faster.

Would you pick a graph that you find significant and explain why you find it relevant?

Not a chart, but a number from the snapshot report. The median heroin sample contains just 17% purity, with huge variation. This variation already creates a risk for people who use heroin but it also means that organised groups wouldn’t have much to do to create a product that is much stronger and substitutes heroin for synthetic opioids. Experience shows us that law enforcement won’t reduce the health risk from this.

To celebrate the core publications for the C-EHRN Civil Society-led Monitoring of Harm Reduction in Europe, we invite you to join the roundup webinar on the 7th of March, 1:00 PM (CET)!

The event will bring together four recently published volumes of the 2023 Data Report:

Essential Harm Reduction Services: Report on Policy Implementation for People Who Use Drugs
Eliminating Hepatitis C in Europe: Report on Policy Implementation for People Who Inject Drugs
New Drug Trends: Insights from Focus Group Discussions
Drug Checking Observations: Q1 & Q2 2023 Snapshot Report and European Drug Checking Trends via TEDI

During the interactive webinar, the primary authors of each publication will join Rafaela Rigoni, C-EHRN’s Head of Research, to debate positive developments and the main advocacy asks arising from the reports’ conclusions. We’ll invite participants to interact via a Q&A session.

Moderator:

Rafaela Rigoni (C-EHRN)

Speakers:
Iga Jeziorska (C-EHRN) – Essential Harm Reduction Services
Tuukka Tammi (THL) – Eliminating Hepatitis C in Europe
Daan van der Gouwe (Trimbos) – New Drug Trends
Guy Jones (TEDI) – Drug Checking Observations and European Drug Checking Trends via TEDI

To join the webinar, register by the 6th of March on this link!

We are launching our publication New Drug Trends: Insights from Focus Group Discussions, part of Correlation – European Harm Reduction Network’s Civil Society-led Monitoring of Harm Reduction In Europe 2023 Data Report.

The study relies on 18 focal group discussions conducted among civil society organisations designated as focal points within the Network and explores the latest insights concerning the emergence of new illicit substances in cities where focal points are located, as well as other developments in drug use patterns, including polydrug use, routes of administration, and changes in local drug markets.

We bring an interview with Daan Van der Gouwe, primary author, researcher at Trimbos Institute and coordinator of the Dutch Harm Reduction Network. Read the interview and download the publication below!

Which main developments would you highlight when it comes to new or unknown substances compared to last year’s report?

We have witnessed a number of developments this year. When we look at the community of people who are engaged in high-risk drug use, we see the appearance of various synthetic opioids in heroin or benzodiazepines, for instance, nitazenes, but fentanyls are also gaining ground in some areas in Europe. With nitazenes, it seems to be geographically limited still in the northwestern part of Europe, mainly in Ireland and the UK. Whereas when it comes to fentanyls that are found in heroin, we see it in other areas of Europe. This is the main finding that we didn’t see so much last year.

Within the group of people with high-risk drug use, we also see an increa

se in the use of cocaine and methamphetamine. This cocaine includes crack cocaine, especially.

People also spoke about the ban on opium cultivation by the Taliban in 2023, that this should have an effect on the heroin market, but we don’t see that very clearly at the moment. Heroin is still available but it may be the case that this year, in 2024, it will be a different situation.

When it comes to recreational drug use, we do not see so much difference. We see some appearance of 2C-B, ketamine, some cathinones and especially also cocaine being more present on local drug markets in Europe.

The findings show that the internet takes up an increasing space in the sale of drugs. Are there any recommendations or best practices on how harm reduction services can respond to this?

Yes, this is a clear finding. We have witnessed this feature for several years already, but last year it was really strong. I’d like to make a plea for harm reduction NGOs to go online and inform themselves about the changing markets, to see what’s going on online, but also to start some interventions there and to do internet-based harm reduction, for instance, online outreach work.

We have had a pioneer, his name is Fernando Caudevilla, DoctorX, who did this work already 10-15 years ago. He did that on the darknet, he answered questions of people who use drugs, and he gave very proper harm reduction advice to anyone who had questions about drug use. Maybe in some countries like the Netherlands, we have this clear-cut information everywhere online, but in many other countries, for instance, in Russia, this information is not available.

This kind of work, online harm reduction services are essential for people to take note of. This would be a very important thing to do and to start conducting.

Would you pick a quote from the report that you find significant and explain why you find it relevant?

I’d like to quote the focal point in Glasgow in the UK, Scotland:

“(…) There are few reports to corroborate (the use of nitazenes), but (…seem to be….) people who have reported long term use of other drugs and have purchased as heroin.” (p. 13.)

I think this quote is a good example of where we are nowadays. We have a number of reports on nitazenes and other synthetic opioids in heroin, but the evidence is lagging behind, particularly because there’s a lack of drug checking services in the European Union or globally. So people do not really know what they are buying and using. This is why it’s very important to have drug checking services so that when people purchase heroin, they could find out that this ‘heroin’ contains no heroin, or contains heroin but also nitazenes, which are much stronger and can be lethal. So it’s essential to have these services all around the globe.

How do you think harm reduction organizations can use the report?

The report can be used as an advocacy tool, to advocate for a better early warning system, especially since now drug markets are more polluted. Look at the heroin market, but some other markets also seem to be more polluted. Also because drug markets continue to go online.

Harm reduction services also need to find funding for better services and for better serving the needs of people who use stimulant drugs, especially crack and methamphetamine, since we have seen an increase in crack and methamphetamine on the market and services for these users are also lagging behind.

This report clearly identifies these developments which are in line with data from, for instance, the EMCDDA [European Monitoring Centre for Drugs and Drug Addiction]. It would be good that harm reduction services use the report and the recommendations to get access to additional funding to serve the people they’re working for in a better way.

Qualitative data is a significant complementary source to gain information, and as you mentioned, there seem to be limitations when it comes to gaining information about the quality or composition of substances, and that’s where drug checking can be very important. How do you think research methods can be combined in the best way and what do you think is necessary for this to happen?

What I think is necessary to develop further is that we look at different sources. In the scientific world, we call it triangulation of data. It means that we use data from the focus groups that we have been conducting for many years now in the framework of Correlation to compare those data with the drug checking data from several cities. But also, I think wastewater analysis could be a very interesting tool. Also, there’s a project going on which identifies and detects drugs in syringes.

I think with all those different sources together we can quickly see trends and developments in the drug markets. Also, what is even more important than just detecting or identifying is to intervene as quickly as possible.

For instance, this situation with nitazenes, it’s very worrying in a specific part of Europe now, but it could extend to the whole of Europe quickly. Then it also needs to be responded to in a very quick and precise manner. The data we get, along with all the other data, for instance from drug checking, could help to do so.

What is the added value of this type of civil society-led monitoring with focal group discussions in comparison with the other types of monitoring of drug trends that are already done by major monitoring agencies?

The added value of the work that we do within the framework of Correlation is that we can get much richer data across than just the valuable data that are being collected by other agencies. They also take some time for publications, which means the day they are published, the data is rather old. We have developed now a system in which we can publish our data in a bit quicker way, which also means that we can intervene more quickly.

The other value is that we can put more layers of information of context in the data that are provided by other services, for instance, about drug markets. As an example, besides the internet-based drug markets that are now emerging, in some focus group discussions, there was a mention of increasing violence in the drug markets. Violence between drug dealers, violence between people who use drugs, violence between people who use drugs and drug dealers, and also violence between people who use drugs, drug dealers and the largest society. It seems that in some cities this violence is becoming more apparent than before, and this is also something we need to address.

What do you think the most urgent steps are that need to be done at the European level?

Two things I’ve already mentioned are the expansion of drug checking services throughout Europe, and also the expansion of harm reduction online.

Since there’s an increase in the appearance and use of stimulant drugs, especially crack cocaine and methamphetamine, but also some cathinones, harm reduction services should step up in delivering services that address the people using these stimulants.

Finally, there’s a need for preparedness for the changing heroin markets. As I said before, we see that the heroin market is increasingly polluted with fentanyls, but also in some areas with nitazines, and we believe that harm reduction services throughout Europe should prepare themselves in the best possible way to respond to the crisis that may emerge in the coming years.

In December, Budapest gave place to C-EHRN’s Expert & Member Meeting, with more than 130 professionals gathering to discuss the key activities of the network!

To find out more about the event and C-EHRN’s key activities, watch the inspiring video by the Rights Reporter Foundation, and look at the summary of the event below.

On Monday the 4th, our focal points discussed the civil society monitoring of harm reduction in Europe process, ways to use the C-EHRN Monitoring data for advocacy purposes and getting familiar with a new data collection and visualisation tool for the C-EHRN monitoring activities. In the meantime, the partners of the Drug-Prep Project had insightful discussions on foresight research and other project activities.

A press conference also took place, introducing drug consumption rooms, drug checking in Europe and the example of Portugal’s health-based drug policy approach, sharing the message that “not only the richest countries in the world can implement efficient drug policies based on decriminalisation” (Marta Pinto, University of Porto). As a result, the conference gained coverage in RTL, one of Hungary’s most popular commercial TVs.

At the end of the day, some meeting participants visited Válaszút Misszió Drogkonzultációs Iroda, learning about their services and the Hungarian context.

Tuesday began with C-EHRN’s director, Katrin Schiffer, opening the official programme for all participants of the event, also introducing C-EHRN’s new visual identity which we launched with the event! During the plenary sessions, we discussed various topics including drug policy and harm reduction in Hungary, civil society monitoring and data collection, and some of the network’s main activities, including research on harm reduction in prison and harm reduction and gender.

Throughout the afternoon’s parallel sessions, we also talked about infectious diseases in community-based settings in the context of the BOOST project, while a migration workshop took place through the SEMID-EU project, and those interested could find out about the application of foresight research in the context of the drugs field (Drug-Prep project). In the following sessions, the civil society involvement case studies conducted in 4 European countries were discussed, while we also spoke about drug consumption rooms and mental health.

Wednesday’s parallel sessions gave space for an engaging conversation about C-EHRN’s strategy for 2024-2028, while drug checking and the state of harm reduction in five European cities (Amsterdam, Bălţi, London, Esch-sur-Alzette and Warsaw) were also discussed.

The Semid-EU plenary delved into the needs and (harm reduction) service access of marginalised migrants who use drugs in the EU, after which we reflected on the outcomes of the time spent together at the member & expert meeting.

To capture the event, we bring you a collection of images below.

Liverpool, UK, gave place to the 12th International Club Health Conference from the 1st to the 3rd of November, a conference committed to fostering a healthy nightlife economy. Among the attendees were Daan van der Gouwe from Trimbos Institute and Rafaela Rigoni, the Scientific Officer at C-EHRN.

The discussions revolved around topics such as the prevention of harmful substance use, addressing violence and mental health issues associated with substance use, promoting diversity and inclusion, and implementing harm reduction measures in nightlife settings.

Drug checking – an essential service that is still underdeveloped or nonexistent in many European countries – has been discussed in several sessions. Existing drug-checking services predominantly focus on recreational drug use, leaving a significant gap in monitoring and understanding new drug trends. Drug checking plays a vital role in obtaining a reliable overview of emerging drug patterns, to which Daan van der Gouwe’s presentation in a parallel session dedicated to interventions and innovation aimed to draw attention.

While introducing the preliminary results on new drug trends detected by C-EHRN’s Focal Points as part of C-EHRN’s Civil Society-led Monitoring of Harm Reduction in Europe, the necessity of extending drug-checking services to individuals with more vulnerable patterns of high-risk drug use, particularly those who frequent harm reduction facilities, was also emphasized.

The conference highlighted that there is a pressing need for advancements in technology and service offerings to facilitate timely and low-threshold testing of substances commonly used by more vulnerable groups, including crack cocaine and heroin.

The Office for National Statistics have published new figures on drug-related deaths in England and Wales for 2021, revealing another increase in drug-related deaths.

According to the report, 4,859 people died from drug poisoning in 2021. Drug related deaths have risen by 85th since 2012; this marks the ninth consecutive year of drug related deaths rising.

Around half the deaths involved opiates (2,219), with cocaine related deaths rising by over 8%.

“Measures which have reversed drug related deaths in other parts of the world need to be considered as a way to stop people dying and promote harm reduction. Overdose Prevention Centres, of which there are over 200 in many countries across the world including Switzerland, Germany and the USA are an undoubtedly proven way of doing just this.”

Overdose Prevention Centres are named as being a critical way of reducing thousands of avoidable drug-related deaths. Unified public services, community-based interventions, outreach programs and drug support services were also named as methods which require more funding.

Read the full article here.

C-EHRN at the UNAD Congress | Exploring Synthetic Opioids and Harm Reduction

Recording – Roundup Webinar | Civil Society Monitoring of Harm Reduction in Europe

Essential Harm Reduction Services: Report on policy implementation for people who use drugs