This report enriches the information and knowledge base of harm reduction interventions in Europe from the viewpoint of civil society organisations (CSOs) that directly work for, and with, people who use drugs. This approach is a necessary, and useful, contribution to the development of drug policy in the region and C-EHRN plans to repeat this reporting on an annual basis to identify developments, changes and trends over time.

The report consists of four parts. The introduction provides background information concerning the development of the questionnaire, the data collection process, methodology used, and the nature of the data. Chapters 2-5 report on civil society involvement in drug policy and related decision-making processes as well as on hepatitis C and drug overdose prevention and management services together with the use of new drugs and new patterns of consumption. Each chapter begins with a short summary of the main results and ends by discussing conclusions and policy implications.

Most CSOs responding to the C-EHRN survey are experienced in contributing to data collection and, crucially, have close contact with many important actors in the field and have access to timely and quality information that complements the data collection mechanisms already in place. Consequently, this report reinforces the added value of the role played by CSOs in the collection of data that can inform harm reduction practice. In most countries, civil society involvement is, to some extent, enabled through dialogue and/ or information exchange but, often, the impact is regarded as unbalanced and ineffective. Permanent and formalised structures that ensure dialogue between civil society and government representatives are beneficial for such civil society involvement as structures allow for cooperation on a regular basis and oversee both the formulation of policy and its implementation. Formalised structures, however, do not safeguard meaningful involvement of civil society if they do not lead to accountable outcomes.

C-EHRN Monitoring shows that people who inject drugs (PWID) are still not allowed access to treatment of the hepatitis C virus (HCV) in 10 European countries. Although 23 countries have guidelines that include specific HCV management for PWID, many C-EHRN respondents are somewhat pessimistic about the impact of such guidelines on improving access to the HCV cascade-of-care in their country, especially to good practice, integrated, test-and-treat services at the same site. HCV testing and treatment at pharmacies remains very rare. On a more positive note, 23 European countries reported PWID organisations working actively to increase political awareness concerning HCV interventions. Compared to 2018, more attention has been paid over the past year to HCV awareness campaigns (in 15 countries), to testing at the service providers’ own premises (in 18 countries), and to treatment at the service providers own site (in 15 countries). The main barriers to address HCV among PWID include a lack of funding, knowledge, recognition, political support and skilful staff as well as weakness of civil society organisations and legal barriers.

In 15 countries of the region, the government monitors the number/proportion of people who progress through each stage of the HCV cascade-ofcare at the national level, with monitoring at the regional or local level also performed in 12 countries whereas monitoring is not performed at any level in a further 9 countries. There are still big differences within Europe as to where and how PWID can undertake a HCV test. This means PWID are in an unequal position in different European countries, regions and cities. Rapid HCV testing is available to prisoners in 21 countries.

Treatment of HCV using direct acting antivirals (DAAs) is available in all countries of the region except North Macedonia. However, 10 of 34 countries still place restrictions on access to DAA’s for those people who are active drug users. However, if access to DAA treatment is achieved, the costs are reimbursable by health insurance or through the public health service in all countries except the United Kingdom.

Consequently, to reduce the HCV-related disease burden among PWID and achieve the 2030 elimination goals as set out in the WHO Global Health Sector Strategy on Hepatitis, a radical change in the HCV response is needed in many European countries. National treatment guidelines that specifically address recommendations for treating PWID, guaranteed access by PWID to DAA treatment, improvements in the continuum-of-care and introduction of one-stop HCV testing and treatment services - including such services delivered by harm reduction organisations - needs to be further developed and adopted by all government and civil society stakeholders.

A further key contribution by civil society is collecting data on the context of drug-related overdose events and interventions at a local level, feeding into already existing data and reports. Only 5 countries reported separate overdose prevention strategies or action plans. Much improvement is needed to be able to adequately respond to overdoses in Europe. Evidence demonstrates that a range of measures – including drug consumption rooms (DCR), take-home naloxone (THN) programmes in the community, and naloxone distribution before release from prison - can reduce opioid and other drug-related overdose deaths. However, C-EHRN Monitoring shows a mixed picture of policies and measures across Europe. There is a significant disparity in how, and by whom, such overdose data is collected which can ultimately influence what is recorded as a drug-related death. To address this, the EMCDDA should encourage the respective national health authorities, their own Reitox Network, as well as others who collect such data, to collaborate more with national harm reduction networks and experts in their field of work. Furthermore, due to the uneven status of naloxone – the safe and simple response to an opioid overdose as recommended by WHO – political authorities are called upon to take appropriate legal initiatives to ensure, without delay, that naloxone is available free of charge and without prescription in pharmacies for people who use drugs; experience from Italy can be the basis for this action. In addition, to obtain a real overview of the number of doses of naloxone administered and data on the successful use of naloxone, a national reference point should be established to collect and analyse this and other data.

In general terms, the results of C-EHRN Monitoring correspond with what we know from other sources concerning new drug trends. In addition, the process of data collection as undertaken by C-EHRN Focal Points in each country has the potential of generating additional information and at a quicker pace than other methods, bringing added, qualitative value to this sector.

A review of the approach used by C-EHRN Monitoring to collect such information suggests that focus groups held several times each year would be more effective than a questionnaire as it would lead to consensus-based data. Also, a focus on drug trends, including new drugs, is preferable rather than the emergence of specific drugs. In addition, the focus should be at the city/urban level, rather than national, as this will likely provide higher quality data, and a reduction in the number of questions is recommended.