Trends in distribution of harm-reducing equipment for people who inject drugs in Norway, 2016-2022. A nationwide data collection

Trends in distribution of harm-reducing equipment for people who inject drugs in Norway, 2016-2022. 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A nationwide data collection Jens Christoffer Skogen, Katharina Natalie Gottschlich, Martin Blindheim, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4501562/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 May, 2025 Read the published version in Harm Reduction Journal → Version 1 posted 13 You are reading this latest preprint version Abstract Harm-reducing strategies are interventions designed to mitigate the adverse effects of substance use when abstinence is not a feasible option. Evidence supports the effectiveness and efficacy of harm reduction as a broad framework for addressing illicit drug use. To ensure the implementation of these measures, Alcohol and Drug Research Western Norway was mandated by the Norwegian Directorate of Health in 2016 to annually assess municipalities' adherence to harm-reduction guidelines. This study aims to present national trends in the distribution of harm-reducing equipment in Norway from 2016 to 2022. Specifically, we investigated the proportion of distributing municipalities, additional equipment distributed, and the population coverage. Our findings indicate an increased coverage in the distribution of harm-reducing equipment in Norway between 2016 and 2022. This positive trend demonstrates progress in addressing the negative consequences of drug use and aligns with Norwegian national strategies to mitigate drug-related harms. Future research should evaluate the effectiveness of these harm-reduction strategies and identify areas for improvement within the Norwegian context, especially related to use of opioid analgesics. Figures Figure 1 Introduction Harm-reducing strategies can be described as a set of interventions which aim to reduce the harms of substance use, when abstinence is not considered a feasible strategy [ 1 ]. This strategy can be applied to alcohol, tobacco and illicit drugs, and even other harmful health behaviors [ 2 ]. However, they are most commonly associated with illicit drugs [ 1 ], particularly opioids and stimulants [ 3 ]. The specific interventions employed in harm-reducing strategies are varied, and covers for example peer education, health promotion, opioid substitution treatment and needle and syringe programmes [ 3 ]. Evidence supports the effectiveness and efficacy of harm-reduction as a broad framework for addressing illicit drug use [ 1 , 3 ]. Current opioid substitution treatment was for instance reported to be associated with substantially reduced health risks and lower levels of criminal activity compared to other groups in a population of needle exchange programme participants in a Norwegian context [ 4 ]. Building upon harm-reducing strategies, the availability and accessibility of needles and syringes (N/S) for people who inject drugs (PWID) in Norway have undergone substantial changes over the past five decades, shaped by public health crises and evolving strategies to address risks associated with drug injection. Historically, N/S were available over-the-counter in pharmacies [ 5 ], but their sale was subject to various local restrictions targeting PWID. During the height of the hepatitis B (HBV) epidemic in the late 1970s, many of these restrictions were lifted (Torbjørn Mork, personal communication). However, the landscape shifted again in 1985, with the AIDS epidemic among PWID. Fearing HIV transmission, some Norwegian pharmacies stopped selling N/S to avoid serving PWID as customers. During the summer of 1985, activists took matters into their own hands by distributing needles and syringes in the streets (Martin Blindheim, personal communication) prompting several municipalities to experiment with various distributing methods [ 5 ]. In 1988, the Aids Information Bus was launched in the capital Oslo, Norway’s first permanent N/S Program [ 6 ]. This bus operated six hours daily, 365 days a year. In 1989, it distributed 212,000 N/S, and the number surged to 1,136,000 in 1995; nearly as many as today despite fewer injecting drug users. In the 1990s, the Norwegian government funded low-threshold health facilities in major cities, with N/S distribution becoming central in harm reduction efforts. Oslo opened a drug injection room in 2005, followed by Bergen (the second largest city in Norway) in 2016, providing a safer environment for drug use while aiming to reduce associated risks [ 7 ]. In 2016, the National Overdose Strategy and the Hepatitis Strategy emphasized N/S availability [ 8 , 9 ], aligning with the World Health Organization's Hepatitis Strategy [ 10 ]. To ensure the implementation of harm reduction measures, Alcohol and Drug Research Western Norway was mandated in 2016 with annually assessing the municipalities' adherence to N/S availability recommendations and other harm-reducing measures. By 2018, the Directorate of Health required municipalities with PWID to provide free sterile injecting equipment linking this mandate to the Act on Control of Communicable Diseases [ 11 ] and the ongoing HCV-epidemic [ 12 ]. In 2019, drug injection rooms were reorganized as User Rooms, promoting less harmful drug use methods. The User Rooms allowed for a broader range of harm reduction strategies, not limited to injecting alone [ 7 ]. This shift represented a significant change in supporting PWID and addressing public health concerns associated with drug use. The present paper addresses aspects of the Norwegian harm-reducing strategies by presenting nationwide pertinent data on the distribution of harm-reducing equipment in Norway offering insights into the reach, accessibility and inclusivity of the harm reduction initiatives across Norway. Aims The aim of this study is to present the national trends in the distribution of harm-reducing equipment through harm-reducing services in Norway from 2016 to 2022. Specifically, we investigated the proportion of distributing municipalities, proportion of specific additional equipment distributed, and population covered. Methods Data collection and procedure of municipality surveys regarding distribution On behalf of the Norwegian Directorate of Health, Center for Alcohol and Drug Research, have conducted a yearly electronic questionnaire survey to Norwegian municipalities regarding the distribution of harm reduction equipment in the period from 2016 to2022. User equipment in this context refers to equipment used for the consumption of substances, naloxone, contraception and lubricants, and disposable toothbrushes. The questionnaire was developed based on input from “Funkishuset”, a low-threshold initiative in Sandnes Municipality and their users, and input from the Norwegian Directorate of Health. Emphasizing a high response rate, the questionnaire was designed to be completed within 10–15 minutes. The survey was sent to the municipality’s post office, with a request to forward it to the municipal doctor. The municipal doctor was requested to forward the survey to the person most knowledgeable in the area if they themselves were not the most informed. During the next 3–4 months, three reminders were carried out. The first reminder was sent to the municipality’s post office, second was sent to available contact persons in each municipality and third reminder was carried out by telephone to municipalities of a certain size (≥ 100 000 inhabitants). Data retrieval The data used in the present study is derived from three sources. Data about distribution is derived from the official yearly reports issued between 2017 and 2023 by Center for Alcohol and Drug research (KORFOR) by appointment of the Norwegian Directorate of Health (data source 1; [ 13 ]). The retrieved information from these reports includes number of participating municipalities, number of distributing municipalities, and estimated needles distributed as well as the number of municipalities distributing additional equipment: i) naloxone, ii) smoking foil, iii) contraception and lubricants and iv) disposable toothbrushes. The questions regarding distribution of i)-iv) are only available from 2017 and onwards, as this was not included in the questionnaire in 2016. The total number of municipalities and population size are retrieved from official governmental information (data source 2; [ 14 ]) and Statistics Norway (data source 3; [ 15 ]), respectively. Statistical procedure Table 1 includes an overview of all included variables for each year between 2016 and 2022. Total numbers are given for each variable at an aggregate level. In Fig. 1 , the estimated proportions and 95% confidence intervals (95%CI) are presented at yearly intervals between 2016 and 2022 for A) distributing municipalities and B) total population covered. For distributing municipalities, the percentage is estimated with the number of participating municipalities as the denominator. For the total population covered, the percentage is estimated with the total population as the denominator. For the years between 2017 and 2022 the estimated proportion and 95%CI for distribution of C) additional equipment is also presented, and the number of participating municipalities were used as the denominator. For statistical inference, a two-sample test of proportions was used to compare the estimated proportion between the first year of observation (2016 or 2017) and the last year of observation (2022). Results The proportion of participating municipalities was 59% in 2016, increasing to between 70% and 73% from 2017 to 2019. During the peak of the COVID-19 pandemic (2020–2021), the participation dropped to 62–64%, but rose again to 70% in 2022 (Table 1 ). Throughout the period, the proportion of distributing municipalities increased, from 26% in 2016 to 62% in 2022, an increase of 36 percentage points (Table 1 and Fig. 1 ). A similar increase in the proportion of the population covered was also observed. In relation to additional equipment a general increase from 2017 to 2022 was observed for i) naloxone, ii) smoking foil, iii) contraception and lubricants and iv) disposable toothbrushes (Table 1 and Fig. 1 ; all p-values < 0.001). In percentage points, the largest increase was observed for distribution of naloxone (23 percentage points) between 2017–2022, while the smallest increase was observed for distribution of disposable toothbrushes (7 percentage points). Also, the proportion of distribution of smoking foil, contraception and lubricants and disposable toothbrushes seems to have levelled off around 2020 and onwards, a pattern most pronounced for distribution of disposable toothbrushes. Table 1 Overview of included variables across years 2016–2022. 2016 2017 2018 2019 2020 2021 2022 Municipalities 428 426 422 422 356 356 356 Participating municipalities 253 298 306 300 227 220 249 Distributing municipalities 67 93 118 148 117 132 154 Municipalities distributing: Naloxone Not included 23 34 53 52 61 78 Smoking foil Not included 29 39 58 57 51 56 Contraception and lubricants Not included 68 78 85 74 73 86 Disposable toothbrushes Not included 35 44 47 40 39 48 Total population, Norway a 5 213 985 5 258 317 5 295 619 5 328 212 5 367 580 5 391 369 5 425 270 Population covered b 2 70 0337 3 031 460 3 407 447 3 804 792 4 183 080 3 977 428 4 340 015 Estimated needles distributed 3 029 344 ~ 2 900 000 ~ 3 000 000 ~ 3 000 000 3 522 411 3 783 134 3 458 614 a Total population retrieved from Statistics Norway. b Population covered based on the total population in distributing municipalities. Municipality population retrieved from statistics Norway. Discussion Summary of main findings In the present study, we investigated the national trend of distribution of harm-reducing equipment through harm reducing services in Norway from 2016 to 2022. Overall, the findings indicated an increase in distribution over the years covered. The proportion of distributing municipalities increased with 36 percentage points from 2016 to 2022 and covered 80% of the Norwegian population by 2022. The observed increase in coverage may be taken as support strengthened potential to mitigate the negative consequences associated with substance use in Norway. Interestingly, the most recent Global Burden of Disease (GBD) estimates indicates a statistically significant decrease from 3.6 (95% uncertainty interval (UI): 3.4–3.8) age-standardized deaths per 100,000 in 2016 to 3.1 (95%UI: 2.9–3.4) in 2021 due to opioid use disorders for Norway [ 16 ]. In fact, the GBD estimates indicate a consistent downward trend in age-standardized deaths due to opioid use disorders after a peak in 2001 (6.5 (95%UI 6.2–6.8) and are more like the other Nordic countries than at the start of the millennium [ 17 ]. Taken together, the present findings are indicative of a progress towards achieving the goals outlined in Norwegian national strategies aimed at addressing substance use and promoting public health. It should, however, be noted that the trend in drug-induced deaths have been slightly increasing since 2013 in Norway [ 18 ]. Although the causes for this increase are complex, a shift from heroin-induced deaths to those induced by other opioids has been observed. A marked increase in deaths induced by synthetic opioids is especially noteworthy. This is indicative of change in the underlying demographic, particularly for deaths associated with opioid analgesics [ 19 ]. This could mean that the harm-reducing efforts needs to be modified to ensure relevant reach and relevance. Strengths and limitations The present study holds some notable strengths. First, the study presents detailed data about trends in distribution across a six-year period at the municipality level in Norway. Second, as the study relies on official yearly reports issued by Center for Alcohol and Drug Research (KORFOR) as appointed by the Norwegian Directorate of Health it lends credibility and reliability to the data. Some limitations are also pertinent when interpreting the findings presented. First, although the participation rate at a municipal level increased after 2016, the number of municipalities not participating is relatively high. However, it is worth keeping in mind that most of the municipalities not participating are among the least populous in Norway – while the most populous municipalities are participants across the years. This is especially important to note, as > 80% the Norwegian population lives in the 100 (out of 356) most populous municipalities. Second, as this study is based on retrieved aggregated data and was executed in a period with large reductions in municipalities due to mergers [ 14 ], accounting for dependence across years for municipality as statistical unit is not possible. Therefore, inferential statistics is based on a two-sample test of proportions, even though the statistical units under observation are dependent and in principle could be paired. We believe the results from this approach to still be valid as the participation rate has increased, and all the trend indicators increased during the period. For this interpretation to be void, the inflated type I error rate must be very strong and uniform, which we believe to be unlikely. Third, for the years 2017–2019, the estimated needles distributed were more approximate than for the other years, as some of the municipalities did not report exact numbers but rounded estimates of needles distributed. We do, however, believe that the reported numbers reflect the actual distribution, and if anything is biased downward when considering the more exact numbers reported before and after this period. Relevance and implications The distribution of harm reducing equipment to individuals with substance use disorders is considered an effective measure for reducing harm associated with drug use [ 1 , 3 ], such as risk for infectious diseases [ 20 ]. Furthermore, the distribution facilitates engagement between users and support services [ 21 , 22 ]. This engagement fosters a sense of self-worth among users and reduces stigma [ 22 ]. Additionally, the threshold for seeking other interventions or substance use treatment is lowered when a connection with support services is already established through the distribution of harm reduction equipment [ 23 ]. The current distribution of N/S, naloxone, and other equipment are all efforts associated with the ongoing overdose strategy in Norway [ 8 , 9 ]. This strategy has relied on a network of municipalities and dedicated personnel responsible for the implementation at local and regional levels. The concerted effort at multiple levels of governance, ranging from central to local, has been a crucial precondition for achieving effective coverage in Norway. Moreover, at every stage, user representatives have been actively involved, ensuring that the initiatives have had support at the level of the users and incorporating their perspectives and needs. The same level of involvement applies to personnel in low-threshold services. Lastly, the concerns regarding potential overdoses and related harm have gathered significant attention at the political level, contributing to a relatively robust and coherent political impetus. For instance, in both the National Overdose Strategy [ 9 ] and the Escalation Plan for the Substance Abuse Field [ 24 ], the Norwegian government aims to assess the need for expanding access to harm reduction equipment. Conclusions In the present study, we found an increased coverage in distribution of harm-reducing equipment in Norway between 2016 and 2022. The observed positive trend indicates progress in addressing the negative consequences of drug use and aligns with Norwegian national strategies aimed at mitigating the harms associated with drug use. Future research should assess the effectiveness and identify areas for improvement in the harm reducing strategies in a Norwegian context, especially related to use of opioid analgesics. Declarations Ethics approval and consent to participate: Not applicable, the data included is based on aggregated data provided by municipalities as mandated by the Norwegian Directorate of Health and official statistics available online. Consent for publication: Not applicable. Availability of data and materials: The data used and analysed during the current study are available from the corresponding author on reasonable request (in Norwegian only), including collated data. In addition, data from official Norwegian sources were employed, and these are available online from Statistics Norway and the Norwegian Government (in Norwegian only). Competing interests: The authors declare that they have no competing interests. Funding: No specific funding was received for this work. Data collection regarding municipality distribution was partly funded by Norwegian Directorate of Health and Center for Alcohol and Drug Research (KORFOR). Authors' contributions: All authors conceived the paper. Data collection was partly facilitated by MB and JÅ. JCS planned and performed the initial analysis, and KNG and JÅ provided feedback. Revised analyses were performed by JCS, and the remaining authors contributed to the interpretation of the results. JCS wrote the first drafts of the papers, while the remaining authors contributed substantially to the revision of the drafts. All authors have read and approved the final manuscript. Acknowledgements: We would like to thank the municipalities for contributing to the data collection. We would also like to thank senior researcher Sverre Nesvåg at Center for Alcohol and Drug Research (KORFOR) for his valuable contributions to design of the municipal data collections and rationale for this study. References Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev. 2006;25(6):611–24. The Canadian Paediatric Society. Harm reduction: An approach to reducing risky health behaviours in adolescents. Paediatr Child Health. 2008;13(1):53–60. Hedrich D, Hartnoll RL et al. Harm-Reduction Interventions , in Textbook of Addiction Treatment: International Perspectives , N. el-Guebaly, Editors. 2021, Springer International Publishing: Cham. pp. 757–775. Gjersing L, Bretteville-Jensen AL. Is opioid substitution treatment beneficial if injecting behaviour continues? Drug Alcohol Depend. 2013;133(1):121–6. The Norwegian Government. Meld. St. 16 (1996–1997): Narkotikapolitikken [Parliamentary White Paper No. 16 (1996–1997): The Drug Policy]. 1997 [cited 2024 19/03]; https://www.regjeringen.no/no/dokumenter/st-meld-nr-16_1996-97/id191004/ . Skretting A, Ervik R, Øie KE. The aidsinformation bus in Oslo. A survey among drug users. Nordisk Alkoholtidsskrift [Nordic Alcohol Studies]. 1994;11(1):18–29. Ministry of Health and Care Services. Lov om ordning med brukerrom for inntak av narkotika (brukerromsloven) [Injection Room Act] , M.o.H.a.C. Services, Editor. 2004-present. Norwegian Directorate of Health. Nasjonale faglige råd: Hepatitt C [National Professional Guidelines: Hepatitis C]. 2019 [cited 2024 19/03]; https://www.helsedirektoratet.no/faglige-rad/hepatitt-c . Norwegian Directorate of Health. Nasjonal overdosestrategi [National overdose strategy]. 2019 [cited 2024 19/03]; https://www.helsedirektoratet.no/faglige-rad/overdose-lokalt-forebyggende-arbeid/bakgrunn . World Health Organization. Global HIV, Hepatitis and STIs Programmes. 2022 [cited 2024 19/03]; https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/strategies/global-health-sector-strategies . Ministry of Health and Care Services. Lov om vern mot smittsomme sykdommer (smittevernloven). [Act on Control of Communicable Diseases] , M.o.H.a.C. Services, Editor. 1995-present. Norwegian Confederation of Addiction. Gratis, tilgjengelig brukerutstyr i alle kommuner! [Free, Accessible User Equipment in All Municipalities!]. 2018 [cited 2024 19/03]; https://www.rusfeltet.no/arkiv/gratis-tilgjengelig-brukerutstyr-i-alle-kommuner . Center for Alcohol and Drug Research (KORFOR). Om KORFOR [Published reports]. 2024 2024/05/29]; https://www.helse-stavanger.no/fag-og-forskning/kompetansetjenester/regionalt-kompetansesenter-for-rusmiddelforskning-i-helse-vest-korfor/om-korfor/ . The Norwegian Government. Kommunesammenslåinger i kommunereformen [Merger of municipalities in the municipal reform]. 2020 [cited 2024 19/03]; https://www.regjeringen.no/no/tema/kommuner-og-regioner/kommunestruktur/nye-kommuner/id2470015/ . Statistics Norway. Population . 2024. Institute for Health Metrics and Evaluation (IHME). GBD Compare. Trends in Norway. IHME, University of Washington: Seattle, WA; 2015. Institute for Health Metrics and Evaluation (IHME). GBD Compare. Comparison of Nordic countries. IHME, University of Washington: Seattle, WA; 2015. Norwegian Institute of Public Health. Høyeste antallet narkotikautløste dødsfall siden 2001 [Highest number of drug-induced deaths since 2001]. Norwegian Institute of Public Health: Oslo; 2024. Amundsen EJ, et al. Patterns of filled prescriptions and the association with risk of drug-induced death. A population-based nested case-control register study. Pharmacoepidemiol Drug Saf. 2024;33(2):e5763. Platt L et al. Public Health Research , in Assessing the impact and cost-effectiveness of needle and syringe provision and opioid substitution therapy on hepatitis C transmission among people who inject drugs in the UK: an analysis of pooled data sets and economic modelling . 2017, NIHR Journals Library (National Institute of Health and Care Research): Southampton (UK). Jones L, et al. Optimal provision of needle and syringe programmes for injecting drug users: A systematic review. Int J Drug Policy. 2010;21(5):335–42. MacNeil J, Pauly B. Needle exchange as a safe haven in an unsafe world. Drug Alcohol Rev. 2011;30(1):26–32. Wodak A, Cooney A. Effectiveness of sterile needle and syringe programmes. Int J Drug Policy. 2005;16:31–44. The Norwegian Government. Opptrappingsplanen for rusfeltet (2016–2020) [Escalation Plan for the Substance Abuse Field (2016–2020) . 2016. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 May, 2025 Read the published version in Harm Reduction Journal → Version 1 posted Editorial decision: Revision requested 15 Oct, 2024 Reviews received at journal 10 Oct, 2024 Reviews received at journal 01 Oct, 2024 Reviewers agreed at journal 30 Sep, 2024 Reviewers agreed at journal 21 Sep, 2024 Reviews received at journal 05 Aug, 2024 Reviewers agreed at journal 25 Jul, 2024 Reviewers agreed at journal 12 Jul, 2024 Reviewers agreed at journal 07 Jul, 2024 Reviewers invited by journal 06 Jul, 2024 Editor assigned by journal 31 May, 2024 Submission checks completed at journal 31 May, 2024 First submitted to journal 30 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4501562","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":312177063,"identity":"4ebb16c6-5b1e-4495-bfa5-3548b995516d","order_by":0,"name":"Jens Christoffer Skogen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABN0lEQVRIie2RMWuEMBSAXwl4S1rXHB69vxAJHBwc/S2KoMsd19HBIVDwFktXt/6URgJ2kXa94YZK4aYOHnRwahtFaGl0L9QPkpe85IP3EoCRkT/IGW+DAKMJ4aqZ2yVcTtLucFhBAIX/rTC871c6hBq/FDfZ999Fu1tZQXTYXpjP2YtwVlswc7d8Dw9BYt1wdB3qhSVPPoH8uIyJh6hw/CUnvmSz4rhJZhlHaaEr6XqhGpLUIMiwTrWkQCaxNY3l5oG4HJ3HunL/xqpWMaVBhPNJwXxUyocM8JCSYkpaBbxGERTAz6cnLp1BJVkviJM3hXlM9eKphe8xyKWdKEVivRd7V7CqiiSd32WlerErapq5XdaRnGMSlK9YfzGbq8n5mWl+BeFuIzQBYN6TU+XWvemRkZGRf8oXEW5rK4zI6IMAAAAASUVORK5CYII=","orcid":"","institution":"Stavanger University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jens","middleName":"Christoffer","lastName":"Skogen","suffix":""},{"id":312177065,"identity":"55d44948-48e2-4aa1-be99-c06d08d6ba18","order_by":1,"name":"Katharina Natalie Gottschlich","email":"","orcid":"","institution":"Stavanger University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Katharina","middleName":"Natalie","lastName":"Gottschlich","suffix":""},{"id":312177067,"identity":"af19904c-47f2-4dd3-bc70-bf4a467c87e6","order_by":2,"name":"Martin Blindheim","email":"","orcid":"","institution":"Norwegian Directorate of Health","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Blindheim","suffix":""},{"id":312177068,"identity":"6099bb46-9758-4a0d-8fba-3f77b3de8216","order_by":3,"name":"Janne Årstad","email":"","orcid":"","institution":"Stavanger University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Janne","middleName":"","lastName":"Årstad","suffix":""}],"badges":[],"createdAt":"2024-05-30 08:36:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4501562/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4501562/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12954-025-01245-5","type":"published","date":"2025-05-30T15:57:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58306502,"identity":"72ec80aa-b760-470e-9a22-f320ce359e19","added_by":"auto","created_at":"2024-06-13 18:29:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":346049,"visible":true,"origin":"","legend":"\u003cp\u003eEstimated proportions and 95% confidence intervals across years for \u003cstrong\u003eA)\u003c/strong\u003e distributing municipalities (2016-2022), \u003cstrong\u003eB) \u003c/strong\u003epopulation of Norway covered (2016-2022), and \u003cstrong\u003eC) \u003c/strong\u003edistribution of naloxone, smoking foil, contraception and lubricants, and disposable toothbrush among distributing municipalities (2017-2022). Difference between first and last year of observation estimated using two-sample test of proportions.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4501562/v1/b4714375830cfbb05bae4186.png"},{"id":83782911,"identity":"6c9c04bc-d4d3-4f55-9ec7-0d3294a74caf","added_by":"auto","created_at":"2025-06-02 16:08:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":627641,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4501562/v1/419f4396-eb87-4cf9-a7ed-8328f91b15b9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Trends in distribution of harm-reducing equipment for people who inject drugs in Norway, 2016-2022. A nationwide data collection","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHarm-reducing strategies can be described as a set of interventions which aim to reduce the harms of substance use, when abstinence is not considered a feasible strategy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This strategy can be applied to alcohol, tobacco and illicit drugs, and even other harmful health behaviors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, they are most commonly associated with illicit drugs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], particularly opioids and stimulants [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The specific interventions employed in harm-reducing strategies are varied, and covers for example peer education, health promotion, opioid substitution treatment and needle and syringe programmes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Evidence supports the effectiveness and efficacy of harm-reduction as a broad framework for addressing illicit drug use [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Current opioid substitution treatment was for instance reported to be associated with substantially reduced health risks and lower levels of criminal activity compared to other groups in a population of needle exchange programme participants in a Norwegian context [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBuilding upon harm-reducing strategies, the availability and accessibility of needles and syringes (N/S) for people who inject drugs (PWID) in Norway have undergone substantial changes over the past five decades, shaped by public health crises and evolving strategies to address risks associated with drug injection. Historically, N/S were available over-the-counter in pharmacies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], but their sale was subject to various local restrictions targeting PWID. During the height of the hepatitis B (HBV) epidemic in the late 1970s, many of these restrictions were lifted (Torbj\u0026oslash;rn Mork, personal communication). However, the landscape shifted again in 1985, with the AIDS epidemic among PWID. Fearing HIV transmission, some Norwegian pharmacies stopped selling N/S to avoid serving PWID as customers. During the summer of 1985, activists took matters into their own hands by distributing needles and syringes in the streets (Martin Blindheim, personal communication) prompting several municipalities to experiment with various distributing methods [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 1988, the Aids Information Bus was launched in the capital Oslo, Norway\u0026rsquo;s first permanent N/S Program [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This bus operated six hours daily, 365 days a year. In 1989, it distributed 212,000 N/S, and the number surged to 1,136,000 in 1995; nearly as many as today despite fewer injecting drug users. In the 1990s, the Norwegian government funded low-threshold health facilities in major cities, with N/S distribution becoming central in harm reduction efforts.\u003c/p\u003e \u003cp\u003eOslo opened a drug injection room in 2005, followed by Bergen (the second largest city in Norway) in 2016, providing a safer environment for drug use while aiming to reduce associated risks [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2016, the National Overdose Strategy and the Hepatitis Strategy emphasized N/S availability [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], aligning with the World Health Organization's Hepatitis Strategy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. To ensure the implementation of harm reduction measures, Alcohol and Drug Research Western Norway was mandated in 2016 with annually assessing the municipalities' adherence to N/S availability recommendations and other harm-reducing measures. By 2018, the Directorate of Health required municipalities with PWID to provide free sterile injecting equipment linking this mandate to the Act on Control of Communicable Diseases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and the ongoing HCV-epidemic [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2019, drug injection rooms were reorganized as User Rooms, promoting less harmful drug use methods. The User Rooms allowed for a broader range of harm reduction strategies, not limited to injecting alone [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This shift represented a significant change in supporting PWID and addressing public health concerns associated with drug use.\u003c/p\u003e \u003cp\u003eThe present paper addresses aspects of the Norwegian harm-reducing strategies by presenting nationwide pertinent data on the distribution of harm-reducing equipment in Norway offering insights into the reach, accessibility and inclusivity of the harm reduction initiatives across Norway.\u003c/p\u003e \u003cp\u003eAims\u003c/p\u003e \u003cp\u003eThe aim of this study is to present the national trends in the distribution of harm-reducing equipment through harm-reducing services in Norway from 2016 to 2022. Specifically, we investigated the proportion of distributing municipalities, proportion of specific additional equipment distributed, and population covered.\u003c/p\u003e"},{"header":"Methods","content":" \u003cp\u003eData collection and procedure of municipality surveys regarding distribution\u003c/p\u003e \u003cp\u003eOn behalf of the Norwegian Directorate of Health, Center for Alcohol and Drug Research, have conducted a yearly electronic questionnaire survey to Norwegian municipalities regarding the distribution of harm reduction equipment in the period from 2016 to2022. User equipment in this context refers to equipment used for the consumption of substances, naloxone, contraception and lubricants, and disposable toothbrushes. The questionnaire was developed based on input from \u0026ldquo;Funkishuset\u0026rdquo;, a low-threshold initiative in Sandnes Municipality and their users, and input from the Norwegian Directorate of Health. Emphasizing a high response rate, the questionnaire was designed to be completed within 10\u0026ndash;15 minutes. The survey was sent to the municipality\u0026rsquo;s post office, with a request to forward it to the municipal doctor. The municipal doctor was requested to forward the survey to the person most knowledgeable in the area if they themselves were not the most informed. During the next 3\u0026ndash;4 months, three reminders were carried out. The first reminder was sent to the municipality\u0026rsquo;s post office, second was sent to available contact persons in each municipality and third reminder was carried out by telephone to municipalities of a certain size (\u0026ge;\u0026thinsp;100 000 inhabitants).\u003c/p\u003e \u003cp\u003eData retrieval\u003c/p\u003e \u003cp\u003eThe data used in the present study is derived from three sources. Data about distribution is derived from the official yearly reports issued between 2017 and 2023 by Center for Alcohol and Drug research (KORFOR) by appointment of the Norwegian Directorate of Health (data source 1; [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]). The retrieved information from these reports includes number of participating municipalities, number of distributing municipalities, and estimated needles distributed as well as the number of municipalities distributing additional equipment: i) naloxone, ii) smoking foil, iii) contraception and lubricants and iv) disposable toothbrushes. The questions regarding distribution of i)-iv) are only available from 2017 and onwards, as this was not included in the questionnaire in 2016. The total number of municipalities and population size are retrieved from official governmental information (data source 2; [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]) and Statistics Norway (data source 3; [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]), respectively.\u003c/p\u003e \u003cp\u003eStatistical procedure\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e includes an overview of all included variables for each year between 2016 and 2022. Total numbers are given for each variable at an aggregate level. In Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the estimated proportions and 95% confidence intervals (95%CI) are presented at yearly intervals between 2016 and 2022 for A) distributing municipalities and B) total population covered. For distributing municipalities, the percentage is estimated with the number of participating municipalities as the denominator. For the total population covered, the percentage is estimated with the total population as the denominator. For the years between 2017 and 2022 the estimated proportion and 95%CI for distribution of C) additional equipment is also presented, and the number of participating municipalities were used as the denominator. For statistical inference, a two-sample test of proportions was used to compare the estimated proportion between the first year of observation (2016 or 2017) and the last year of observation (2022).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe proportion of participating municipalities was 59% in 2016, increasing to between 70% and 73% from 2017 to 2019. During the peak of the COVID-19 pandemic (2020\u0026ndash;2021), the participation dropped to 62\u0026ndash;64%, but rose again to 70% in 2022 (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Throughout the period, the proportion of distributing municipalities increased, from 26% in 2016 to 62% in 2022, an increase of 36 percentage points (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A similar increase in the proportion of the population covered was also observed. In relation to additional equipment a general increase from 2017 to 2022 was observed for i) naloxone, ii) smoking foil, iii) contraception and lubricants and iv) disposable toothbrushes (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; all p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In percentage points, the largest increase was observed for distribution of naloxone (23 percentage points) between 2017\u0026ndash;2022, while the smallest increase was observed for distribution of disposable toothbrushes (7 percentage points). Also, the proportion of distribution of smoking foil, contraception and lubricants and disposable toothbrushes seems to have levelled off around 2020 and onwards, a pattern most pronounced for distribution of disposable toothbrushes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of included variables across years 2016\u0026ndash;2022.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMunicipalities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e428\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e426\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e422\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e422\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e356\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipating municipalities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e249\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistributing municipalities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMunicipalities distributing:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNaloxone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNot included\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSmoking foil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNot included\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eContraception and lubricants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNot included\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDisposable toothbrushes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNot included\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal population, Norway\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u0026nbsp;213 985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026nbsp;258 317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u0026nbsp;295 619\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u0026nbsp;328 212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u0026nbsp;367 580\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5\u0026nbsp;391 369\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5\u0026nbsp;425 270\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePopulation covered\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 70 0337\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026nbsp;031 460\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u0026nbsp;407 447\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u0026nbsp;804 792\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u0026nbsp;183 080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u0026nbsp;977 428\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4\u0026nbsp;340 015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated needles distributed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026nbsp;029 344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e~\u0026thinsp;2\u0026nbsp;900 000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e~\u0026thinsp;3\u0026nbsp;000 000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e~\u0026thinsp;3\u0026nbsp;000 000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u0026nbsp;522 411\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u0026nbsp;783 134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3\u0026nbsp;458 614\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eTotal population retrieved from Statistics Norway.\u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003ePopulation covered based on the total population in distributing municipalities. Municipality population retrieved from statistics Norway.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSummary of main findings\u003c/p\u003e \u003cp\u003eIn the present study, we investigated the national trend of distribution of harm-reducing equipment through harm reducing services in Norway from 2016 to 2022. Overall, the findings indicated an increase in distribution over the years covered. The proportion of distributing municipalities increased with 36 percentage points from 2016 to 2022 and covered 80% of the Norwegian population by 2022. The observed increase in coverage may be taken as support strengthened potential to mitigate the negative consequences associated with substance use in Norway. Interestingly, the most recent Global Burden of Disease (GBD) estimates indicates a statistically significant decrease from 3.6 (95% uncertainty interval (UI): 3.4\u0026ndash;3.8) age-standardized deaths per 100,000 in 2016 to 3.1 (95%UI: 2.9\u0026ndash;3.4) in 2021 due to opioid use disorders for Norway [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In fact, the GBD estimates indicate a consistent downward trend in age-standardized deaths due to opioid use disorders after a peak in 2001 (6.5 (95%UI 6.2\u0026ndash;6.8) and are more like the other Nordic countries than at the start of the millennium [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Taken together, the present findings are indicative of a progress towards achieving the goals outlined in Norwegian national strategies aimed at addressing substance use and promoting public health. It should, however, be noted that the trend in drug-induced deaths have been slightly increasing since 2013 in Norway [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although the causes for this increase are complex, a shift from heroin-induced deaths to those induced by other opioids has been observed. A marked increase in deaths induced by synthetic opioids is especially noteworthy. This is indicative of change in the underlying demographic, particularly for deaths associated with opioid analgesics [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This could mean that the harm-reducing efforts needs to be modified to ensure relevant reach and relevance.\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eThe present study holds some notable strengths. First, the study presents detailed data about trends in distribution across a six-year period at the municipality level in Norway. Second, as the study relies on official yearly reports issued by Center for Alcohol and Drug Research (KORFOR) as appointed by the Norwegian Directorate of Health it lends credibility and reliability to the data. Some limitations are also pertinent when interpreting the findings presented. First, although the participation rate at a municipal level increased after 2016, the number of municipalities not participating is relatively high. However, it is worth keeping in mind that most of the municipalities not participating are among the least populous in Norway \u0026ndash; while the most populous municipalities are participants across the years. This is especially important to note, as \u0026gt;\u0026thinsp;80% the Norwegian population lives in the 100 (out of 356) most populous municipalities. Second, as this study is based on retrieved aggregated data and was executed in a period with large reductions in municipalities due to mergers [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], accounting for dependence across years for municipality as statistical unit is not possible. Therefore, inferential statistics is based on a two-sample test of proportions, even though the statistical units under observation are dependent and in principle could be paired. We believe the results from this approach to still be valid as the participation rate has increased, and all the trend indicators increased during the period. For this interpretation to be void, the inflated type I error rate must be very strong and uniform, which we believe to be unlikely. Third, for the years 2017\u0026ndash;2019, the estimated needles distributed were more approximate than for the other years, as some of the municipalities did not report exact numbers but rounded estimates of needles distributed. We do, however, believe that the reported numbers reflect the actual distribution, and if anything is biased downward when considering the more exact numbers reported before and after this period.\u003c/p\u003e \u003cp\u003eRelevance and implications\u003c/p\u003e \u003cp\u003eThe distribution of harm reducing equipment to individuals with substance use disorders is considered an effective measure for reducing harm associated with drug use [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], such as risk for infectious diseases [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Furthermore, the distribution facilitates engagement between users and support services [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This engagement fosters a sense of self-worth among users and reduces stigma [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Additionally, the threshold for seeking other interventions or substance use treatment is lowered when a connection with support services is already established through the distribution of harm reduction equipment [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current distribution of N/S, naloxone, and other equipment are all efforts associated with the ongoing overdose strategy in Norway [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This strategy has relied on a network of municipalities and dedicated personnel responsible for the implementation at local and regional levels. The concerted effort at multiple levels of governance, ranging from central to local, has been a crucial precondition for achieving effective coverage in Norway. Moreover, at every stage, user representatives have been actively involved, ensuring that the initiatives have had support at the level of the users and incorporating their perspectives and needs. The same level of involvement applies to personnel in low-threshold services. Lastly, the concerns regarding potential overdoses and related harm have gathered significant attention at the political level, contributing to a relatively robust and coherent political impetus. For instance, in both the National Overdose Strategy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and the Escalation Plan for the Substance Abuse Field [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], the Norwegian government aims to assess the need for expanding access to harm reduction equipment.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn the present study, we found an increased coverage in distribution of harm-reducing equipment in Norway between 2016 and 2022. The observed positive trend indicates progress in addressing the negative consequences of drug use and aligns with Norwegian national strategies aimed at mitigating the harms associated with drug use. Future research should assess the effectiveness and identify areas for improvement in the harm reducing strategies in a Norwegian context, especially related to use of opioid analgesics.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: Not applicable, the data included is based on aggregated data provided by municipalities as mandated by the Norwegian Directorate of Health and official statistics available online.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The data used and analysed during the current study are available from the corresponding author on reasonable request (in Norwegian only), including collated data. In addition, data from official Norwegian sources were employed, and these are available online from Statistics Norway and the Norwegian Government (in Norwegian only).\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: No specific funding was received for this work. Data collection regarding municipality distribution was partly funded by Norwegian Directorate of Health and Center for Alcohol and Drug Research (KORFOR).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: All authors conceived the paper. Data collection was partly facilitated by MB and J\u0026Aring;. JCS planned and performed the initial analysis, and KNG and J\u0026Aring; provided feedback. Revised analyses were performed by JCS, and the remaining authors contributed to the interpretation of the results. JCS wrote the first drafts of the papers, while the remaining authors contributed substantially to the revision of the drafts. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: We would like to thank the municipalities for contributing to the data collection. We would also like to thank senior researcher Sverre Nesv\u0026aring;g at Center for Alcohol and Drug Research (KORFOR) for his valuable contributions to design of the municipal data collections and rationale for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRitter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev. 2006;25(6):611\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe Canadian Paediatric Society. Harm reduction: An approach to reducing risky health behaviours in adolescents. 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Pharmacoepidemiol Drug Saf. 2024;33(2):e5763.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlatt L et al. \u003cem\u003ePublic Health Research\u003c/em\u003e, in \u003cem\u003eAssessing the impact and cost-effectiveness of needle and syringe provision and opioid substitution therapy on hepatitis C transmission among people who inject drugs in the UK: an analysis of pooled data sets and economic modelling\u003c/em\u003e. 2017, NIHR Journals Library (National Institute of Health and Care Research): Southampton (UK).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones L, et al. Optimal provision of needle and syringe programmes for injecting drug users: A systematic review. Int J Drug Policy. 2010;21(5):335\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacNeil J, Pauly B. Needle exchange as a safe haven in an unsafe world. Drug Alcohol Rev. 2011;30(1):26\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWodak A, Cooney A. Effectiveness of sterile needle and syringe programmes. Int J Drug Policy. 2005;16:31\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe Norwegian Government. \u003cem\u003eOpptrappingsplanen for rusfeltet (2016\u0026ndash;2020) [Escalation Plan for the Substance Abuse Field (2016\u0026ndash;2020)\u003c/em\u003e. 2016.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4501562/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4501562/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHarm-reducing strategies are interventions designed to mitigate the adverse effects of substance use when abstinence is not a feasible option. Evidence supports the effectiveness and efficacy of harm reduction as a broad framework for addressing illicit drug use. To ensure the implementation of these measures, Alcohol and Drug Research Western Norway was mandated by the Norwegian Directorate of Health in 2016 to annually assess municipalities' adherence to harm-reduction guidelines. This study aims to present national trends in the distribution of harm-reducing equipment in Norway from 2016 to 2022. Specifically, we investigated the proportion of distributing municipalities, additional equipment distributed, and the population coverage. Our findings indicate an increased coverage in the distribution of harm-reducing equipment in Norway between 2016 and 2022. This positive trend demonstrates progress in addressing the negative consequences of drug use and aligns with Norwegian national strategies to mitigate drug-related harms. Future research should evaluate the effectiveness of these harm-reduction strategies and identify areas for improvement within the Norwegian context, especially related to use of opioid analgesics.\u003c/p\u003e","manuscriptTitle":"Trends in distribution of harm-reducing equipment for people who inject drugs in Norway, 2016-2022. 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