"People who use heroin (PWUH) have increased morbidity and mortality compared to the general population [1].

"Residential treatment is often considered the highest intensity of treatment for individuals with OUD [40], and may by particularly important for those with unstable housing, co-morbid mental health conditions, or high medical need [41].

"Growing evidence suggests that outpatient treatment, when coupled with MOUD, may be superior to other treatment settings.

"Methodology and Limitations

"The data available have limitations in respect to quality and coverage, however, the information available suggests that heroin was only present in the majority of overdose deaths in a relatively small number of EU countries. A significant share of overdose deaths was reported by Austria (67%), Italy (56%), Ireland (46% in 2017), Poland (44% in 2016) and Romania (43%).

"In 2021, the proportion of overdose deaths involving benzodiazepines increased in several countries and was present in more than half of the cases in Denmark, Austria, Portugal and Finland (see figure Proportion of drug-induced deaths with benzodiazepines involved in selected countries, 2019–2021 in Drug-induced deaths in Europe)."

"In 2022, generally very low levels of ketamine residues in municipal wastewater were reported by 15 cities, with the highest mass loads being detected in cities in Denmark, Spain, Italy and Portugal (see the figure Ketamine residues in wastewater in selected European cities, 2022, below)."

"Among first-time clients entering specialised drug treatment in 2021, or most recent year available, with heroin as their primary drug, 19% (down from 38% in 2013) reported injecting as their main route of administration. In this group, levels of injecting vary between countries, from less than 10% in Denmark, Spain, France and Portugal to 60% or more in Czechia, Estonia, Latvia, Lithuania, Romania and Slovakia."

"To be sure, the Portuguese model is not perfect. It has been criticized, for example, on the ground that there is a contradiction between the ideas of consent to treatment and the obligation to go to Commissions which, in turn, can apply sanctions (to people who do not have a substance use disorder) [6]. That is especially relevant today, as 90% of people using drugs are classified as not having a disorder (a vast majority of them using cannabis).

"In Vancouver and Lisbon, there are other critical gaps in harm reduction services and programs for YPWUD as well. In both settings, youth-dedicated safer injection, safer smoking, and overdose prevention sites do not exist. The COVID-19 pandemic prompted a scaling up of harm reduction initiatives in both Vancouver and Lisbon [9, 16].