Colombia expands harm reduction, but access and policy remain uneven

AIMS: To provide a comprehensive national profile of substance use patterns, drug-related harms, treatment and harm reduction responses, and policy developments in Colombia, and to analyze how public health reforms coexist with historically prohibitionist frameworks. METHODS: We synthesized data from national household, school, and university surveys, epidemiological surveillance systems, official statistics, policy documents, and peer-reviewed research. Evidence was analyzed to describe trends in substance use, overdose and related harms, treatment access, harm reduction initiatives, and the broader legal and institutional context. RESULTS: Alcohol, tobacco, and cannabis remain the most widely used substances in Colombia, while emerging synthetic drugs and opioid use have increased pressure on health and social services. Drug-related harms, including overdose and mental health problems, show significant regional and socioeconomic disparities. Although treatment coverage and harm reduction interventions, including community-based programs and supervised consumption services, have expanded in recent years, access remains uneven, particularly in rural and peripheral areas. Colombia's contemporary drug policy reflects a hybrid governance model in which constitutional protections of personal autonomy and recent harm reduction reforms coexist with enforcement-oriented practices shaped by illicit drug markets, armed conflict, and territorial inequality. SUMMARY: Colombia illustrates both the opportunities and the structural constraints of public health-oriented drug policy in middle-income countries deeply embedded in transnational drug economies. Strengthening surveillance systems, expanding territorially adapted services, and integrating health policy with broader social and development strategies will be essential to consolidate more coherent and equitable responses.