Europe has been the first home for the harm reduction movement, acknowledging its values and principles relatively early, although not without challenges. Built on successful experiences starting in the early 1980s, some pioneering European countries committed, invested in and implemented a broad spectrum of harm reduction services over the years. The HIV/AIDS epidemic helped to establish a broader recognition of the effectiveness of harm reduction policies in other countries as well by the mid-1990s. However, we argue that the adoption of harm reduction is lagging behind in important ways, leading to uneven and poor implementation of services. In this perspective-paper, we highlight some reasons that may have contributed to this, and we explore how multiple societal trends and the current conceptualisation of harm reduction have hindered further acceptance and implementation. We do this by revealing assumptions underlying the concept of harm reduction. Finally, we explore how we may move harm reduction forward as a field.