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Illicit drug use poses significant threats to health and drug-related harm often creates life-threatening consequences for the individual. A country's drug policy and ideological beliefs can affect the way harm minimization measures are offered in society. A country's ability to scale-up access to treatment and prevention can be affected by not officially incorporating harm reduction (HR) strategies in policy. HR in itself is not a new concept in drug policy but is not universally accepted (Jourdan, 2009). Conflicting perspectives on HR exists in Sweden among professionals; this causes long-standing effects often reflected in national drug policy. The way data is analyzed and interpreted by professionals also differs. These differing interpretations do not allow for convergence in what approaches are used for problematic drug use (PDU) population. PDU is defined as "injecting drug use or long duration or regular use of opioids, cocaine and/or amphetamines" (EMCDDA, 2010). Drug policy affects the availability of treatment, care and support to problematic drug users (PDUs). Thus, it is necessary to examine a country's national policy governing drug control.
Sweden's drug model stands out in countries of the European Union (EU) and is faced with principles that are often viewed as counter-productive for the marginalized community of drug users. Sweden shares similar cultural and moral views with its Danish neighbour but differs in terms of outlook on HR in policy - Denmark having a rather HR friendly policy compared to Sweden. The restrictiveness of the Swedish drug policy does not always allow HR strategies to be easily brought forth onto the political table (Boekhout, 1997). As with other EU countries, Sweden complies with three international conventions on narcotic drugs established by the United Nations - the Single Convention on Drugs, 1961; the Psychotropic Convention, 1971; and the Convention against illicit handling of drugs and psychotropic substances, 1988 (INCB, 2009). Sweden's drug policy goal is to have a drug free society - a goal not viewed as realistic by many EU countries - but fits in with the zero tolerance approach on illicit drugs.
As Sweden's neighbouring country, Denmark also has a national drug policy that is centered on restricting the use of non-medical/scientific drugs; complying with international conventions on narcotic drugs. The policy focuses on preventive intervention, multi-pronged, comprehensive treatment programmes and efficient control (Reitox National Focal Point, 2008a). The aim of this study is to seek the knowledge and beliefs of professionals in the field of HR and policy work to understand the internal inconsistencies seen in the Swedish drug policy. It is important to note that this study does not attempt to evaluate the success of Sweden's drug policy, but to understand general anti-HR attitudes despite present HR interventions. References to the Danish drug policy will also be made in this study.
1.1 Problem Drug Use
Lifetime prevalence and non-problematic drug use in students and the general public are relatively low in Sweden compared with other countries in the rest of Europe (UNODC, 2007) and the prevalence rate of PDU among 15 to 64 year olds in Sweden is 0.44% compared to the EU-25 average of 0.52% (Figure 1). PDU compromises health and the most common risks associated with it includes blood borne viral infections, overdose and drug-related deaths, psychiatric co-morbidity and trauma (EMCDDA, 2010).
Sweden differs from most countries in Western Europe, in that the main problematic drugs of choice are psycho stimulants, specifically amphetamine. Since the 1970s, opioid use - especially heroin - has generally been the main problematic drug across Europe. Heroin use in Sweden has been increasing over the years (UNODC, 1997) with treatment services not adequately equipped to deal with users.
The HIV/AIDS epidemic has triggered many responses to improving access and quality to prevention, treatment and care. Universally, there are 33.4 million people living with HIV and 2.7 million new infections occurred in 2008 (WHO, UNAIDS, UNICEF, 2009). The World Health Organization (WHO) suggests that the global number of injecting drug users (IDUs) is increasing and estimates that between 11 and 21 million people inject drugs with 0.6 million to 6.6 million of them living with HIV (WHO, UNAIDS, UNICEF, 2009). Injecting drugs is a principle mode of HIV/AIDS transmission and the total number of newly diagnosed HIV cases in 2006 reported from 50 countries in the European Region was 86 912. More than 25% (24 102) were from IDUs (EuroHIV, 2007). IDUs are defined as "any person who has ever in their lifetime injected a drug for non-medical purposes" (EMCDDA, 2010). The number of individuals infected by HIV by means of injection has been low in Sweden, 14% of all transmissions are from injecting, compared with 38% for all of Europe (UNODC, 2007 and Reitox National Focal Point, 2008b).
While the high European prevalence of HIV in IDUs is limited to the east, hepatitis in IDUs is prevalent across Europe (EMCDDA, 2010). 21 million and 2 million new cases of hepatitis B virus (HBV) and hepatitis C virus (HCV) are respectively due to unsafe injection practices in the European Region (WHO, 2010). Sweden and Denmark are still showing signs of increasing HCV among IDUs (SMI, 2009 and Reitox National Focal Point, 2008a).
1.4 Harm Reduction
HR is a legal and practical concept that includes interventions, strategies and policies to help limit risks to society as a result of problematic drug use. A universally agreed upon definition does not currently exist but this straightforward definition from the International Harm Reduction Association (IHRA) encompasses all the main principles of HR: "â€¦policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the user of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community" (IHRA, 2009). Various HR interventions exist, including needle and syringe exchange programmes (NEP); opioid substitution therapy (OST); testing and counselling; safe injecting facilities; and de-penalization of drug-related offences.
This study is case-based and qualitative in nature; it utilizes thematic data to explore how HR is viewed in light of the Swedish drug policy.
2.1 Conceptual Framework
Drug abuse is evident in all societies and no one intervention can effectively curb the problem. The overarching framework used in this study is interpretivist in nature. By using an interpretivist perspective, conflicting interpretations among cases are discussed using naturalistic methodology (Miles & Huberman, 1994).
The use of this perspective allows for extraction of knowledge and beliefs from informants. It is the author's assumption that drug policy leading to harm reduction policy are socially constructed and negotiated within a cultural containment. This theoretical belief allowed the author to discuss several claims to the knowledge of HR strategies in the context of drug policy. In general, there are two views regarding HR and each view shall be candidates for cases - anti-HR and pro-HR.
2.2 Selection of Informants
At first, nine key informants were purposefully selected based on their professional affiliation to harm reduction and drug policy. Informants were selected based on their experience and their availability to discuss issues within their specific area of expertise. Emails requesting interviews were sent out and four informants responded back confirming interest and availability. These interviews resulted in a snowball effect and three more key informants were indentified. In total, seven interviews were included in this study - one female and six males.
It was not necessary for informants to have similar professional requirements. In fact, this helped to gain different insight into the research questions and the Swedish society. It was important to describe the understanding of different professionals in order to increase variability in the study.
2.3 Study Design
A qualitative method - more specifically cross-case analysis - was used in this study. The benefit of using this qualitative approach was to gain insight into an already existing problem through interviews and complementary techniques appropriate for explaining data (Miles & Huberman, 1994). Case study methodology is suitable to use when understanding a complex issue such as drug policy and supplements what is already known through previous research (Yin, 1984). Cross-case analysis will aid in revealing common and different patterns in the development of the findings (Khan & VanWynsberghe, 2008).
2.4 Study Setting
Four face-to-face individual interviews (two in Malmö, two in Copenhagen); one Skype interview; and two telephone interviews were conducted. Face-to-face interviews were held in the offices of the informants. Observations were also made at the needle and syringe exchange clinic in Malmö and at the heroin clinic in Copenhagen.
2.5 Data Collection
Multiple sources of data are often used in cross-case analysis to establish trustworthiness (Miles & Huberman, 1994). Three sources of evidence were used to collect data in this study.
Documentation: government reports, scientific journal articles, newspaper articles, political blogs, reports from international agencies, data from government and non-governmental institutions, treatment centres, advocacy centres, etc were reviewed. Some data were sometimes translated from Swedish or Danish to English.
Interviews: from 18 March to 19 April 2010, seven individual interviews were conducted using a semi-structured interview guide. Interviews were tape-recorded with permission and conducted in English. A systematic, yet flexible approach was taken, where informants had similar types of questions which were prepared prior to interviews. Notes taken during interviews were included in transcribed data.
Direct observation: data were also collected from observing two informants at the needle and syringe exchange clinic and the heroin clinic. This resulted in three informal conversations with drug addicts at both clinics services - two at the needle exchange clinic in Malmö and one at heroin clinic in Copenhagen. Notes were taken during observations.
2.6 Data Analysis
It was necessary for the author to articulate to key informants that the concept of HR in this study was not a solitary term. It was up to the key informants to define what they considered HR to be. Interviews were transcribed and interpreted by the author over a period of four weeks. Notes from direct observations were transcribed into summaries and included in analysis.
Cross-case analysis began with first level coding of transcribed data. This involved reading through transcribed texts and summarizing segments of data (Miles & Huberman, 1994). Descriptive codes were written down next to summaries to verify that informants were categorized into appropriate cases based on the theoretical framework. For comparison purposes, cases were designated as C1 and C2 (Table 1).
Within each case, patterns were identified and codes were written next to underlined texts (Table 2). Tentative themes and patterns were written down next to individual statement(s). Data from cases were then separated into clustered themes. Then similarities and differences across cases were identified.
Key informants were not told prior to the interview which case they would be grouped in and for reasons of confidentiality, interview and observational extracts are only identified by the professional area in which the person works or the clinic in which observations were made.
2.7 Ethical Considerations
Participation in this study was strictly voluntary. It was not necessary to gain approval from an ethical committee as this is a Lund University student project. Terms of confidentiality were addressed and ethical guidelines were followed as per Kvale and Brinkmann's (2008) ethical guidelines while interviewing.
Findings resulted into three main themes: (1) what is 'harm reduction?' with the sub-theme, multiple harm reduction strategies; (2) best approach, with three sub-themes, needle and syringe exchange programmes, opioid substitution therapy and long waiting lists; (3) the successful Swedish drug policy with two sub-themes, utopian drug policy and exportation of policy.
What is 'harm reduction?'
A universal definition of harm reduction does not currently exist, but for the most part the concept was described and understood similarly across cases.
"[Harm reduction] includes a comprehensive package aimed to prevent HIV infection and other infectionsâ€¦, [the interventions are] not listed in terms of most effective, but in strength of evidence". - WHO staff member; C1
"â€¦minimize(s) the risk for persons who are using drugs both socially and health wise. We have to try to cope with the bad situation of stigmatization, exclusion, housing and other health matters [for drug abusers]. But this is all gathered in the harm reduction philosophy of Denmarkâ€¦not really in Sweden though" - Danish general practitioner; C1
"The way [harm reduction] is viewed from common opinionâ€¦it's used in organizations for legalization to help addicts to go on with their addiction, but also to help them with all the problems they are having because of their addiction" - Swedish liberal politician; C2
Multiple harm reduction strategies
A unanimous consensus on the need for multiple HR approaches was apparent in both cases. HR strategies that were mentioned included therapeutic communities, financial and housing support, testing and counselling, outreach and awareness programmes, vaccinations, treatment clinics, NEP and substitution treatment.
"Typically you need a combination of interventionsâ€¦no single approach is going to work in any given situationâ€¦there are nine interventions that have been determined (by WHO), but there are other [interventions] as well." - WHO staff member; C1
"You have a tradition of more low-threshold harm reduction alternatives in Denmark than Swedenâ€¦Like housing where homeless (drug abuses) can stayâ€¦" - Swedish professor of social work; C1
To the question "what is considered the best harm reduction strategy for IDUs?" C2 informants mentioned that of all strategies offered, testing and counselling was of utmost importance. C1 informants also recognized the importance of testing and counselling, but it was not the top strategy that was mentioned in all interviews.
"The thing that has been successful in terms of getting down the spread of HIV among the drug users in Stockholm, is that we have been very effective in testing and drug users have been very willing to test themselvesâ€¦for HIV and they have requested for each other to take the test and also requested to disclose the result among themselves so they can be sure if they do share needles that the one that they share with is not positiveâ€¦" - Swedish researcher and clinician; C2
Discord across cases arose on types of strategies that should be recommended and followed in connection to treatment.
"â€¦if you look at the evidence of the effectiveness, the most effective intervention would be needle and syringe programmes, followed by opioid substitution therapy and then third in order of magnitude would be antiretroviral therapy for drug injectors." - WHO staff member; C1
"...the approach for drug strategy is not to get them to quit [abusing drugs] but get them to the level where they can be part of society again." - Danish general practitioner; C1
"We know that it is wrong in Sweden to have the abusers continue their abuse with drugsâ€¦that is the wrong policy. The focus should be on preventing drug use in the first place." - Swedish liberal politician; C2
NEP and OST were two HR strategies fervently not agreed upon in terms of its effectiveness. Whereas other strategies like testing, counselling and education, and vaccinations were favourably viewed by all informants.
Needle and syringe exchange programmes
All key informants, regardless of their stance on harm reduction agreed that NEP would not encourage more drug abuse.
"I don't think it enables more drug use. Sweden is just ideologically against providing needlesâ€¦I don't think it'll make very much change (in increasing drug abuse) because drug users are being fairly rational and they're trying to clean the syringes and this has been demanded from the drug users organization. So why should we not for once do something that they want instead of always coming down with a bad impression of them. I think it's a way for society to say look, we're willing to take your side and we can help you. If you look at it from a world perspective, it seems clear that the needle exchange programmes have been positive." - Swedish policy researcher; C1
"There are some people that think if you provide needles, more people will inject drugs. I have tried to find out if there's a connection of the availability of syringes and needles and injecting in my researchâ€¦I've been discussing it with lets say 100 to 150 heroin or amphetamines users and they say it's not likely they would inject more if clean needles were providedâ€¦ people don't start injecting more because they know someone is providing them with some more needles for free - Swedish professor of social work; C1
"I'm not that worried about needle exchange as I am about injection roomsâ€¦but I don't think it's (NEP) the first thing you should doâ€¦it's very important to do HIV testingâ€¦I think it's a mistake from the WHO to not have a high priority of HIV testing, because the first thing WHO listed to do is needle exchange." - Swedish researcher and clinician; C2
The ability to exchange used needles and syringes with clean ones was received positively by addicts in the clinics and one addict mentioned he would not have wanted to travel all the way to Lund if the clinic in Malmö did not exist and it was good that there have not been any new cases of HIV in Malmö during the eight months he has been going to exchange needles and syringes.
Scientific evidence for the effectiveness of NEP in reducing the prevalence of HIV among IDUs differed across cases. Some informants in both cases used the Montreal and Vancouver studies, in which the HIV prevalence increased among IDUs after the implementation of needle and syringe clinics, to justify their positions. C1 informants favoured the studies' conclusion and accepted it as scientifically accurate, while those in C2 disagreed with the conclusions and analyse them differently. Other reasons cases did not agree were also mentioned.
"The NEP study in Vancouver in '88 among IDUs in Vancouverâ€¦didn't show that NEP protected them (IDUs)â€¦the prevalence actually went up. This means it wasn't really effectiveâ€¦I'm not saying it's not good to do, but there are more effective ways to help addicts if we're talking about harm reduction." - Swedish researcher and clinician; C2
"The reason the prevalence (of HIV) increased was due to the success of the programme. The programme was the only one of its kind and it was so attractive to drug users, it was attracting in the most risky users and as more of these users were coming in, of course coming along with their risk behaviour, were the consequences of their risk behaviour. So it was actually attracting new clients that were positive. So prevalence would go up." - WHO staff member; C1
"The only way a clean needle can be effective is if it's used only once. After that it is no longer cleanâ€¦and it has been shown that they (IDUs) still share it among themselvesâ€¦so it's no longer clean when the second, third, even fifth person uses the same needleâ€¦so then saying that exchange programmes is effective is wrong thing to say when sharing still occurs in the community." - Swedish liberal politician, C2
"â€¦the (NEP) clinic in Malmö has been proven not to be effectiveâ€¦less addicts are visiting the clinic. The number of visits have decreased over the years, so you can't tell me this is still effective." - Swedish liberal politician; C2
"If you look at the evidence to support harm reduction, the most effective is NEPâ€¦every study shows that the actual percentage of people sharing (needles) decreases. Typically between rates of between 50-60-70 percentage of people that are sharing, generally after a year, drop to 20 percent and eventually down to 15 percent and maybe down to 10 percent...I'm not saying that every single person stops sharing, but the sharing rates between people who share and don't share decreases." - WHO staff member; C1
Opioid substitution therapy
The provision of OST was regarded as imprudent by C2 informants but relevant by C1 informants. It was mentioned that the quality of life of addicts settled on long-term opioid substitutes was not in line with the goal of equal health for all. Crossing this with C1 informants, OST was the most effective means of stabilizing and re-integrating heavy and long-time drug addicts into society. Improvements in quality of life for addicts in these programmes included: less vulnerability to infectious diseases, overdoses and death; not as involved in criminal activity and better chances of gaining meaningful employment.