Background:

This study explores why Swedish people who use drugs (PWUD) relocate to Denmark, in the context of differing drug policy approaches in the two countries. Specifically, the aim was to understand how PWUD experience and value different drug scenes and policy contexts, and reason about the benefits and risks of changing environments.

Methods:

We conducted 17 semi-structured interviews with PWUD who moved from Sweden to Denmark, recruiting participants from harm reduction sites in both countries, and through snowball sampling.

Results:

Key drivers for relocation included: harm reduction service availability, stigma, social networks, policing, and financial factors. Mobility between settings increased risks such as violence, exposure to new drugs, polysubstance use, and incomplete access to care. Participants presented evolving motivations over time, all but one participant reported several motivations.

Conclusion:

The study presented a contextual view of the nature and character of PWUD’s movement. The policy environment particularly influenced mobility. While aspects in one setting may promote well-being, other factors can increase potential for risk. Given the rapidly changing drug policy landscape in many parts of the world, this study offers insights into how PWUD navigate these settings, and can offer opportunities to better meet the needs of these individuals.

Professionals' understandings of substance use interventions and treatment goals impact treatment recommendations. We aimed to explore social work professionals' (SWP) attitudes towards harm reduction philosophy and measures in three areas of Sweden with very differing development of their harm reduction: Malm & ouml; (most developed), Gothenburg (moderately developed), G & auml;vleborg (least developed). We conducted a survey of SWP working with people who use drugs, utilizing the Harm Reduction Acceptability Scale (HRAS). An ANOVA with Bonferroni post-hoc correction was performed to assess for differences in mean HRAS score. There were 208 valid survey responses (Malm & ouml;: 79, Gothenburg: 82, G & auml;vleborg: 47). The overall mean score indicated positive attitudes towards harm reduction. Means differed based on geographic location, with Malm & ouml; and Gothenburg scores indicating significantly more positive attitudes towards harm reduction than scores in G & auml;vleborg. Opinions on implementation of new harm reduction measures such as heroin assisted treatment, supervised consumption sites, and decriminalization of drugs for personal use were more negative overall. These opinions followed the above trend, with regard to differences based on geography. Differences indicated that SWP who are more exposed to harm reduction have more positive attitudes. Increased knowledge of harm reduction among SWP could lead to improved access to interventions and reduced risks for people who use drugs.

Background Policies to address substance use differ greatly between settings, where goals may range from zero-tolerance to harm reduction. Different approaches impact formats of care, policing, and even interpersonal interactions, and may play a role in the labelling and stigmatization of people who use drugs (PWUD). Where Sweden has a more restrictive policy, aiming to have a society free from drugs, Denmark has embraced harm reduction principles. The aim of this study was to explore PWUDs' experiences of interpersonal interactions, policing, and service formats in the two countries.Methods The data consists of 17 qualitative semi-structured interviews with Swedish PWUD who have been in both Sweden and Denmark. Recruitment took place at harm reduction sites in both countries, and through snowball sampling.Results Participants reflected on how they were perceived by those in public spaces, and received by care systems and personnel. In public settings in Sweden, participants felt they were ignored, rendered invisible, and lost their humanity. In Denmark, they were perceived and acknowledged, valued as people. This was simultaneously linked to being embodied by the availability of differing service offerings and policing practices, which solidified their "right to be out" in public. Reflecting on their reception in the treatment system, strict formatting in Sweden caused participants to feel that an identity was projected upon them, limiting their opportunities or growth of new facets of identity. Care relations in Denmark fostered more opportunity for autonomy and trust.Conclusion A zero-tolerance policy and associated public discourses could solidify and universalize stigmatizing categorizations as a central feature of PWUD identity and reception from those around them, exacerbating social exclusion. Conversely, harm reduction-centered policies fostered positive interactions between individuals with care providers, public, and police, which may promote inclusion, empowerment, and wellbeing.

Sweden has a history of a restrictive drug policy, with a national policy focus on achieving a “drug free society.” This has led to a relatively slow development of “harm reduction” services, those services which aim to reduce risk and vulnerability for people who use drugs (PWUD), without requiring drug abstention. The harm reduction services which do exist are inequitably distributed across the country. In this context, this project aims to explore the attitudes of social work professionals (SWP) towards harm reduction, and the experiences of Swedish PWUD. The data consist of a survey of SWP (208 responses), interviews with PWUD in an area of limited harm reduction (11), and interviews with PWUD who had travelled to Denmark, a country with a less restrictive drug policy approach (17). 

Article I utilizes survey data to explore the perspectives of Swedish SWP regarding the philosophy of harm reduction and specific harm reduction initiatives. The study reveals a generally positive attitude towards harm reduction, albeit with significant geographical variances. There were low levels of support concerning the adoption of newer harm reduction strategies. Less positive attitudes and negativity regarding new interventions were significantly associated with SWP in areas with lesser exposure to harm reduction practices. 

Article II examines how PWUD in a small urban center handle the absence of local harm reduction services. The participants’ experiences are interpreted using the theoretical concept of “risk environment” which highlights how various environmental factors interact to produce risk of drug-related harm. Strategies ranged from traveling to external needle exchange programs, relying on unofficial secondary distribution, to risk behaviours such as stealing, reusing, or sharing injection equipment. Many were homeless, articulating a continuous struggle to find temporary shelter. They injected drugs in unsafe places, such as public toilets, increasing risk of overdose or infection. They also expressed 10 feeling stigmatized and excluded from society which compounded their stress, risk of disease transmission and overdose, and poor overall wellbeing. 

Article III explores the motivations behind the mobility of PWUD from Sweden to Denmark. The “risk environment” framework was used to contextualize decision-making and risks, based on the physical, social, policy, and economic environments. The study identifies harm reduction service availability, stigma, social networks, the drug scene, and policing practices, as key drivers for relocation. Despite the perceived benefits of moving, such as improved access to harm reduction services, participants also reported exposure to new risks, including violence, potential exclusion from a range of services, and exposure to new drugs. 

Article IV analyzes the reflections of PWUD on their experiences in Sweden and Denmark in the context of each nation’s drug policy. The analysis explored experiences of stigma and coupled these to concepts of identity and social exclusion. In daily interactions, participants felt ignored and dehumanized in Sweden’s zero-tolerance environment, whereas in Denmark, a country with a harm reduction approach, they felt visible and valued as individuals. This, combined with more developed services and a less punitive policing approach, led participants to feel included in society in Denmark. Contrasts between experiences in the two countries were also echoed in participants’ interactions with the healthcare system, relating to feeling controlled in Sweden, or being given autonomy and trust over their care in Denmark. 

Collectively, this thesis highlights the interplay between drug policies, care formats, policing practices, social interactions, the attitudes of SWP, and the lived experiences of PWUD. While overall positive, the attitudes towards care goals and interventions differ between different areas, among professionals who provide care to PWUD. PWUDs’ movement to and experiences in different settings can be used to offer an insight into their own policy preferences. The project demonstrates the role of constructions, and resulting drug policy, in how they influence PWUDs’ experiences of stigma and exclusion, and their risk environments. 

Background: The development of harm reduction has been limited in many areas of Sweden. This study aims to understand the implications that this has for the life circumstances and risk management of people who use drugs in areas of low access. Methods: Eleven qualitative, semi-structured interviews were undertaken with people who use drugs in a small urban centre with no needle and syringe exchange program (NSP) or Housing First policy. Results: Participants reported many solutions to lack of NSP, including travel to an external NSP, creating bridging distribution networks, stealing, borrowing, reusing, ordering online, and smuggling injection equipment. They were at risk of having their equipment confscated by police. Participants were mostly homeless, and to address exclusion from housing services, were forced to frequently fnd new temporary solutions, sheltering themselves in public places, with friends, in cars, among others. Participants felt the lack of services refected stigmatized notions of drug use and heightened their exclusion from general society. For example, they avoided accessing other health care services for fear of discrimination. These issues caused high levels of stress and anxiety, in addition to serious risk for many somatic and psychological health conditions, including HIV and HCV transmission. Conclusion: Lack of harm reduction services placed a great burden on study participants to develop strategies due to gaps in ofcial programming. It also contributes to a vicious cycle of exclusion from services. The implementation of such evidence-based programs will reduce this burden, as well as provide the indirect, symbolic efect of inclusion.