Background

Denmark and Sweden have similar welfare systems, but different drug policies. Denmark has historically a more liberal and more harm reduction-oriented drug policy than Sweden. On this background, we present a study of risks and use of formal and informal resources among structurally vulnerable people who use drugs in Copenhagen in Denmark and Malmö in Sweden.

Methods

The study reports from research projects in each city that investigated the everyday lives and risks- and enabling environments of structurally vulnerable people who use drugs. Both projects involved the same survey. Participants were recruited at treatment and low-threshold services in Copenhagen (n = 243) and Malmö (n = 231).

Results

The participants in the two cities used many different resources provided by the welfare system, but participants from Copenhagen made more use of available harm reduction services. The participants from Malmö used drugs in more risky settings and relied more on other people who use drugs for resources and had more concerns regarding overdoses and other drug-related harms and about being arrested by the police.

Conclusions

In both cities, the Nordic welfare state plays a large role in providing resources, but drug policy can influence access to harm reduction resources and the experience of criminalization. These differences can play a role in shaping the local risk environments, although the patterns identified should be interpreted with caution given the exploratory nature of the study. More comparative research is needed to explore how drug policy shape risk environments.

National drug policies and legislation set the framework for the police's work against drugs. However, police officers use their discretion to implement policy into everyday drug law enforcement. This study is based on qualitative interviews with 19 police officers in Malmö, Sweden, with the aim of analyzing police officers’ views on and actions in relation to personal use and possession of drugs in a zero-tolerance drug policy setting. Our analysis focuses on three main areas: (1) police officers’ views on the criminalization of drug possession for personal use, (2) how they perceive and categorize people who use drugs (PWUD), and (3) how they apply discretion when handling complex cases, making decisions, and prioritizing enforcement actions. The results show that the police officers support the continued criminalization of minor drug offenses, motivated by a deterrence and prevention-based perspective and by a strategic use of the law to reach higher levels of drug market hierarchies. However, the police used categorization work to differentiate between user groups, resulting in an informal two-track system in which one leans toward de facto depenalization and harm reduction principles for marginalized PWUD and the other favors punitive interventions for youth and first-time offenders. The study also demonstrates how police discretion can involve uncertainty but also flexibility, allowing for more experience-based and context-sensitive judgments in the face of complex situations. Sweden constitutes an interesting case for studying how police officers relate to punitive drug policies. The study emphasizes the critical need to examine how drug policy unfolds locally, shaped by police culture and discretion in everyday practice. The way discretion is exercised can have a profound impact on the risks and opportunities faced by PWUD, with significant implications for both public health and justice outcomes.

BACKGROUND: The growing population of older adults with long-term drug use has been largely overlooked in research. While most research on street culture have focused on younger men, the experiences of aging within these environments have received limited attention. This study seeks to address that gap.

METHODS: We conducted 20 semi-structured interviews with men aged 55 or older with current and long-term drug use, in Malmö, Sweden. The data were analyzed using a thematic approach.

RESULTS: Our analysis identified three overarching themes that illustrate the men's status and strategies within street culture: (1) Mastering the game - Age as street capital: The men often viewed older age as an asset, associating it with accumulated knowledge and respect within street culture. (2) Staying in the game - Adapting to aging: Some men described adapting their methods of obtaining money and drugs in response to age-related changes. (3) Leaving the game - Withdrawal and marginalization: Others distanced themselves from people and activities within street culture.

CONCLUSION: Our findings show how aging reshapes older men's status, relationships, and survival strategies within street culture, revealing both resilience and vulnerability. Aging, in this context, is understood as a social process, emphasizing its significance within street culture.

Older adults with long-term drug use have long been overlooked in both drug research and agingresearch. More knowledge is needed about their experiences and needs. Drug use is often seen asa youth phenomenon and as something that with time leads to destructiveness and compulsion. Amore nuanced picture of who uses drugs and what the use may look like over time is necessary.There is limited insight into what it means to age with drug use, based on individuals’ own storiesand experiences. We conducted 27 semistructured interviews in Sweden with individuals aged 55or older who reported current and long-term drug use. In this article, we demonstrate how the relationship with drugs evolves over time and how the interviewees contemplate stopping or continuingtheir use. Three themes were identified: (1) Aging out of drug use: Thoughts on drug cessation. Someexpressed a desire to end their drug use. The reasons behind this varied, but there was a clear patternrelated to older age. (2) Aging with drug use: Thoughts on continued use. Some had a desire to continueusing drugs and expressed concern about how everyday life would be without them. (3) Age adapteddrug use: A change in drug use. Several participants stated that their drug consumption had changedover time and with age. Drugs no longer dominated their lives as before but still served essential functions. The themes should not be seen as rigid categories, but as fluid narratives. Understanding thisvariation provides a deeper insight into people’s often complex relationship with drugs.

The use of alcohol or illicit substances by youths may be related to sexual motives and experiences. Accordingly, child welfare workers need to address young people's sexuality in their investigative work. In this study, we have examined the significance of different social categories, namely gender and sexual orientation, when child welfare workers assess young people with a substance use and their related sexual health. Fifteen child welfare workers were recruited through a strategic sampling to participate in semi-structured interviews, which were analysed using thematic content analysis. The results consist of three sub-themes: Sexually vulnerable girls; Boys as perpetrators; and Unseen LGBTQ+ youth. Together, these sub-themes constitute an overarching theme where the heterosexual matrix appears to be the interpretative framework when investigating a problematic substance use. The suggested implications for practice include education in sexual and reproductive health and rights for child welfare workers aiming to achieve an equitable assessment process for all youth with a problematic substance use. 

Socialsekreterares förståelse av kön, sexuell läggning och sexuell hälsa i utredningar av unga med substansmissbruk 

Ungas substansanvändning kan ibland relateras till sexuella motiv och erfarenheter. Det är därför av vikt att socialsekreterare adresserar dylika frågor i barnavårdsutredningar som är fokuserade på ungas eventuella missbruksproblematik. I denna studie har vi därför undersökt hur olika sociala kategorier – kön och sexuell läggning – relateras till ungas sexuella hälsa, men också hur det får betydelse i utredningar av unga med missbruk. Femton socialsekreterare har intervjuats med stöd av en semi-strukturerad intervjuguide, vartefter resultatet analyserats med hjälp av en tematisk innehållsanalys. Det slutgiltiga resultatet ledde fram till tre sub-teman: sexuellt sårbara tjejer; killar som förövare; osynliga HBTQ+ -ungdomar. Dessa tre teman bildar tillsammans ett övergripande tema; den heterosexuella matrisen fungerar som tolkningsram i utredningsarbete av ungas substansmissbruk. Implikationer för praktiken innefattar bland annat utbildning i sexuell och reproduktiv hälsa och rättigheter (SRHR) för socialsekreterare inom den sociala barnavården i syfte att säkerställa jämlika utredningsprocesser för alla unga med substansmissbruk. 

A number of ideas have been put forward to help understand the relationship between, on the one hand, individuals within a family (or the family as a whole) who are affected when a member of that family develops an addiction-type problem (with alcohol or other drugs or gambling), and on the other hand, that person in the family who has developed such a problem. This chapter outlines some of the main perspectives that have been developed, including genetic and biological perspectives, psychological perspectives (including psychodynamic, ‘co-dependency’, stress-coping and family systems) and sociological/political models (such as feminism and community psychology). It then examines the implications of these various conceptual models for theory, policy and practice, before concluding with a summary of the AFINet approach.

BACKGROUND: Opioid agonist treatment (OAT) is a highly effective treatment option for people with opioid use disorder. The potent medications used create dilemmas regarding low or high thresholds to access treatment, patient autonomy and regulations. OAT in Scania County in the south of Sweden has seen the implementation of regulatory changes resulting in liberalization through a patient choice model and increased access to treatment. In this setting, in which OAT has developed from high threshold to low threshold because of policy changes at both national and local levels, we aimed to analyze how patients and staff view the risks and benefits of OAT.

METHODS: We conducted qualitative interviews with 32 OAT patients and 15 OAT staff in Malmö, Sweden. We analyzed the data with a thematic analysis approach.

RESULTS: Patients reported that OAT helped them to "stabilize" their lives although many felt a sense of being locked into treatment, which acted as a barrier to normalization. A significant risk was being offered illicit drugs by patients and dealers when visiting the clinic. Patients who had enrolled in OAT before liberalization found current guidelines too lenient and expressed worry that persons being enrolled were too young. Staff viewed liberalization with some ambivalence, with a positive view of increased access to OAT, although they had worries about the enrollment of young patients and difficulties supporting patients with ongoing drug use. Staff also viewed the sale of drugs in and outside of clinics as a significant problem. Some staff viewed medicines as the most important aspect of OAT, while others positioned the social support as most important.

CONCLUSIONS: Patient and staff perspectives were relatively congruent as they highlighted substantial risks regarding drug dealing at OAT clinics and were ambivalent toward the liberalization of OAT guidelines and the increased access to OAT. Liberalization impacted both patients and staff in their everyday lives and in professional practice, in a setting where OAT is both a desirable treatment and sometimes the basis of a problematic drug scene.

Many faith-based organisations (FBOs) provide social work services to marginalised groups in need of care such as people who use drugs (PWUD), but little is known about how diaconal or faith-based social work with PWUD is carried out and how staff view their work. The aim of this study was to explore how social work with PWUD within FBOs in Sweden is conducted. This study is based on semi-structured qualitative interviews with 14 employees at a range of churches in Sweden. The empirical material was analysed with qualitative textual analysis. FBO staff channeled a personal calling to offer services through their organisations and found PWUD be in need mainly of emergency support. Staff engaged in boundary work such as differentiating between activities conducted at the church premises or on the streets. Staff accompanied clients to meetings with publicly funded welfare services to the benefit of the clients, and they appreciated their free role compared to social services staff. FBOs mainly act as stabilisers in relation to official public welfare services. The role of prophetic diaconal work aiming at social justice was limited and clients’ emergency needs were in focus, which indicates that FBOs in Sweden mainly complement welfare state services.

‘En fri position på mittfältet' – En kvalitativ studie om diakonalt socialt arbete med personer som använder narkotika i Sverige

Många diakonala organisationer (FBOs) utövar socialt arbete riktat mot marginaliserade grupper såsom personer som använder narkotika, men vi vet lite om hur diakonalt eller trosbaserat social arbete med denna grupp genomförs och hur personal ser på sitt arbete. Syftet med den här studien var att utforska hur socialt arbete med missbruk och beroende inom diakonala organisationer bedrivs. Studien är baserad på semistrukturerade kvalitativa intervjuer med 14 anställda vid olika kyrkor i Sverige. Det empiriska materialet analyserades med hjälp av kvalitativ textanalys. Personalen kanaliserar ett personligt kall genom att erbjuda sociala insatser via organisationerna och de ansåg att personer med missbruk framför allt behöver akuthjälp. Personalen ägnade sig åt gränsdragningsarbete som att skilja mellan aktiviteter genomförda i kyrkan eller på gatunivå. Personal följde med klienter till möten med socialtjänst för att bistå klienterna och de såg fördelar med den mer fria rollen jämfört med socialtjänstpersonalen. Organisationerna agerar framför allt som stabiliserande i relation till offentliga sociala välfärdsinsatser. Profetiskt diakonalt arbete med fokus på social rättvisa var begränsat och klienternas nödhjälpsbehov var i fokus, vilket indikerar att organisationerna mestadels kompletterar det sociala välfärdssystemet i Sverige.

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.