Are we fighting a war on drugs or on those addicted to them? A case for harm-reduction services in Sweden

Author: Melinda Rocchi. I am an Italian Medical Doctor and current Master’s of Public Health student at Lund University, Sweden. My research has focused on primary health care, disability, and mental health.

Substance addiction is a growing health issue that necessitates a public and mental health approach. Despite this, a majority of governments and public opinion consider it a criminal justice issue that can be solved by imposing penalties. This stems from the common prejudice that people who use drugs are responsible for what they do: they are dangerous individuals who don’t deserve help, unpredictable menaces to society. But are they? When health is so connected to society and its inequities, can we say that people with substance addiction are entirely responsible for their health? Personal choice is important, but we can’t keep thinking that addiction is only an individual problem.

I recently read an article¹ from the New York Times discussing harm-reduction and how hard it is to implement such services. Harm-reduction refers to policies and programs that aim to reduce the negative consequences associated with drug use. Even though these measures have been confirmed to be a good way to reduce overdose deaths, reduce the spread of infections transmitted through needles, and increase the number of people seeking treatment and rehabilitation, the debate around them is still huge. Since stigma surrounding addiction is still alive and well, those who oppose these practices say they are just a way to increase drug use among the population and make the community less safe. But if harm-reduction is not provided, does that mean that people with addiction will stop using drugs? Or just that more people will use them unsafely and die more often? Those who struggle with addiction shouldn’t be left at the margins of society: they should find a safe space where they are not shamed, and where they can get the support they need. After all, the Sustainable Development Goals (SDGs)² mention the strengthening of prevention and treatment of substance abuse as part of their objectives.

This made me think about the situation in the country I currently live in, Sweden. Since the 1980s, Sweden has had a zero-tolerance approach to drug use, meaning that policies³ surrounding this issue are based on criminalization. As is often the case with topics seen as sensitive, policies regarding addiction are often influenced by emotional arguments, or ideological beliefs rather than evidence. This approach led to restricted access to harm-reduction services, often seen as an obstacle to a drug-free society, even after changes made in the law⁴ in 2019. Harm-reduction experimental clinics first opened in Lund and Malmö, Skåne in 1986 and 1987 but the first one outside the region opened in 2012. The impact of those services has been massive since, and its efficacy has been supported by a government HIV report in 2010 noting that the growing number of HCV and HIV cases in Stockholm could partially be explained by harm-reduction services absence at the time⁵. While improvements are happening, they are not uniform in the country, and a lot of people are still not covered.

Overall, as a 2022 article⁶ from Malmö University confirms, this approach has been shown to not be effective for the goal of reducing negative outcomes, with Sweden being one of the European countries with the highest number of overdose deaths.

Where harm-reduction centers are not present, people have to travel to other regions to get clean needles and support. But not everyone can do that, especially since people with addiction often live at the margins of society or have job and housing insecurity. Some may have to resort to secondary needle exchanges, illegal import from nearby countries, or theft. In the worst-case scenario, they just don’t use clean needles, don’t have treatment for overdose nor safe places where to inject drugs. It’s easy to see how this is a problem, not only for the individual but also for public health and the community.

Even where harm-reduction services are present, people may have a hard time accessing them. The stigma that comes from society and criminalization is often internalized and individuals may feel ashamed to ask for help or fear social repercussions. Legal consequences are also an issue. Since drug possession is a crime, people are afraid to be stopped by the police outside of centers or that their health records may interfere with the opportunity to get a job or housing in the future.

Individuals with substance addiction are not second-class citizens and shouldn’t be treated as such. Their health matters as much as that of everyone else and, if we can avoid them risking their life and suffering, why should we not do that? Addiction is a problem rooted in society and, while aiming at a drug-free society is a noble effort, it’s not a simple one. We don’t live in an ideal world and, as health professionals and/or policymakers, we must work with what we have and make sure we don’t leave anyone behind.

References:

1.        Interlandi J. Opinion | Inside New York City’s Radical Approach to America’s Overdose Crisis. The New York Times. https://www.nytimes.com/2023/02/22/opinion/drug-crisis-addiction-harm-reduction.html. Published February 22, 2023. Accessed July 27, 2023.

2.        SDG Target 3.5 | Substance abuse: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol. Accessed July 27, 2023. https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-group-details/GHO/sdg-target-3.5-substance-abuse#

3.        Narkotikastrafflag. Sveriges riksdag, Ministry of Justice (Justitiedepartementet L5 ); 1968. Accessed July 27, 2023. https://www.riksdagen.se/sv/dokument-och-lagar/dokument/svensk-forfattningssamling/narkotikastrafflag-196864_sfs-1968-64/

4.        Lag Om Utbyte Av Sprutor Och Kanyler. Sveriges riksdag, Ministry of Social Affairs (Socialdepartementet); 2006. Accessed July 27, 2023. https://www.riksdagen.se/sv/dokument-och-lagar/dokument/svensk-forfattningssamling/lag-2006323-om-utbyte-av-sprutor-och-kanyler_sfs-2006-323/

5.        Karlsson N, Berglund T, Ekström AM, Hammarberg A, Tammi T. Could 30 years of political controversy on needle exchange programmes in Sweden contribute to scaling-up harm reduction services in the world? Nordisk Alkohol Nark. 2021 Feb;38(1):66-88. doi: 10.1177/1455072520965013. Epub 2020 Dec 17. PMID: 35309093; PMCID: PMC8899060.

6.        Holeksa J. Dealing with low access to harm reduction: a qualitative study of the strategies and risk environments of people who use drugs in a small Swedish city. Harm Reduction Journal 2022 19:1. 2022;19(1):1-16. doi:10.1186/S12954-022-00602-Y