APPENDIX 1
2005 NATIONAL REPORT (2004 data) TO THE EMCDDA by the Reitox National Focal Point
Sweden New Development, Trends and in-depth information on selected issues
REITOX
FOREWORD
This Report on the Drug Situation in Sweden is produced for the European Monitoring Centre for Drugs and Drug Addiction in accordance with the decisions of the Management Board of the Centre. The report has been prepared in cooperation with a number of national agencies, institutions and experts. Main authors are Mr Bengt Andersson, Ms Kajsa Mickelsson, Mr Bertil Pettersson, Ms Jenny Sandgren and Ms Sara Ullman at the National Institute of Public Health. The report is mainly an update of previously delivered data in areas where new information has developed or where the guidelines are changed in relation to previous reports. Chapter 11 is written by Ms Karin Trulsson and Ms Ulla-Carin Hedin and the major part of chapter 13 by Mr Philip Lalander.
Gunnar Ågren Director General National Institute of Public Health
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Table of Contents
Summary ...... 4
Part A: New Developments and Trends...... 6
1. National policies and context ...... 6
2. Drug Use in the Population...... 10
3. Prevention...... 13
4. Problem Drug Use ...... 19
5. Drug-Related Treatment...... 24
6. Health Correlates and Consequences ...... 29
7. Responses to Health Correlates and Consequences ...... 33
8. Social Correlates and Consequences...... 36
9. Responses to Social correlates and Consequences ...... 38
10. Drug Markets ...... 41
Part B – Selected Issues ...... 46
11. Gender Differences ...... 46
12. European Drug policies: extended beyond illicit drugs ...... 63
13. Developments in drug use within recreational settings ...... 68
Part C- Bibliography, Annexes ...... 77
14. Bibliography ...... 77
15. Annexes ...... 88
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Summary
Most of the indicators used to monitor the drug situation in Sweden indicate that the problem with illicit drugs is serious but also that positive changes are observed in some areas. Prevalence figures are levelling of or decreasing, public attitudes to drugs support a restrictive policy, the need for treatment and rehabilitation is recognised and is given priority, the local level is integrated in the work and a multitude of efforts are initiated within the scope of the national action plan on drugs.
Drug use as measured in various surveys is usually stable or levelling of. Cannabis life time prevalence (LTP) in the general population has in the last four surveys (98, 00, 04 and 05) been 19%, 16%, 18 % and 15% (men) and 10 %, 9 %, 10 % and 9% (women). In the school population (age 15-16) the rapidly increasing LTP during the 1990s (peak 10% in 2000 and 2001) has turned and for the years 2002 and 2003 there is a decrease. In the survey 2003, LTP was 7 % for both boys and girls and this holds true also for 2004. The last 30 days prevalence for boys decreased from 3 % to 2 % between 2002 and 2003 and was in 2003 the same for both sexes. In 2004, an increase to 3% was noted for both sexes. Also in the group military conscripts (age 18), there was a decrease in LTP between 2002 and 2004, from 18% to 15% and a slight decrease in the last 30 days prevalence from 3% to 2%.
Regarding attitudes to drugs there is a continuous support for a restrictive drug policy as reported previously. From the studies initiated by the National Drugs Policy Coordinator (NDPCo) under the title “to take drugs occasionally” a liberal view is expressed in the youth groups interviewed regarding cannabis but simultaneously the support for the Swedish restrictive policy prevails. This is also mirrored by the section 13 review on recreational drug use. It can be seen from the qualitative studies that a large majority of those who have tried illegal drugs consider drug use as an exception, not as a central or normal part of their lives. Most of them are aware that drugs can have a negative impact on their future if they let their drug-taking become more frequent or long-term. For this reason, they develop risk- management strategies such as taking drugs only at particular occasions, never using in their hometown or never buying drugs – only accepting when offered. Most young people have been influenced by society’s message that drugs are a bad thing, and this guides their decisions and actions to some extent so that they either do not try at all or, if they decide to do so, impose certain limits on their drug use. Taking drugs is not a normalised action, but rather an exception.
The problematic drug use is difficult to estimate and studies are not performed regularly. Most recent data as presented in this report shows a decrease in problematic drug use over the last years giving a central rate/100 000 of 4.5 in the 15-64 intervals in 2003.
Sweden is primarily a market for illegal drugs produced abroad and smuggled into the country. Mirrored as seizures cannabis is the dominating drug followed by amphetamine, illegally obtained pharmaceuticals (tranquilisers and pain killers) heroin and cocaine. Mirrored as prevalence in different surveys cannabis is by far the drug most experienced. A worrying and possibly increasing problem is the not uncommon use of GHB or some of its analogues (GBL, 1,4-BD). GHB is most likely the only illegal drug found to be clandestine manufactured in Sweden (from GBL or 1,4-BD) at a scale intended for sale at the illegal market. GHB was classified as a narcotic drug in 2000 and since September 2005 GBL and 1,4-BD are controlled under act on prohibition of goods dangerous to health. The implication is that permission is needed for all use.
An investigation of the price development for illegal drugs over the last 15 years shows that the price at street level (adjusted to the 2004 monetary value) is about halved for hashish and cocaine since the end of the eighties. In 2004 one gram of hashish was reported to cost around 8 € and one gram of cocaine around 80 €. For amphetamine and brown heroin prices
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are about 60 per cent lower today than 15 years ago. Prices per gram of amphetamine and brown heroin in 2004 were around 25 € and 100 € respectively.
The implementation of the national action plan on drugs (introduced in 2002) is run by the national drugs policy coordinator (NDPCo). A marked increase in drug prevention activities, mainly due to initiatives from the coordinator is noted. By government support, the majority of the 290 local authorities in Sweden have been able to appoint local drug coordinators for the alcohol- and drug preventive work in order to strengthen the local mobilisation. The NDPCo has also initiated a wide variety of activities in the areas of research, supply and demand reduction, opinion forming, treatment and rehabilitation - including the prison and probation area, training and mobilisation at the local level as well as interventions in the recreational area. Some results are presented in this report but most activities are still running.
The responses to health correlates and consequences of drug abuse have been down-sized for a long period. Based on a series of reports the NDPCo highlights the unfulfilled needs of drug abusers in the 2004 annual report. Some of the conclusions from the NDPCo are: - A functional treatment system has a positive effect on health development and on decreased mortality, - The problematic abusers and immigrants with drug problems do not receive the kind of treatment they need, - Outreach work is nearly extinct. The NDPCo proposes that there should be a strengthening of resources in several areas, and among them, a guarantee securing treatment for those in need, and professional drug treatment within the prison system. Two other areas of priority for the NDPCo are to i) develop the Prison and probation system to a high-qualitative treatment system for drug abusers and ii) to upgrade and coordinate the efforts against the organised crime in drugs, commonly international. In the bill for 2005 the government allocated 90 million € to drug related treatment for the period 2005 – 2007. It is further proposed that an agreement should be established between the state and the municipality sector with the purpose to strengthen and clarify the actions to be taken by the municipalities on the treatment of alcohol- and drug addicts.
From January 1st 2005 all medically assisted treatment of drug abuse (opiates) must be performed at clinics with special authorisation and could be given to patients 20 years of age or older with at least two years of opiate dependence. Physicians in general are thus not allowed to prescribe for instance buprenorphine to a patient.
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Part A: New Developments and Trends
1. National policies and context
Overview / summary on legal, policy and institutional framework, strategies and social context Legal framework
Laws, regulations, directives or guidelines in the field of drug issues (demand and supply,) In October 2005 fifteen substances are controlled under the Act on the Prohibition of certain Goods Dangerous to Health (SFS 1999:42). The list of goods dangerous to health is published as an appendix to the Ordinance on the Prohibition of certain Goods Dangerous to Health (SFS 1999:58). The list consists of MBDB, BDB, 1-benzylpiperazine, DOC, 5-MeO- DMT, 5-MeO-DIPT, 5-MeO-AMT, AMT, 2C-C, 2C-D, 2C-E, 4-AcO-DIPT, 4 HO-DIPT, GBL and 1,4-butandiol.
4-AcO-DET, 4-HO-DET, 4-AcO-MIPT, 4-HO-MIPT and methylone are according to a governmental decision to be controlled under the Act on the Prohibition of certain Goods Dangerous to Health (SFS 1999:42) as from November 2005. The previously listed substances under this act, 2C-T-2 and 2C-T-7, were in March 2004 transferred to the list of substances controlled as narcotics. Simultaneously 2C-I and TMA-2 were added to the list of substances controlled as narcotics (Amendments to the Ordinance on Control of Narcotic Substances) (SFS 1992:1554).
Due to the decision to control the commercially interesting chemicals GBL and 1,4-butandiol under the Act on the Prohibition of certain Goods Dangerous to Health (SFS 1999:42) as from September 2005 a change in the act is carried through regarding permission for handling. For all handling of the goods under the act, retail as well as industrially, permission is required if it is not evident that the goods is denaturized in a way that prohibits use or is part of a product or goods in such a way that it could not be used for intoxication. Permissions are handled by the Medical Product Agency (MPA). The MPA is also able to make exceptions from the rule that permission is needed by regulations on the subject.
Ketamine is now listed as a narcotic substance, list IV. The regulation is an amendment to the Ordinance on Control of Narcotic Substances (SFS 1992:1554) and came into force in July 2005.
As from September 2005 all goods with ephedrine is covered by the medicinal product act (SFS 1992:859). Consequently, all goods with ephedrine that are not accepted as a medicine by the MPA will be illegal to trade.
Regulation (EC) No 273/2004 of 11 February 2004 on drug precursors and regulation (EC) No 111/2005 of 22 December 2004 laying down rules for the monitoring of trade between the Community and third countries in drug precursors has entered into force. Sweden has therefore amended the Act on Control of Narcotic Substances (SFS 1992:860) and the Ordinance on Control of Narcotic Substances (SFS 1992:1554). The amendments came into force 18 august 2005.
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Laws implementation In 2004 just above 45 000 crimes against the Narcotic punishment act were reported. This is a little more than four per cent of all crimes reported in Sweden 2004 (BRÅ 2004a). The majority (48 %) of reports were on sole consumption.
12 606 cases of illegal drug crimes arrived to the Prosecutors in 2004. This was an increase by 17 percent compared to 2003, 30 percent compared to 2002 and 49 percent compared to 2001. It was simultaneously reported that the Prosecutors closed 13 percent more cases of illegal drug related crimes in 2004 than in 2003. In total the closure of all crimes counted increased by 4 percent. (Åklagarmyndigheten 2005). No persons were convicted for crime against the Act on the Prohibition of certain Goods Dangerous to Health in 2004. The corresponding figures for 2003, 2002 and 2001 are four, two and one respectively.
Out of the 22 000 crimes reported due to driving under the influence of drink in 2004, 6 600 were under the influence of narcotics, an increase from 2003 with 6 per cent in total. (BRÅ 2004a).
In 2004 the National Drug Policy Coordinator (NDPCo) initiated a project to combat the sales of illegal drugs at Internet. The project was carried out in collaboration between the National Criminal Investigation Department, the Customs and the Office of the Public Prosecutor and the budget was 210 000 €. (See section 10)
Institutional framework, strategies and policies
Coordination arrangements No new information available.
National plan and/or strategies A new action plan on drugs will be presented by the government late in 2005.
Implementation of policies and strategies In April 2005 the government presented a report to the parliament regarding the contributions to prevent drug abuse in accordance with the national action plan on drugs (Skr. 2004/05:152). The report concludes that the national action plan on drugs adopted by the parliament and government in 2002 has had a major impact and resulted in an upgrading of the drug issue on the political agenda at the local, regional and national level. The nomination of a national drug policy coordinator (NDPCo) has resulted in a powerful mobilization of the drug policy in all areas of the national action plan on drugs. The report concludes that the majority of municipalities today have some form of action plan on drugs.
Impact of policies and strategies In the report on the national action plan on drugs (ibid Skr. 2004/05:152) the government concludes that the drug issue is given a higher priority and that the coordination of the contributions is improved at local, regional and national level. Information and opinion forming has increased and the intended target groups are reached. The majority of municipalities has to an increasing level given priority to drug efforts and also adopted some form of action plan. Coordination and cooperation between the different stakeholders in the area has increased. The treatment of drug abusers has developed in terms of methods as well as availability. However, continuing supportive efforts are necessary. The special effort within the prison and probation service has contributed the development of methods and strategies making the prison and probation service better adopted for treatment and care of the drug abusing clients. The crime fighting agencies have increased their efforts in combating drugs and special resources have been allocated for this task. Approximately sixty research projects to increase the knowledge of the drug issue are initiated as a consequence
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of the action plan. Some of these are presented at http://www.mobilisera.nu/templates/GeneralPage____2298.asp. Sweden has taken action in international forum to fight illegal drugs. Within the EC and UN Sweden has acted to improve the international control of illegal drugs.
Budget and public expenditure
In a project, initiated by the EMCDDA, the Swedish researcher Mats Ramstedt estimates the total public expenditure of the Swedish drug policy in 2002 (Ramstedt 2005). The calculations include costs of measures that, direct or indirect, aim at dealing with the drug use and its consequences. The following costs are included in the calculations;
Law enforcement Law enforcement contains costs for the police, customs and judicial interventions. It is estimated that 6 % of the police service budget is devoted to fighting drug crime. According to several rapports from the police, up to 30 % of the total budget is spent on crimes committed by drug users. This can be identified as an indirect expenditure. Ramstedt estimates that the police service spent between 95-400 million € on crimes that in one way or another are related to drugs.
The drug related expenditure of the custom service is estimated to be 30 million €. The Justice’s spending on drug- law offences were calculated to be 19-106 million € and the costs of the incarceration of individuals convicted for drug related crimes adds up to 160 million €. If drug users, imprisoned for crimes that are not directly drug related, are included the total amount is estimated to be 248 million €. Since approximately half of the clients in the Swedish prison and probation services are drug addicts, Ramstedt assumes that 50 % of the costs are drug related.
Social and health care Health care includes care and treatment of drug users on hospitals, treatment clinics etc. which were estimated to cost 133-260 million €. The social care includes costs for financial support to drug addicts within the scope of the social policy and the labor-market policy, such as social allowance and sickness benefit. These measures were calculated to cost approximately 170-212 million €.
Prevention1 The expenditure of measures, such as campaigns and information, that aims at preventing people to use drugs where estimated to be 8 million €. This sum is based on the allowance that was given by the county administrative board to the local authorities in order to contribute to the anti-drug activities.
Conclusion Ramstedt reckons the total cost of the above standing measures to be between 0.5 and 1.2 billion € during 2002. Of this sum, 48-60 % was devoted to the law enforcement, approximately 22 % to costs of health care, 18-29% to social care measures and 1 % to prevention2.
1 The school prevention activities or the municipal contributions to create meaningful recreational settings for the youth and early detection of risk behaviours as part of an over all preventive effort is not included in Ramstedts estimate. A recent estimate of the costs for the alcohol, tobacco and illegal drug prevention in school (compulsory school + grammar school) landed on 53 million € (SoS, to be published).
2 The estimated costs of the Swedish drug policy in 2002 is based on a year when the first comprehensive national action plan on drugs was introduced but none or very few contributions yet was started to fulfil the plan. In the years following 2002 a significant increase in activities occurred in sectors related to care and treatment as well as demand reduction in terms of information and opinion forming efforts as presented in this and previous NRs. Thus, the year 2002, with activities and contributions scheduled in 2001, could possibly be regarded as a year awaiting the priorities and directives of the coming action
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The main results indicate that the public costs are dominated by the law enforcement. When comparing the public expenditure from 2002 with calculations of the 1991 public expenditure, Ramstedt shows that the sum spent by the police service on drug related crime has increased with 126 %. For the courts, the augmentation adds up to 234 % and for the prison and probation services up to 160 %.
Funding arrangements In the government bill for 2005, the government proposes a subsidy of 87 million € that will be allocated to the local authorities during 2005-2007, in order to reinforce the rehabilitation of drug addicts. This special funding is part of the project A contract for life, which aims at stimulating the local authorities to develop and strengthen the treatment sector for people in abuse of illegal drugs (Regeringens skrivelse 2004).
Non governmental organisations (NGOs) in the alcohol and drugs field are funded by approximately 4.3 million € annually. The funding is handled by the National Board of Health and Welfare (NBHW) and grants are awarded based on applications from the NGOs.
Social and cultural context No new information available.
plan. In particular this is true for the prevention sector regarding information and opinion forming initiatives. The appointment of a national drug policy coordinator for the implementation of the national action plan on drugs in combination with budgetary allocations as reported on previously implies that the treatment and prevention sectors have developed over the years following 2002. It is also likely that the costs for law enforcement have increased, or at least remained stable, over the same period as a consequence of the action plan.
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2. Drug Use in the Population
Overview / summary on drug use and attitudes to drugs. Prevalence and incidence of use, characteristics of users (gender, social characteristics, age at first use)
Regular surveys are made annually only among school pupils in grade 9 and among military conscripts 18 years old (almost all are males). Surveys are also made in grade 6, but only every second year. In 2004 surveys in grade 12 were performed with a questionnaire that is similar to that used in the regular surveys in grade 9. By governmental support a test period of three years for grade 12 surveys is guaranteed. During the 1990s several surveys in the general population aged 16-24 and 15-75 were made on a national basis. It is still pending if these surveys will be repeated. In 2004 and 2005 the SNIPH has conducted a postal public health survey in the general population that includes a drug related issue, a question about cannabis prevalence. It is probable that the survey will be repeated at regular intervals but it is not likely that it will contain more on drugs than presently.
Drug Use in the general population
A postal public health survey, containing one question regarding cannabis use, was conducted in 2005 among 16-84 year olds, comprising a total of approximately 64,000 persons (gross sample size) with a response rate of 63% (Statens folkhälsoinstitut 2005b). The sampling frame was all persons 16-84 years old living in Sweden (approximately 7 million persons). The results regarding lifetime prevalence, last year prevalence and last month prevalence of cannabis use for the age group 16-64 years are presented in the EMCDDA Standard Table set. Table 1 shows cannabis prevalence data for the age group 18-64 years (the 16-17 year olds have been excluded in order to compare the results between different survey years for the years 1994-2005). Compared to the similar public health survey performed in 2004 (Statens folkhälsoinstitut 2004c), the only notable change is the decrease in lifetime prevalence of cannabis use for men from 18% in 2004 to 15% in 2005.
Table 1. Cannabis prevalence (%) among 18-64 year olds, for men and women separately, 1994-2005.(CAN 1994, 1996, 2000b, a, Statens folkhälsoinstitut 2004c, 2005b)
Lifetime Lifetime Last 12 Last 12 Last 30 Last 30 months months days days Year Men Women Men Women Men Women 1994 8 7 * * * * 1996 13 8 * * * * 1998 19 10 2 0 1 0 2000 16 9 1 0 0 0 2004 18 10 3 2 1 0 2005 15 9 3 1 1 1 *Not asked for
Drug Use in the school and youth population
In 2004, two national school surveys regarding drug use were carried out: one among pupils turning 16 (CAN 2004c) and one among pupils turning 18 (CAN 2005c) during 2004. In both
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surveys, 300 schools were selected at random (stratified on region). In each school, one or two classes per school (depending on class size) were randomly selected to participate in the survey. The sampling frame was approximately 120,000 persons among the 16 year olds and approximately 110,000 among the 18 year olds. Among the younger pupils, the response rate was 92%, and among the older it was 84%. The results and methods of both surveys are presented in further detail in table 2 in EMCDDA Standard Table set.
Surveys among pupils turning 16 during the year of survey have been carried out annually since 1971. The lifetime prevalence of ever having used an illegal drug for the years 1971- 2004 are presented in figure 1. For 2004, the lifetime prevalence was 7% for both boys and girls, which is the same as for 2003. The last month prevalence was 3% for both boys and girls, which is slightly higher than the previous year (2% for both genders in 2003).
Figure 1. Lifetime and last month prevalence of having used an illegal drug among pupils turning 16 during the year of survey, for boys and girls separately, 1986-2004. (CAN 2004c)
The survey carried out among pupils turning 18 was the first of its kind (CAN 2005c). The lifetime prevalence of ever having used an illegal drug was 17% for the boys and 14% for the girls. The last month prevalence was 5% for the boys and 2% for the girls.
The gender differences in lifetime and last month prevalence was pronounced among the 18- year olds, whereas the consumption pattern among the 16-year olds was similar among boys and girls.
The most frequent illegal drug was cannabis: among the 16 year olds, 59 % of both boys and girls who had ever used an illicit drug had used cannabis only. The corresponding numbers for the 18 year olds was 68% for the boys, and 57% for the girls.
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In both surveys, pupils who had tried illegal drugs liked school less, and cut classes more often than other pupils.
Drug Use among specific groups
Conscripts Surveys among military conscripts have been carried out since 1971. The conscripts are Swedish male citizens, of which the majority turned 18 during the year of survey. All conscripts coming to one of the five conscript offices take part in the survey. The results and methods of the five latest surveys are also presented in table 30 of the EMCDDA Standard Table set. Approximately 40 000 persons responded to the questionnaire in 2004 giving a response rate of 89% (CAN 2005d).
The lifetime prevalence of having used an illegal drug has decreased slightly in the last couple of years (Figure 2) from around 17 to 18% in the early years of the millennium, to 15.3% in 2004. Lifetime prevalence of cannabis use was 14.3% in 2004, compared to 16.7% in 2002 and 15.2% in 2003. Lifetime prevalence of amphetamine use was 2.0%, compared to 3.0% in 2002 and 2.6% in 2003 and also the lifetime prevalence’s of cocaine and heroin seems to decrease. The last month prevalence of having used an illegal drug has decreased over the last two years. In the years 1999 to 2002, the last month prevalence varied between 3.0% and 3.1%. However, in 2003, the last month prevalence was 2.5%, and in 2004 it continued to decrease to 2.3% (CAN 2005d).
Figure 2. Lifetime prevalence of having used an illegal drug among military conscripts, 1971- 2004. (CAN 2005d)
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3. Prevention
Overview / summary of framework, strategies and interventions in relation to universal and selective prevention (incl. National definitions)
The increased drug prevention activities as reported on in 2004 NR due to initiatives supported by the National Drug Policy Coordinator (NDPCo) are ongoing. The efforts cover a wide area of activities, from Internet communication to campaigns at specific arenas and in specific groups. Follow-up or evaluations are not yet reported apart from what has been presented in previous NRs. A majority of the activities supported or initiated by the NDPCo is governed by the principle of evidence or research based methods and the aim to be evaluated or followed up. This is highlighted in a pilot project comprising six municipalities reported on below.
By governmental support the majority of the 290 Swedish local authorities have been able to appoint local drug co-ordinators for the alcohol and drug preventive work. The co-ordinators are also the key players in the training and education programs as well as local prevention programmes initiated by the NDPCo and the National Alcohol Commission (NAC). In 2003 close to 80 % of the 290 municipalities reported that an alcohol and/or drug policy was adopted and in 2004, 67 % reported having appointed a full- or part time drug-coordinator for the alcohol and/or drug preventive work. In 2003 the school is reported to be in focus for the drug preventive work in close to 85 % of the municipalities that had adopted an alcohol and/or drug policy. The second most common area in 2003 to be involved in preventive work was recreational settings.
Universal prevention
In the autumn of 2002 all 290 Swedish municipalities were given the opportunity to apply for participation in a three-year development project in order to strengthen their preventive work. The intention was to reduce the harm and problems associated with alcohol and illegal drugs. Among 68 applicants, six municipalities were selected, representing different parts of the country and different population sizes. These municipalities have been working for a year and a half, starting in January 2003, together with the NAC (which is in charge of implementing the national action plan against alcohol), the NDPCo and the Swedish National Institute of Public Health (SNIPH), to strengthen their local alcohol and drug prevention. The following text is a translation of the summary of the project and the summary of the conclusions from “the half way report”, published in the autumn 2004 (Statens folkhälsoinstitut 2004b).
Developing municipal alcohol and drug prevention An important part of this development work is an increased focus on research-based methods for alcohol and drug prevention as well as on local mobilization of various actors. Knowledge support from an expert group of resource persons attached to the project, training of alcohol and drug co-coordinators, training of trainers and regular feedback on results of surveys will help the municipalities design and implement preventive actions that will continue in the long term as part of regular activities.
The municipalities are offered skills development in the form of training in effective methods, exchange of experience and ongoing support from a group of resource persons attached to the project as well as financial getting-started support of SEK 200 000. For the entire duration of the project, the municipalities are provided with evaluation support from evaluators at the SNIPH. After the first year and a half of operation, all six municipalities
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participating in the project have chosen three to four areas which they particularly wish to develop. Examples include responsible serving of alcohol in restaurants, family programs oriented towards parents of school-age children, and alcohol counseling within primary health care.
One representative each from the NAC, the NDPCo and the SNIPH have formed the central steering group for this project and collectively undertaken central planning. Within this framework, the NAC and the NDPCo have handled implementation while the Swedish National Institute of Public Health has been in charge of evaluation. Evaluation results are presented to the pilot municipalities twice a year. The aspects evaluated include data from central records on accidents, crime and morbidity related to alcohol and illegal drugs; survey data on alcohol and illegal-drug consumption as well as attitudes towards preventive work; monitoring of alcohol- and drug-related items in the local media; and results from experiments where under-age persons try to buy alcohol. This half-time report is structured on the basis of four broad main categories: availability, consumption, harm and activities. After a year and a half, there are no differences in alcohol and drug development between the pilot municipalities and the controls. The only difference found is that, throughout the project period, media activity and the number of media items on alcohol and drugs have been greater in the pilot municipalities than in the controls. The development in the pilot and control municipalities is similar to that in Sweden in general. Alcohol and drug consumption is increasing, as are the problems associated with alcohol and drugs.
The lack of differences in terms of impact is not surprising – on the contrary, it is expected, given that the pilot municipalities did not begin their actions within their development areas until the autumn of 2004. At the same time, it is clear that recent development has been very positive. Municipal executive committees have started to take a range of initiatives of their own, showing greater interest and commitment. At a meeting for politicians from the participant municipalities which was held in November 2004 in the city of Umeå, one of the decisions taken was to continue their work after the project ends in 2005; calls were also made for the evaluation period to be extended.
Summary of conclusions The overall issue investigated in the follow-up of the development project was how alcohol consumption and illegal-drug use developed in the pilot municipalities as compared with the control municipalities and Sweden in general. We also investigated the extent of drinking for intoxication purposes, age at first consumption, risk factors, harm and attitudes. Our conclusion is that, a year and a half into the project, there are no great differences in these respects between the pilot municipalities and the controls. The only exception found relates to media coverage: considerably more is written about alcohol and drug prevention in the pilot municipalities – which may be an indirect sign of a higher level of activity in those municipalities. The lack of differences in terms of impact is not surprising – on the contrary, it is expected, given that the pilot municipalities did not begin their actions within their development areas until the autumn of 2004.
A matter of greater interest at this stage may be whether there are any differences as regards the process evaluation. This evaluation started with a number of questions relating to the development of alcohol and drug prevention in the municipalities concerned: whether these issues were a priority at the executive level, how local government interacted with other organizations, what methods were used and how the local population felt about alcohol and drug issues and preventive action. Here we find that, based on interviews with key people in the pilot and control municipalities, alcohol and drug prevention is generally perceived as very important in both groups of municipalities. Commitment in practice, however, is considered to be weaker, given that these issues need to compete for attention and resources with other important issues in local politics – in this respect, there are no major differences between the pilot municipalities and the controls.
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However, a difference can be observed as regards activities and the degree of structure. In general, the level of activity is slightly higher in the pilot municipalities than in the controls. One sign of this can be seen in survey data for 2003 collected via county councils by the SNIPH. These differences are small, though: on average, the pilot municipalities score about 10 per cent higher on the activity index and structure index calculated for the municipalities. Their slightly higher score on the structure index reflects the fact that the pilot municipalities are implementing their various activities with a greater degree of coordination. Further, their activities are more long-term whereas those of the control municipalities are more temporary in nature.
Most pilot municipalities have full-time co-coordinators, whereas most control municipalities either lack a cocoordinator or have part-time posts. As regards the orientation and methods of their preventive efforts, the control municipalities come across as slightly more traditional. They focus on young people to a greater extent, and actions addressing availability are less common. A predominant focus on young people is found in the pilot municipalities as well, but there is a progressive shift towards more evidence-based methods, such as parent programs and social and emotional training, as well as an increasing number of supplementary measures targeting the adult population, such as responsible serving of alcohol, alcohol counseling within primary health care and maternal care, and sober driving. When it comes to the attitudes of the local population – that is, whether alcohol and/or illegal drugs are seen as serious problems in the municipality, and the degree of support for various types of preventive activities –-, there is no difference between the pilot and control municipalities.
School The Swedish National Agency for School Improvement and the SNIPH, together with the Swedish Association of Local Authorities and Regions, have analyzed possible measures to strengthen drug-related harm-reduction activities at schools (Statens folkhälsoinstitut 2003c). Main conclusions and recommendations were presented in NR 2003.
In 2004, the Swedish Government instructed the SNIPH to appoint a working party to update and carry out the implementation plan included in the analysis report carried out jointly with the National Alcohol Commission (which is in charge of implementing the national action plan against alcohol) and NDPCo. The SNIPH shall bring forward knowledge on effective methods and how to strengthen the alcohol- and drug preventive work in school. The work should be done in cooperation and dialogue with a number of agencies and should be reported in December 2007.
In 2002, within the framework of the co-operation with the three largest cities – Stockholm, Göteborg and Malmö –, the NDPCo initiated development work at ten comprehensive schools (age group 6–15 years) and two upper-secondary schools (16–19 years). This work, which is being carried out by the schools’ own staff and representatives of the three large cities, is based on experience from recent research. It is now being evaluated, and results for the first year will be presented in 2005. In all, close to 3 000 pupils and their parents will be reached during the three years of development work (Regeringens skrivelse 2005).
In 2004, 38 % of the municipalities report to have programmes for mapping the psychosocial environment in schools and to take measures and 32 % report to have school programmes for externalising behaviours (Statens folkhälsoinstitut 2005a).The contents of these programmes are not known to the National Focal Point.
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Family Courses to support parents and strengthen preventive work at schools have been offered as part of the development work in six pilot municipalities as reported under “Universal prevention” above.
85 % of the municipalities in Sweden reported on meetings with parents on issues regarding alcohol and drugs in 2004. Most likely referring to the school managed meetings with parents where alcohol, tobacco and illegal drugs are the main topics for discussion, consideration and action. (Statens folkhälsoinstitut 2005a)
49 % of the municipalities reported on programs on alcohol and drugs for parents with children in grad 6 – 9 in 2004 and for the same year 54 % of the municipalities reported on the distribution of information material in the alcohol and drugs area directed to parents (Statens folkhälsoinstitut 2005a). The National Focal Point does not know the content of these programs.
An analysis of how support to parents could be of real use for the children was recently reported by the SNIPH (Statens folkhälsoinstitut 2003b, 2004e). Today there are more than 100 high quality studies showing that support to the parents could prevent mental problems for the children during upbringing and later as grown ups. The report takes its starting point in this new knowledge and present proposals (programs) for support to the parents during different phases of the upbringing. The programs do not question the competence of the parents but rather seeks to include and develop the collected experience of parent groups.
During the infant period, methods supporting a faithful connection with the parents are recommended, during the nursery school, interaction programs promoting the parents ability to give affection as well as setting standards and during the school age, communication programs particularly aiming at reducing the risk that the youths should start to use tobacco, alcohol or drugs or committing crime.
The report also brings up different methods for support e.g. consulting via the telephone, support via books, newspapers, magazines, radio, TV and Internet. The report is presented as a tool of knowledge produced for decision makers and professionals responsible for children and youth at local, regional and national authorities and agencies as well as people working in NGOs and in the private sector.
Community The establishment of municipal drug plans are encouraged and given priority to in the National action plan on drugs 2002-2005 (Regeringens proposition 2002b). The municipalities are free to draw up guidelines for the drug preventive work, though it is recommended by the government that a drug coordinator is appointed in each municipality. In 2003 close to 80 % of the 290 municipalities reported that an alcohol and/or drug policy was adopted (Statens folkhälsoinstitut 2004d) and in 2004, 67 % reported having appointed a full - or part time drug coordinator for the alcohol and/or drug preventive work (Statens folkhälsoinstitut 2005a). In 2003 the school is reported to be in focus for the drug preventive work in close to 85 % of the municipalities that had adopted an alcohol and/or drug policy (Statens folkhälsoinstitut 2004d) The second most common area to be involved in preventive work was recreational settings (Statens folkhälsoinstitut 2004d). According to the 2004 edition of the same report the most obvious increase in activities compared to previous years were noted for programs for “pre-school children at risk” and “school children with externalising behaviours”. The number of municipalities with these programmes was approximately doubled. Nothing is however said about the frequency of the programmes at the single community level (Statens folkhälsoinstitut 2005a).
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Prevention network To facilitate young people’s commitment at local level, the NDPCo initiated in 2003 a network for young people engaged in drug prevention (ung-nätverket). It consists mainly of youth organisations active in the prevention of drug abuse. One of the objectives is to make young people participate in projects and to stimulate the dissemination of new, creative methods for preventive work. It is also hoped that the network will serve as a source of information about new patterns of abuse (Regeringens skrivelse 2005). The network was in 2005 reorganised and renamed to Local Hero and has its own website: http://www.local- hero.nu/LHTemplates/Page.aspx?id=347. The objective is the same, to support and inspire young people to participate in preventive work. Inspiration to the network comes from a UN tool.
Civil society In November 2004, the Government invited the social partners to discuss joint action in order to reduce the harmful effects of alcohol and illegal drugs at workplaces. The organisations which took part in these discussions were the Swedish Trade Union Confederation, the Confederation of Professional Employees, the Swedish Confederation of Professional Associations, the Confederation of Swedish Enterprise, the Swedish Association of Local Authorities, the Swedish Federation of County Councils and the Swedish Agency for Government Employers. There was found to be a general consensus that employers and trade unions should meet the threat of increasing drug-related problems in working life by taking preventive action (Regeringens skrivelse 2005).
During its years of operation, the NDPCo and the NAC have also started several projects jointly with trade unions as representatives of working life. To lay the foundation for a common policy, discussions about drug problems in working life were held in 2003 and 2004 with the leaders of unions such as the Swedish Trade Union Confederation and the Swedish Confederation of Professional Associations (Regeringens skrivelse 2005).
Together with local units of study associations (adult-education associations which are not part of the regular educational establishment in Sweden), a major programme called ‘Popular Education against Drugs’ (Folkbildning mot narkotika) has been implemented in 2003 and 2004. About 40 local popular-education projects have been carried out in order to enhance young people’s participation and self-esteem. Besides the study associations, the sports movement and various ethnic organisations have also taken part in anti-drugs work (Regeringens skrivelse 2005).
Selective/indicated prevention
Early intervention for persons in an early phase of abuse or “at risk” is specifically commented on in the national action plan on drugs 02 – 05. No single group is addressed. Instead the action plan points to the fact that ethnic and cultural belonging as well as sex, age, pattern of abuse are important factors to observe in the planning and performance of the selective prevention.
The carrying through of selective prevention is the responsibility of the municipality. The availability could thus look quite different in different municipalities. No inventory of the prevalence of the availability of interventions for different groups or different problems is performed in the 290 municipalities in Sweden.
Recreational settings No new information available.
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At-risk groups “How can we protect at-risk groups? – by limiting the supply and through anti-gang efforts”. In September 2005 a one day supplementary course was given for the local alcohol- and drug prevention coordinators on this topic. Organizers were the NDPCo and the NAC. The training was open for the prevention coordinators that had fulfilled the basal education.
The training connected to a recent qualitative research project initiated by the NDPCo. The main findings of the study was summarized in a report by Olli Puhakka in June 2005 titled”Kriminella ungdomsnätverk –utanförskapets pris. En förstudie” (“Criminal youth networks – the cost of alienation. A pilot study”). The purpose of the project was to examine criminal youth networks in a selection of Swedish cities. The researchers seek to investigate the extent of these networks, who take part of it, what criminal activity the networks are involved in as well as the public’s and the authorities’ reaction to them and the measures taken to prevent this kind of activity (Puhakka 2005) .
The methods used in the study are qualitative interviews with key informants from authorities and other organizations involved with the problems (police, schools, social services and prosecutors) and group interviews with citizens in the current municipalities.
The main results reveal that different kinds of criminal groupings exist in all cities involved in the project, principally concentrated to socio-economic disfavored areas. There are mainly two types of networks that can be distinguished (though it is hard to draw a distinct line between them); youth networks where the criminal activities are spontaneous and networks consisting of older members earning their livings by heavier criminality. The key informants describe the networks as groupings with a core of a few persons with close relations and a looser network of people around them, shifting all the time. The members are almost exclusively men between 15 – 30 years old with different ethnical backgrounds. Drug abuse is not unusual, neither are drug offences.
The interviewees reckon segregation, poverty alienation and lack of trust in the future and in authorities as the main reasons for the appearance of these networks. The groupings offer an alternative way of living for those who experience that their admission to the society is limited.
The interviewees also mention that the networks affect their neighborhood in a negative way (for example deterioration of different services such as the local traffic and more expensive insurances) and that the citizens feel they have no possibilities to change the situation.
In the interviews with the citizens it emerged that they meet prejudice of immigrants and a lack of knowledge of their cultural background when in contact with the police, schools and the social service. The interviewees mention this as a reason for the insufficient cooperation between the authorities and the people living in these neighborhoods. Education and recruitment of persons with a foreign background to authorities were brought up as possible ways to improve the cooperation. A strengthen dialogue between schools, the social service and families as well as an increase in the supply of recreational activity to youths were also mentioned as solutions to problems occurring in these areas.
At risk families No new information available.
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4. Problem Drug Use
Prevalence and incidence estimates
The over all picture The estimated number of problem drug users (PDUs) was close to 26 000 in 2003 giving a central rate/100 000 of 4.5 in the 15 - 64 interval. The figures are from a governmental report presented in October 2005 (SOU 2005:82). The estimated number of problem drug users in 2003 is about the same as in the latest case-finding study in 1998 (Lander, I. et al. 2002). According to the report, the number of PDUs has been rather constant over the years since 1998 with a peak in 2001 of close to 28 000-problem drug users.
Figure 3. Estimated number of problem drug users in Sweden 1998 – 2003. (SOU 2005:82)
The method used for the prevalence estimates was presented in last years NR. In the treated population used for estimating the hidden population of problem drug users the mean age varied between 37 and 38 years and the female ratio varied between 35% and 36% in the period studied. No categorization on substances abused is reported from the study but the issue will be elaborated on in 2006.
From the Stockholm municipality study on problem drug use reported on in 2003 and 2004 NR (Finne 2003) it is concluded that 34% are opiate users, 38% abuse amphetamine type stimulants and 14% cannabis. This ratio is however likely to have regional variations. For the opiate and amphetamine PDUs the major route of administration is i.v.
The incidence of problem drug use is not considered in the government report (SOU 2005:82). However, the national estimate of PDU reported on in NR 2004 (Granath et al. 2003)concludes that the incidence was raising and had been so over the last 10 years. The rate of increase was defined as number of new cases within the closed care system during a defined period and with a drug related diagnosis as main diagnosis. An increase was shown for the number of treatment occasions, number of treated persons and number of first time treated persons.
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By substance used Problematic drug use is dominated by heroin and amphetamine. In a national survey 1998 (Olsson, B. et al. 2001) it was found that 73 % hade used amphetamine during the latest twelve months, and that 32 % had that substance as their primary drug. In the foregoing survey, in 1992, these figures were 82 and 48 % respectively. Problematic drug abusers are known to use also other substances, i.e. alcohol and pharmaceuticals. In the 1998 survey (ibid) it was found that nearly 1/3 of all problematic drug abusers had cannabis, alcohol or pharmaceuticals as their dominating drug. However, the report is vague about the details.
A bi-annually report from the National Board of Health and Welfare (NBHW), the latest regarding 2003 (Socialstyrelsen 2002), found that on a given date 12 096 people 18 years old or older were undergoing treatment for drug abuse and about as many alcohol abusers. 3 376 were known as IDUs. The report distinguishes between alcohol and drugs but not between various substances.
Amphetamine has always been the most used substance among problematic IDUs, but its share is decreasing. In the 1998 case-finding study 32 % had amphetamine as their drug of choice. Heroin, on the other hand, is increasing its part and reached 28 % in 1998.
Most used substances (per cent) among problematic drug users in three nation-wide case- finding studies (Olsson, O. et al. 1993, Olsson, B. et al. 2001):
Year: 1979 1992 1998 Substance: Amphetamine 47 48 32 Heroin 15 26 28 Cannabis 33 17 8
The alterations in drug habits can also be illustrated with a table showing the proportion (per cent) of problematic drug users who have used a certain substance during the latest twelve months according to three nation-wide case-finding studies (Olsson, B. et al. 2001):
Year: 1979 1992 1998 Substance: Amphetamine 77 82 73 Heroin 30 34 47 Cannabis 61 66 52
The most obvious trend is the growing role for heroin. This is also what clinicians and drug abusers state when they speak out in the media. If they are correct this trend has not weaken.
Treatment data from KIM (TDI) shows (Statistical Tables 04) that amphetamine is more common than heroin. In 2004 35 % had amphetamine as their primary drug, while 24 % preferred heroin. Cannabis was the drug of choice for 19.5 %. For patients treated fort the first time during 2004 amphetamine was the most preferred drug for 27.7 %. Heroin was chosen by only 8.2 %. Cannabis was more common among the new patients, with 31.4 %. Among the new patients intravenous use has dropped comparing with the year before.
TDI shows to some degree a contradictory development (Statistical Tables 04) than other sources with a slightly diminishing role for heroin. This is most probably caused by the increasing number of out patient units that has been incorporated in the reporting system. While heroin abusers are common, sometimes even dominating in institutional settings, they do not have the same weight in out patient treatment.
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In 1988 19 % of persons given summary convictions or were sentenced for crimes against the Narcotics Drugs Act regarding heroin was below 25 years old. Today (2003) that part is 21 %. In 1988 only 8 % were over 40, while today 24 % is over 40. It can be read as if the population of heroin users is growing older. The young group is slightly bigger today that in the beginning of the period.
Seizures of heroin by Customs and the Police is another indicator that could underpin the trend with a growing problem, but this is surprisingly not the case as seizures of heroin, and only heroin, has leveled off quite distinctly in the latest years; from 59 kilo in 2002 (but only 32 kilo the year before) to 13 kilo in 2003. In 1988 9 kilo was seized. The average amount of heroin seized during the latest ten years has been 36 kilo. Analysts within the Customs and the Police are convinced that the drop in 2003 (13 kilo) and 2004 (34 kilo) from levels as 59 kilo (2002), 64 kilo (1999) and 71 kilo (1998) is explained by new modus of operandi by the operators as they have not observed any regress in heroin abuse among known abusers. Neither have the treatment centers.
Street level prices have not followed the curve for seizures if the formula is that high prices mirror shortage of the substance caused by effective customs and police work. The number of seizures has grown from 294 (and 9 kilo) to 1 057 (13 kilo) between 1988 and 2003 (the reporting from 2004 is not fully compatible with earlier years, but were 900). Prices on the street dropped 60 % during this period (CAN 2004b). Supply of heroin is seemingly good. In late 2004 one gram of heroin was prized 1 400 SEK for white heroin (predominantly sold in Stockholm) and 1 200 SEK for brown heroin.
By injecting drug use (ever and current) In all of the national case-finding studies that were referred to above (in 1979, 1992 and 1998) over 90 % of all problematic drug users were IDUs. There is a tradition among problematic drug users to prefer amphetamine. This dates back to the 1960s. Amphetamine has always been used by the injecting route. It has been noted that its part of the total market has been somewhat reduced when heroin instead has increased its part. Problematic drug use is thereby almost synonymous with intravenous use of amphetamine or heroin.
Profile of clients in treatment
The overall picture Sweden has no registration that gives an overall view of clients in treatment. The TDI- registration (KIM) so far covers only a part of all specialized units and it is not fully representative of clients in treatment. The NBHW publish an overview of all known treatment contacts but it is not possible to give a closer view of the clients from that presentation. The TDI-system is supposed to have that role. Data from TDI has been reported to the EMCDDA by NBHW (R. Holmberg) for Statistical Tables.
The number of treatment episodes in institutional care during a year has varied between 14 000 and 15 000 in the latest years, in 2003 it was 14 438. The number of clients has varied between 8 000 and 9 000, in 2003 it was 8 516 (discharged cases). The number of persons first treated has been slightly over 4 000, but in 2003 it was 3 994. The proportion of treatment episodes is 1 % of all treatment offered in institutional care. This reporting from the NBHW is presented annually and occurs in the standard work Drogutvecklingen i Sverige (Drug trends in Sweden, which has an English summary) from CAN (www.can.se).
The number of drug abusers incarcerated in prison has been slightly over 6 000 per year, in 2003 it was 6 614 or 59 % of all incarcerated persons (N= 11 343). The prison system had 2 359 clients (2 190 males) assessed by the Addiction Severity Index, ASI, in 2004 (reported
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to the EMCDDA by Kriminalvårdsstyrelsen; Schlyter & Rehme in Oct 2005). The ASI instrument is a means to help sort out those inmates that need – and are prepared to take advantage of – treatment for drug abuse during their prison term.
By substance used Hospital treatment is registered by the NBHW. Heroin is the dominating drug in hospital treatment and abstinent treatment in hospitals (Socialstyrelsen 2005b).
During 2003, 1 294 persons had 2 328 treatment episodes for heroin abuse. The same year, which is the last reported, 490 persons had 788 treatment episodes for amphetamine (and other psycho stimulants) abuse and 222 persons with cannabis abuse had 314 treatment episodes. To that can be added that 590 persons had abstinent treatment at 784 occasions. These figures shall be added to the numbers above, but they are not reported per drug. Over the last three years the hospital data show a decrease in patients (-600) and treatment episodes (-1000). However, for amphetamine (and other psycho stimulants) abuse the trend has been reversed. An increase of 77 patients and 157 treatment episodes was reported. The TDI-registration (KIM) is so far predominantly constructed of treatment units organized by the social welfare system, not least outpatient units, and based on less than half of all existing units.
In the TDI-system cannabis was the dominating drug for 34 % of the clients in outpatient care and for 13 % in inpatient treatment. Heroin and other opiates was the dominating drug for 28 % in outpatient care and for 31 % in inpatient treatment. Amphetamine and other psycho stimulants (including cocaine) was the dominating drug for 28 % in outpatient care and for 45 % in inpatient care. The loss in patient and treatment episodes is explained by the heroin abusers who are 464 patients fewer in 2003 than in 2001 (treatment episodes – 317). The reason for this decrease is unclear since reports from the field indicate that the number of heroin abusers is increasing. The heroin abusers are the largest group of drug addicts in hospital care.
By centre types The number of persons with alcohol- and drug problems that have had help from the social welfare system has been more or less the same between 1999 and 2003 (the last reporting; Individ och familjeomsorg 2004), namely roughly 21 000 individuals per year (which is the number of clients at a given day, the 1st of November).
The number of clients in outpatient care has somewhat increased but has been the same or decreased in other forms of care and treatment.
By gender In disparity with alcohol there has not been observed any clear differences between males and females in the development during the latest years and the proportion of males and females have always been the same. However, some differences exist between different drugs, but these have been there for long. In the figures mentioned above (substances used) regarding hospital data 1 622 out of 2 328 heroin abusers were males. For amphetamine 528 out of 788 were males and for cannabis 277 out of 314 were males. In abstinent treatment 528 out of 784 patients were males. 65 - 75 percent of the abusing population is males. This is a common pattern. In three nationwide case finding studies of problematic drug abuse (1979, 1992 and 1998), 76-77 % was males. The trend in pattern of hospital treatment is the same for women and men.
In a reporting system based on half-yearly reports from the field (the CRD-system, administered by the CAN) it has been suspected that the proportion of males is slowly increasing, but nothing is said whether this is among new abusers or the group as a whole (CAN 2005a).
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Main characteristics and patterns of use from non-treatment sources
The overall picture Surveys and research projects among problematic drug users are not frequently occurring. A few national case finding studies are performed and from these speculations on the development have been made as reported above.
By substance used Assessments of drug preferences usually follow data that are provided by treatment sources. At least this is true when it is about amphetamine and heroin. Other substances, like ecstasy, are much harder to estimate but they are not very popular among problematic drug users. Amphetamine and heroin constitute the “main course” among (injecting) problematic drug abusers. Cannabis has a special role as it is commonly used by all drug users.
Injecting drug-users It is difficult to estimate the number of injecting drug abusers. In 2003 the number of problematic drug users was estimated to be around 26 000 (BRÅ 2003), which is less than in the years before. However, there have been signals from the local and regional reporting system CRD (CAN 2005a) and from the National Drug Policy Coordinator (NDPCo) (Mobilisering mot narkotika 2005a), that heroin is becoming more common in 2004. The NDPCo also suspects that the initial drug career is becoming more rapid nowadays. The CRD-system (CAN) have seen (late 2004) an increase in intravenous use of heroin in parts of the country.
Other specific sub-populations Research on young second-generation immigrants in a Swedish low-status suburb was presented by Lalander & Carmona Santis’s in 2004 (Lalander and Carmona Santis 2004). On the one hand, drugs were found to offer a temporary escape from a difficult and marginalized position in Swedish society, and on the other hand they were part and parcel of a tough, masculine and criminal lifestyle. Many of the persons studied started to sell drugs and moved on to intensive drug use. Their childhood and adolescence had been characterized by social exclusion and failure at school. The report is primarily focused on the social and cultural exclusion and do not discuss specific drugs of abuse or drug patterns.
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5. Drug-Related Treatment
Overview / summary of framework, strategies and interventions in relation to drug related treatment (incl. national definitions)
Presently treatment data can only partly be used as an indicator of the development of the drug problem. Availability of treatment varies from year to year. The NBHW has explained this with reduction in funding during a number of years. A recent trend, however, is that the funding and quality of professional care seems to be improved. In a report to the Parliament in 2005 the government judges that the drug-related treatment has developed both regarding methods and availability. Continuous support is however needed and in the bill for 2005 the government allocated 90 million € for the period 2005 – 2007. It is further proposed that an agreement should be established between the state and the municipality sector with the purpose to strengthen and clarify the actions to be taken by the municipalities on the treatment of alcohol- and drug addicts.
Treatment system
Drug treatment can be arranged by the social services in the local community (within ordinary service or at specialized units such as outpatient clinics), hospitals (detoxification or treatment for certain complications to drug abuse such as infectious diseases, i.e. hepatitis, HIV/aids, psychiatric symptoms, etc) or therapeutic communities. In severe cases drug abusers might be committed to an institution for compulsory treatment. Such treatment is arranged by the National Board of Institutional Care and it is regulated in the Care of Alcoholics, Drug Abusers and Abusers of Volatile Solvents Act, LVM. Still another treatment milieu is the prison and probation system. As roughly half of all prisoners have drug problems treatment for drug abuse is now offered during prison terms. Persons in detention often have acute abstinence symptoms, so all custodies has access to a physician to help with a detoxification procedure. After-care after a period in hospital, therapeutic community or prison is arranged by the social services. Five units for long term substitution treatment (methadone and buprenorphine) are dimensioned for 800 patients (an upper limit of 1 200 has been decided, but resources holds this ambition back).
The National Board of Health and Welfare (NBHW) has (2003) counted 611 specialized units for treatment of alcohol and drug problems (Socialstyrelsen 2004a) with a total of 23 500 clients (31 % women). Specialized units can be found in all systems; community social service, hospitals, therapeutic communities, and prisons. Outpatient treatment comprised 82 % of all contacts, residential treatment 12 % and 2 % were undergoing inpatient treatment in hospitals. 4 % participated in various programs in prison. 45 % of all patients received treatment for alcohol misuse only, 22 % for drugs and 33 % for both alcohol and drug problems. 3 376 patients was identified as injecting drug users.
Recently, a state committee (SOU 2004:3) showed that to a very high proportion it is the same clients that move around in all forms of treatment. Therefore, it concluded, it is essential that resources for treatment are allocated with regard to this. The National Drug Policy Coordinator (NDPCo) has also put his finger on this, and in the latest report (Mobilisering mot narkotika 2004) he adds that economic resources are scarce. The NDPCo observes that extensive reductions have taken place in the treatment system in the same period that has seen an escalation of heavy drug abuse. This group of abusers also presents a complex picture with poly drug abuse and co-morbidity. With reference to a progress report from NBHW it was also reminded that costs for treatment (alcohol and drugs together) has
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been reduced with 20 % between 1995 and 2003 (about 100 million Euro). In spite of a growing need the reductions continues (Socialstyrelsen 2003).
It has also been showed that response to patient needs varies throughout the country (Socialstyrelsen 2004d). This is partly explained by professional or ideological standpoints but not least by economic considerations as there is a clear tendency to choose outpatient treatment before residential treatment.
The Government has reacted upon the signals and in its coming state budget reserved funds for “A contract for life”, were the treatment system will receive national support (Regeringskansliet 2004).
Increased policy and financial support to treatment. As a response to the reports on shortcomings in the alcohol- and drug treatment sector discussed in previous NRs there is presently a policy and financial input from the government on care and treatment issues directly or indirectly affecting the problematic alcohol and/or drug abusers. In the budgetary bill for 2005 the government allocates 90 million € for the period 2005 – 2007 in a project named “A contract for life”. The purpose is to improve the treatment for alcohol and/or drug abusers and major actors are the prison and probation service, municipalities and county councils. The establishment of a treatment chain that holds together the transition from inpatient to open treatment, housing and employment is given priority (Regeringens skrivelse 2005).
Treatment agreement between the state and the municipalities. An investigation initiated by the government reported in October 2005 a proposal for an agreement between the state and the municipality sector on the treatment of alcohol- and drug addicts (SOU 2005:82). The task of the investigation was to specify the actions to be taken by the municipalities in order to be part of a state subsidy of 37 million € for 2006 and 2007.
The investigation proposes that the subsidy primarily should be used for the treatment and care of persons with problematic abuse in combination with somatic and/or psychiatric illness and social rejection, among them unemployment, depths and housing problems. According to the investigation three factors are of crucial importance for the development of an efficient treatment with high quality: – knowledge on what efforts brings results (evidence based activities), - coordinated contributions from all involved agencies and – that the principle of “the individual in focus” should be governing how the treatment is organized and performed.
The investigation brings up the fact that actions initiated by time-limited state subsidize runs the risk of closing down when the money fail to appear. It is therefore proposed that grants only should be allowed for the development of work methods and work organization. To monitor if and how the state subsidy contributes to an improved treatment of problematic alcohol- and/or drug abusers the National Board of Health and Welfare (NBHW) should be given the task to follow up and evaluate the project. In particular local attempts with treatment guarantee3 should be observed.
Drug free treatment
According to the social legislation it is the social services in the local community that are responsible that treatment of drug (or alcohol) abuse come about. This is a pro-active stand that has not developed to a routine. This field has been investigated and reported during the
3 Treatment guarantee in this context means that a person with problematic alcohol- and/or drug abuse who applies for treatment should have a first call for contact within 2-3 days and a personal treatment plan within 4 weeks.
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last two years, but are already reported in last years NR. The NBHW publish every second year a report about services and clients in substance misuse treatment units. The last report (Socialstyrelsen 2004a) covers 2003 and it further sharpens the picture from 2001 and the accompanying report (Socialstyrelsen 2004d) that reductions has taken place in several ways; less funding, shorter treatment periods, less residential treatment, less outreach work, etc.
Inpatient treatments Due foremost by financial shortcomings there has been a reduction in treatment programs and a transfer of patients from inpatient to outpatient treatment. Specially tailored treatment has decreased for several target groups in recent years and time spent in inpatient treatment has been seemingly shortened (Socialstyrelsen 2004a). See also section 4 above.
Outpatient treatments Traditionally, specialized outpatient treatment has different roles in different phases of the drug career. First; in the early phase of recreational drug use before the client has established a manifest drug problem and has been detected by police and social authorities. Such contacts can be opened by the young user himself, by his parents or by referrals from schools or others. Contacts can also be opened by outreach work. Secondly; contacts when drug use has been established and different forms of problems emerge. This is the main body of clients. These cases are opened through own initiative or referrals. Usually several other bodies are involved, although responsibility is most often submitted to the outpatient clinic. Third; as after-care to long term treatment in residential treatment or after a period spent in prison.
In the first phase strivings aim at putting the client back to basics, i.e. re-establish contact with the family, the school, etc. In the second phase this ambition is usually too high. Instead ambition is to raise the client’s motivation, to support him and to arrange for ever more qualified efforts. In the third phase the client is excluded from an ordinary life and needs support to re-establishing himself.
This is how it has been working since the beginning of the 1970s. When HIV/Aids entered the arena in the 1980s national funding made it possible to strengthen outpatient work as funding was directed to outpatient clinics and outreach work. This was very obvious between 1986 and 1989. After that a gradual reduction took place when the national sponsoring was substantially reduced. In the early 1990s this reduction accelerated due to the economic climate at that time. Today many specialized outpatient clinics has been closed down and staff has been redirected to the ordinary social welfare office. It is only bigger towns that can afford to have resources specially directed to alcohol- and drug abusers.
A pilot project on multisystemic therapy (MST) is initiated in the three major cities and the city of Halmstad (Mobilisering mot narkotika 2005c). The project is part of the previously reported prevention initiative by the NDPCo comprising the three major cities in Sweden (NR 2003). So far a base line recording is made and a six month follow up is planned for the spring 2006. Responsible for the Swedish evaluation is Knut Sundell at the R&D unit of Stockholm city.
Medically assisted treatment
Withdrawal treatment Withdrawal treatment, or detoxification, has traditionally been arranged in specialized wards within regional hospitals, usually in psychiatric clinics. Withdrawal treatment has often been a pre-requisite to residential treatment and has always been the first phase in substitution treatment with methadone.
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The number of berths in detoxification units has been substantially reduced during the last decade. In response to that some therapeutic communities now integrate withdrawal treatment in their program. New patients are then in one way or another secluded from patients that have reached a higher level in stepwise treatment program. Newly (2003) one of the oldest detoxification units (in Lund, opened in 1970) was forced to reorganize its program to a day-care unit. According to small talk at conferences and courses drug treatment units is always under discussion when “reorganizations” of hospitals is under way.
The NDPCo have identified three areas that needs immediate concern, whereupon treatment is one (the others are treatment-guarantees for drug abusers and transnational actions against drug trafficking). Shortcomings in the withdrawal treatment organization were expressly mentioned (Mobilisering mot narkotika 2004).
Substitution treatment Methadone and buprenorphine are the only officially recognized preparations for substitution treatment and the previously reported guidelines for substitution treatment are in force since 1 January 2005. Substitution treatment is controlled by a regulation (SOSFS 2004:8) issued by the NBHW and the guidelines are part of the regulation. The conditions and provisions for substitution treatment were presented in the 2004 NR. To the knowledge of the National Focal Point there is no report on possible Pros and Cons of the introduction of the guidelines and regulation.
Sweden has five treatment units at hospitals in Uppsala (opened in 1966), Stockholm, Lund, Malmö and Helsingborg. Substitution treatment with methadone has always been surrounded with strict regulations. Even the number of patients that can be in the program has been regulated a few years ago. The “roof” was set to 800 patients, but that has very recently been raised to 1 200. However, resources at the five units do not allow more than a few new patients per year to enter treatment. Methadone treatment demand much from patients as well as from staff and therefore it is also considered to be the most advanced and expensive form of treatment within the field.
Patients need a documented history of heroin addiction and several serious trials with other forms of treatment before they can have a referral from a specialist physician in a drug clinic. The patient then can be called to a methadone program for further investigation. If the patient is accepted, and a treatment plan has been set together with the responsible local social service, he enters a six months long day care treatment were he gets his very personal adjusted dose (the patient is not aware of the magnitude of the dose, but as a general rule doses are higher than in most programs around the world, which minimizes risk of relapse) of methadone and undergoes a training program during a full working day. Urine specimens are taken daily to secure he actually has taken his dose (which is taken in the premises) and that no illegal drugs have been used. After six months his contacts with the clinic is gradually reduced and he can collect his dose at a selected pharmacy, where he also delivers his urine specimen.
Buprenorphine (Subutex) has been under trials in specialized clinics during several years (Heilig and Kakko 2003). As the substance has not been regulated to the same degree as methadone there have appeared a few general practitioners in the arena who has prescribed Subutex. In one case a pensioner physician had more patients in substitution treatment than a methadone clinic usually has. His license as a physician is now suspended. As noted above buprenorphine treatment is now regulated in the same manner as methadone.
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Other medically assisted treatment4 The regulations that cover substitution treatment do not allow other pharmaceuticals than those who are listed by the Medical Products Agency, namely methadone and buprenorphine. Accordingly heroin can not be used. However, other sorts of pharmaceuticals can be prescribed as most specialized units have access to a physician, most often a psychiatrist and sometimes a psychiatrist with competence in drug abuse and working in a drug clinic.
4 This may also include combined (medical assisted and drug free treatment)
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6. Health Correlates and Consequences
Overview / summary on health correlates and consequences (incl. if required definitions)
Researchers often remain readers that the shift between editions of the ICD-system makes it very difficult to follow trends over the years. In the drug field it is also possible that the phenomena of double-diagnosis, which has been a widespread notion cherished by all in later years, in reality is something that always have been existing among drug abusers – for those who were trained to see it. It is also possible that after decades of epidemic drug abuse there nowadays exist so many older problematic abusers that they dominate the scene. There are other conditions that complicate the interpretation of the situation. Obviously, the number of HCV as well as HIV cases can only grow, which means the overall picture of the health situation in the drug abusing population is worse today.
Drug abusers also make extensive use of alcohol and pharmaceuticals. The latter has come to be more high-lighted in Sweden in later years as it complicates matter for the abusers (as well as for the treatment provider).
Drug related deaths and mortality of drug users
Direct overdoses and (differentiated) indirect drug related deaths No new information available due to the fact that the official statistics for 2003 is not yet compiled.
Mortality and causes of deaths among drug users A study on the mortality of GHB or its precursors (GBL and 1,4-BD) found 36 cases over the period 1996 (1 case) – 2004 (9 cases). 83% of the cases were men, mean age 25 (youngest 16, oldest 37). The majority of cases are classified as accidents, mainly poisoning, and suicides, where poisoning also was the most common diagnosis. (Steinholtz et al. 2005)
Drug related infectious diseases
HIV In 2002-2004, approximately 30 cases of HIV among intravenous drug users were notified annually, comprising approximately 6-12% of the total number of notified HIV cases (27 cases were notified in 2004, which was 6% of all notified cases). When interpreting time trends among HIV positive intravenous drug users, one should keep the low absolute number of cases in mind. The percentage of women varied between 11-36% in the years 1997-2004, with no clear time trend. There seems to be a slight increase in mean age at diagnosis among the intravenous drug users (mean age was 31 in 1991, compared to 40 years in 2004). The share of HIV cases among intravenous drug users, who were infected in Sweden, varied between 70% and 88% in the years 1997-2003. However, in 2004, the share was 56%. (Statistics from the web site of the Swedish Institute for Infectious Disease Control (SMI), http://www.smittskyddsinstitutet.se/SMItemplates/Article.aspx?id=2834)
Hepatitis C The number of new hepatitis C cases per year, has decreased steadily since the mid 1990s: from almost 2 900 cases in 1995, to 1 900 – 2 000 in the first years of the new millennium (in 2004, 1 864 new cases of HCV were notified). The share of intravenous drug users has also
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decreased: in 1995 they made up 92% of the new cases with a known transmission route, compared to 83% in 2004. The share of women among the intravenous drug users diagnosed with hepatitis C in 2004 was 27%, which is about the same as previous years. There have been no relevant changes in the age distribution among the intravenous drug users in the last five years. The figures are from standard table 9 to the 2005 NR based on a special extraction from the SMI registers.
Hepatitis B The number of new hepatitis B cases per year increased during the first years of the new millennium, peaking at 372 cases in 2003. In 2004, 258 new cases were reported. There are also indications of a decrease when it comes to the share of intravenous drug users: in 2004 they made up 52% of the new cases with a known transmission route, compared to 66% the year before. In the last five years, women make up 22-29% of the cases among intravenous drug users. The age distribution among the new cases of intravenous drug users per year has been about the same in the last five years according to standard table 9 in the 2005 NR. More than 70% of all new cases of hepatitis B reported in 2004, had been previously diagnosed with hepatitis C within a year as reported on the website of the SMI (SMI statistics http://www.smittskyddsinstitutet.se/SMItemplates/Article.aspx?id=2864).
Psychiatric co-morbidity (dual diagnosis) No new information available
Other drug-related health correlates and consequences
Experience of violence among female drug addicts Within the scope of a research project examining exposure to violence among women addicts, 103 women were interviewed regarding their experience of violent behaviour. The project was initiated by the National Drug Policy Coordinator (NDPCo) due to the lack of empirical studies concerning experience of violence among this special group. Among the interviewees 94 answered they had at least one time, in grown up age been exposed to physical violence, sexual violence or mental assault. 77 women had been exposed to physical violence and 41 responded having experienced sexual violence. 88 of the respondents reported experience of more than one type of assault. In most of the cases the perpetrator was a man and 74 of the women reported that the perpetrator was a former partner (Holmberg, C. et al. 2005). Even though the results cannot be generalized to the whole population of women addicts the authors claim they indicate that experience of violence is far more common among female drug abusers than among women with no drug addiction. By focusing on this group of people, the authors wish to increase the comprehension for these women and their experiences among social workers, treatment staff and other professionals that might come in contact with female drug abusers.
Driving and other accidents Driving under the influence of alcohol/drugs have increased over the last five years (see section 8). A study of fatal accidents in the south of Sweden shows that about 25 percent of the accidents were alcohol or drugs related. One method to follow the development of alcohol/drugs related accidents is to use figures from accidents where the driver was killed. Since 1997 the proportion of killed car drivers that were under influence has increased and was 29 % in 2003 according to the SRA (Vägverket 2005).
Pregnancies and children born to drug users Pregnancy is a key situation for women exhibiting advanced alcohol and drug abuse as well, as shown by the life-story narratives of a number of addicted mothers. Most pregnant women
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break off or reduce their abuse, partly out of concern for the child and partly owing to greater openness to their relationship with their own mother and other women in the context of preparing for the birth of their own child (Trulsson, K. 1999, Trulsson, Karin 2003a). This may be part of the reason why many studies show particularly positive treatment outcomes for pregnant addicts and mothers of small children, but also part of the reason why the failure to make interventions, mainly repressive ones, may lead to negative consequences (Andersson, G. 1995, Eriksson 1997, Steneroth et al. 1996, Trulsson, K. and Nötesjö 2000). Motherhood has proved to be an important driving force when it comes to approaching treatment services and completing treatment (Dahlgren, Lena 1992, Laanemets 2002, Trulsson, K. 2000a). Göransson (Göransson 2004) has studied a group consisting of slightly less than half of 300 women who were going to have their first baby and who attended either of two maternity- care centres. These women underwent special screening as regards their alcohol habits before the pregnancy and during the first trimester. The other group of women received standard maternity care. This screening identified a group of 15 per cent of the women who had continued to drink at a level, which can be considered damaging to the foetus according to internationally established guidelines. What gives cause for concern, according to Göransson, is that almost none of these women were identified by the maternity-care centres. This prompted further training of the midwives in screening alcohol consumption by means of AUDIT (Alcohol Use Disorders Identification) and TLFB (Timeline Follow-Back Interviews), after which they performed at an adequate level in establishing alcohol use through screening. Almost all women were willing to discuss their alcohol consumption. On Göransson’s interpretation, this indicates that pregnancy is a period in life when women are prepared to change their habits. While motherhood has been the subject of a series of studies, only one Swedish study involving in-depth interviews has specifically studied the importance of fatherhood to addicted and socially marginalised men. Bangura Arvidsson (Bangura Arvidsson 2003) characterises substance-abusing fathers as “questioned fathers”. A great many of them want to take part in raising their children, but social authorities see them only as addicts, even though they consider themselves capable and important in their children’s lives. Social services focus on addicted mothers, both as regards various interventions and as regards responsibility for the children. The lack of a gender perspective entails that addiction treatment and research on substance abuse are managed on the basis of a hegemonic masculinity, whereas social child-care and research on children and young people tend to have motherhood and a hegemonic femininity as their starting-points. This situation risks causing a lack of holistic vision in addiction treatment, leading to neglect of the family perspective. For instance, there is limited knowledge about the consequences for those children, who are exposed during pregnancy, to the opiate-like medical drug Subutex, whose active substance is buprenorphine. Treatment with Subutex in connection with opiate abuse has become common in the past few years. Major studies have been initiated, including in Sweden and the other Scandinavian countries, as part of a major international effort. While findings from these studies have been delayed, however, according to the Stockholm drug services there has been a “baby boom”, fertility being higher with Subutex treatment than with for instance methadone treatment. In Norway, two dissertations (Slinning 2004, Moe 2003) have investigated 42 substance-exposed children and compared them with 50 non-substance- exposed ones. The study shows that there are large differences between the two groups and identifies specific problems affecting the substance-exposed children. Children manifesting neonatal abstinence syndrome (NAS), of which 78 per cent had been exposed to opiates, exhibited signs of over-active nervous system, sleep disruptions, feeding problems and problems in their relationship with their mother or other carer. The researchers point out the need for both preventive action and interventions in favour of the exposed children.
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Problematic consumption of medicines classified as narcotic drugs. In statistical terms about 0.5 million individuals in Sweden use sedatives (bensodiazepine and analogues) and about 200 000 individuals use painkillers (opioid type) daily. This is reported by the NDPCo in a report mapping the consumption of medicines classified as narcotic drugs and proposals for solutions to reduce the problem (Mobilisering mot narkotika 2005d). The report concludes among other things that - the consumption of medicines classified as narcotic drugs is too high - patients above the age of 15 that for medical reasons starts to use bensodiazepines continue the use for an exceptional long time (60% after two years, 33% after 8 years and 25% after 13 years) - many physicians prescribe medicines classified as narcotic drugs without knowing if the patient all ready has prescriptions for similar medicines - amounts and intervals of medicines classified as narcotic drugs are prescribed in a way that call into question - younger people introduced to the use of this medicines are a particular risk group - the sex difference is notable with women having a considerable over consumption compared to men. Proposals from the NDPCo to improve the situation include - a systematic survey of the state of the art of addictive medicines (bensodiazepines and opioids) including epidemiology and treatment. - national guidelines for the use of medicines classified as narcotic drugs - regulation of the validity time for prescriptions of addictive medicines - improvement of the training of concerned staff (nurses, physicians, psychologists, social workers) at base level as well as in specialist training.
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7. Responses to Health Correlates and Consequences
Overview / summary of framework, strategies and interventions in relation to prevention of health consequences (incl. if required definitions)
The national action plan on drugs, which is valid 2002-2005, has implied a vitalisation in the drug field – from prevention to treatment and supply reduction. The action plan, which is co- ordinated by the NDPCo, has also made it possible to test new methods and start new and specialised projects from which new directions are supposed to develop. Some of these have already been evaluated, but for the majority of the enterprises there is still one year left. There are strong signals of a continuation of this model for a new period.
Prevention of drug related deaths: No new information available
Prevention and treatment of drug-related infectious diseases
Prevention Vaccination against hepatitis is offered as presented in the 2003 NR. The most developed initiatives are in the existing syringe exchange programmes. As of 2005 testing and vaccination of hepatitis B is offered all inmates in the Swedish prison and probation system (no reliable data for 2004). In Stockholm’s custody office, by far the largest in the country, all inmates are offered a hepatitis B, hepatitis C and HIV test, a specially financed project by the Swedish National Institute of Public Health (SNIPH). Of the 589 people taking part in the project 2004, 374 identified themselves as infected drug users (IDU). Of the 374 IDU’s, 21 (incidence 5.6%) were HIV-positive (18 known cases and 3 new cases). 339 (91%) reported that they had been tested for HIV before. Approximately 2/3 of the IDU’s reported amphetamine as their primary drug whereas the remaining 1/3 reported heroin as their primary drug-use. Information on the infectious risks with injecting drug use and sexual contacts is given by NGOs in contact with addicts as well as from the social services, the health and treatment sector, the prison and probation system and many other institutions in contact with drug addicts. Frequently condoms are also available for the addicts in these contacts, in particular in the existing syringe programs. Regarding the previously (NR 2003) presented proposal by the National Drug Policy Coordinator (NDPCo) on a future needle exchange programs the opinion among professionals and political parties is divided. A decision by Parliament regarding legalising needle-exchange programmes in all regions of Sweden is expected at the end of 2005.
Counselling and testing The custody in Stockholm has operated a HIV-prevention programme since Mars 2002. Since then 1 031 detainees has participated. 5 new cases of HIV have been found until the end of 2004. 589 persons participated during 2004 (441 for the first time). 374 were IDUs (240 amphetamine, 130 heroin, the remaining other drugs). 70 persons were females. 709 persons with a known drug abuse were offered participation, but 120 (17 %) were not interested. Among IDUs 374 persons out of 447 accepted the invitation (73 or 16 % did not want to participate). The programme is a counselling, testing and vaccination programme which also offer remittance opportunities to other treatment facilities.
Infectious disease treatment No new information available.
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Interventions related to psychiatric co-morbidity No new information available.
Interventions related to other health correlates and consequences
Prevention and reduction of driving accidents related to drug use In 2004 the police carried out 1 563 000 breathalyzer tests, a 13 % increase compared to 2003. This increase in tests is estimated to have led to 7 less deaths and 72 fewer serious injuries (Vägverket 2005).
Offering treatment to addicts. In 2005, a pilot project was initiated in collaboration between the Police in Stockholm, the county council of Stockholm, the City of Stockholm and the NDPCo. The project aims at closing the open drug arenas in Stockholm by offering treatment to addicts and is an alternative and complement to the law enforcement efforts taken by the police regarding this issue. During the period April – June 227 drug addicts have been contacted through outreach activity in connection with the drug arenas and offered to participate in drug related treatment. The project is carried on during the autumn 2005 and a pronounced objective is that about 40 persons shall be guided into a patients' pathway before the project can be fully evaluated (Mobilisering mot narkotika 2005b).
Experience of violence among female drug addicts Within the scope of a research project examining exposure to violence among women addicts, 103 women were interviewed regarding their experience of violent behaviour. The project was initiated by the NDPCo due to the lack of empirical studies concerning experience of violence among this special group. The aim is to increase the comprehension for women addicts and their experiences among social workers, treatment staff and other professionals that might come in contact with female drug abusers (Holmberg, C. et al. 2005)
Interventions concerning pregnancies and children born to drug users Maternity-care services carry out important preventive work offering support to women during their pregnancies. In Sweden practically 100 per cent of all women are reached (Österling 2002). The overwhelming majority of women abstain from using alcohol while pregnant, but a remaining group continues to drink at a level entailing a risk of foetal damage.
Within compulsive institutional care, differences between men and women have become clearly visible. To women, forming a good relationship with their children and resuming responsibility for their fellow human beings are important objectives. Women often see being placed in compulsive care as help in an emergency, and they want individual conversational therapy. Men, however, see care as a coercive intervention against them and do not want any treatment (Kurube 2004)). Experience from the Ambulatory – an outreach activity targeting pregnant addicts as a joint effort by health and social services – shows positive effects of providing female addicts with support and treatment at an early stage of their pregnancies and continuing to provide follow- up support while the children are small (Björkhagen Turesson 2001, Österling 2002). The largest cities in Sweden have specialist clinics for pregnant addicts, which aim for drug-free pregnancies. Their objective is to initiate comprehensive support and treatment interventions, but this has become more difficult over the last decade as a consequence of financial cuts and a strong decrease in the availability of treatment resources in both inpatient and outpatient care. For opiate addicts, inpatient treatment during pregnancy is recommended to minimise the risks associated with a relapse into abuse. Sarman (Sarman 2000) discusses the increasing opiate abuse in Sweden, the problems in connection with health care of pregnant opiate addicts, and the consequences for the foetus in terms of neonatal abstinence syndrome (NAS). He shows the benefits of centralising the care of pregnant
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addicts to special units, which have access to comprehensive knowledge about the social and medical consequences of substance abuse.
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8. Social Correlates and Consequences
Overview / summary on social correlates and consequences (incl. if required national definitions
Data on social exclusion is not collected and processed in a regular and standardised way. It is through research projects that information can be gathered, and then often for a limited cohort. Criminality is well knitted to drug abuse, and the general public is well aware of this. The NDPCo has initiated projects that study the connection between drug abuse and criminality, drug trafficking, organised crime and other aspects of the subject. Social costs of drug abuse have attracted some interest, which now seems to result in an attempt to sort the problem out.
Social Exclusion No new information available.
Drug related Crime
Drug offences In 2004 just over 45 000 crimes against the Narcotic punishment act were reported. This is little more than four per cent of all crimes reported in Sweden 2004 (BRÅ 2004a). The majority (48 %) of the reports were on sole consumption.
12 606 cases of illegal drug crimes arrived to the Prosecutors in 2004. This was an increase by 17 percent compared to 2003, 30 percent compared to 2002 and 49 percent compared to 2001. It was simultaneously reported that the Prosecutors closed 13 percent more cases of illegal drug related crimes in 2004 than in 2003. In total, the closure of all crimes counted increased by 4 percent (Åklagarmyndigheten 2005). Statistics from the National Council for Crime Prevention (NCCP) on arrests/reports for drug law offences (ST 11 to the 2005 NR) show that cannabis and amphetamine still are the dominating drugs.
In 2004, no one was convicted for crime against the Act on the Prohibition of certain Goods Dangerous to Health. The corresponding figures for 2003, 2002 and 2001 are four, two and one respectively.
Driving and other accidents Reported offences of driving under the influence of alcohol/drugs (table 2) have increased over the last five years (Vägverket 2005). However, as pointed out by the Swedish Road Administration (SRA) the number of drink driving offences does not provide a very clear picture of alcohol and drugs in the traffic as these are dependent on the police force’s activities. Calculations by the SRA show that drivers are under the influence of alcohol in about 14 000 car journeys a day in Sweden. One method to follow the development of alcohol/drugs related accidents is to use figures from accidents where the driver was killed. Since 1997 the proportion of killed car drivers that were under influence has increased and was 29 % in 2003 according to the SRA (Vägverket 2005).
Table 2. Annually reported cases of drink driving, 2000-2004. (Vägverket 2005)
2000 2001 2002 2003 2004
Drink driving offences 16 523 17 276 18 975 20 836 22 098 Of which drug driving 3 805 4 645 4 616 5 485 6 549 Percent drug driving 23 27 24 26 30
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Organizational patterns of drug crime The NCCP has published a report where the organizational patterns of drug crime in Sweden are examined (Korsell et al. 2005). The authors seek to map the organized drug crimes in Sweden by reviewing all court judgments and pre-trial investigations of serious drug smuggling offences carried out in 2002 and interviewing relevant persons (inmates, customs officers, police and prosecutors). The report is the first scientific attempt at describing and analyzing this form of drug crime in Sweden.
127 persons, convicted with serious drug offences or serious drug smuggling charges in 2003, where examined in the study. This showed that the 127 persons had together been in contact, directly or indirectly, with at least 7000 persons who had been suspected of committing a crime. These contacts constitute a criminal network, which is mainly concentrated to the metropolitan districts of Stockholm, Gothenburg and Malmö. It is stated that international contacts or contacts in the county of Skåne (which is a strategic location for smuggling activities), are advantageous, since most of the drugs in Sweden are bought in the Baltic States, Poland, Denmark, Holland, Africa and South America. A majority of the drugs brought in to Sweden (among the examined cases) were purchased in Holland. One of the general conclusions in the report is that the criminal organizations in Sweden are less hierarchical and consist largely of instable networks than outside of Sweden, where the groupings seem to be more stable and organized. People recruited to these networks are mostly young people already familiar with criminal activities, adults with a criminal record and people from other countries with contacts abroad. This is confirmed by a study made by the Swedish National Drug Policy Coordinator in which criminal networks in the cities of Stockholm, Uppsala and Malmö are mapped (Puhakka 2005). The study reveals groupings of individuals (mostly men between 15-30 years old) engaged in crimes such as drug offences, thefts, violence, vandalism and robbery. These groupings are concentrated to areas that are socio-economically underprivileged. In the report from BRÅ it is stated that improving the possibilities for integration into society for people living in these areas would be a way to decrease the recruitment to criminal networks. BRÅ also claims that since these networks involve many persons and therefore are flexible, arresting single players on the drug market will not prevent this sort of organized crime. One of the strategies to knock out the networks would be to undermine the trust that binds the networks together. According to BRÅ, this can be done by intensifying the contacts with informers and offering better advantages to defectors.
Drug Use in prison
No new information available.
Social Costs
No new information available
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9. Responses to Social correlates and Consequences
Overview / summary of framework, strategies and interventions in relation to prevention of social consequences (incl. if required national definitions)
The 2004 situation report from the NBHW (Socialstyrelsen 2005a) shows that the goal to reach all the drug abusers with offers of help and treatment for the abuse is not reached. The number of persons having received treatment, housing or other kinds of support has been at the same level 1999–2003 (about 21 000 persons at the consensus date). In spite of that, the cost for the municipalities for alcohol and/or substance abuse has increased by 9.5% between 2002 and 2003. 50% of the increase is correlated to support for housing. According to the NBHW, this could be a trend shift because since the middle of the 90s until 2002 there was a reduction of the support simultaneously with an increasing problematic drug abuse. Also, the number of drug abusers receiving support in terms of day care and housing has increased whereas the number of persons in voluntary institutional care, family home care or compulsory care has been constant.
Establishing a national action plan on drugs with a corresponding funding for the NDPCo to distribute has implied that responses to the actual situation have been possible to launch. It has also been a period of formulating agendas and to lay down broad outlines for responses to various aspects of the drug problem. This is a process over a couple of years. Already the last NR could report on some of these responses. As the present action plan ends in 2005 it implies that more results will be presented next year.
Social Reintegration
A situation report on individual- and family care shows that the goal to reach all drug abusers with offers on care and treatment for the abuse has not been reached (Socialstyrelsen 2005a). The number of drug addicts having received care in terms of treatment, housing or other support have been more or less unchanged for the period 1999 – 2003 (approximately 21 000 persons at the day of investigation, April 1). Although the number of persons receiving care was unchanged the costs increased by 9.5% between 2002 and 2003. About half of the increase was caused by support for housing. According to the NBHW the number of abusers receiving care in terms of open treatment and housing have increased while the occasions for compulsory care, family home care and voluntary institutional care have been constant.
Prevention of drug related Crime
Drug-Related Treatment in Penal institutions One of the principal objectives presented by the NDPCo is that more persons with drug- problems are to meet treatment clinics. As a considerable number of inmates in penal institutions are drug abusers5 the Prison and Probation Service (PPS) is considered an important arena for fighting drug-addiction. In the view of this, the PPS initiated a three-year strategy (2002-2005) including a drug-treatment program in order to fight drug-addiction amongst prisoners. The strategy was commissioned and financed by the government (for further information on this, see NR 2003, chapter 12).
5 In 2002 the number of inmates with drug-addiction where estimated to be 6387 which corresponds to 62 % of the total number of prisoners. 4551 of these were considered to have serious drug problems.
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By order of the government, the National Council for Crime Prevention (NCCP) launched a study to follow up and evaluate the results of the drug-treatment program within the PPS. The main findings of the study were summarized in a report in 2005 (BRÅ 2005).
The NCCP states that the PPS had a high level of intentions and ambitions but that the drug- treatment program was strongly influenced by overcrowding in prisons and a lack of financial resources. Another problem that attracted attention in the report was that the drug-treatment program reached far from all drug abusers. Many of the inmates sentenced with a drug offence are only incarcerated for a shorter time and are thus, because of lack of time not likely to be affected by the treatment provided by the PPS. In order to meet the criticism the PPS has strengthen the efforts to investigate the needs and motivation of drug abusers with shorter imprisonment by using the ASI instrument (see NR 2003, chapter 12.1) The results of the investigation will then be transferred to the Probation Care, where many prisoners with shorter sentences are likely to come, and treatment can be carried out.
One of the goals with the drug-treatment program was to increase the amount of placing according to section 34 of the Prison Treatment Act (SFS 1974:203)6, which was reached according to the NCCP. However, the amount of placing in 2003 was less than during the greater part of the 1990s.
The NCCP was also requested to examine the effects that the drug-treatment program might have had on relapse into crime among drug abusers. The NCCP has compared the relapse among inmates who were released before the program started with relapse among those who were released after. The intention was to investigate if:
- the number of relapse into crime has decreased - the time period before relapse into crime has increased - fewer crimes are committed after the release - smaller proportions are sentenced to imprisonment again.
The investigation shows no noticeable differences between the two groups. Approximately two thirds of the inmates with drug addiction tend to relapse into crime after one year and almost 50 % are sentenced to imprisonment again. The only visible positive effect was that those who took part in a treatment program while in prison tended to have a slightly longer time before relapse into crime than those who did not participate in any treatment program.
Studies on the efficacy of treatment in prisons Simultaneously to the carrying through of the PPS drug-treatment program a study of evaluated studies made on the effects of treatment for drug abusers in prison was initiated. The carrying through of a meta-analysis on 22 studies showed that treatment had a positive effect on relapse into drug abuse and crime in most of the studied cases, even though the effects were weak (BRÅ 2005). The authors give two possible explanations to why effects of treatment in prison seem to be quite limited. First of all the criminal norm system, often present in prisons, might have a negative effect on treatment groups trying to establish other norms. Second, the ambition that all clients are to be offered treatment might result in that persons, not receptive to treatment, will conceal the positive results reached by others. Furthermore, the authors present a few suggestions for increasing the efficiency of treatment in prisons:
- the efforts should be focused on those with drug abuse as a primary problem and criminality as a secondary since treatment is shown to have more effect on those
6 Section 34 of the Prison Treatment Act affirm that a prisoner may be placed on a treatment facility outside prison while still serving prison sentence.
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persons than on those with criminality as the major problem and drug abuse as the secondary. - treatment professionals should have therapeutic competence, which might increase their ability to help clients with failing motivation - clients should be able to continue treatment after imprisonment - a reward system would increase the number of clients fulfilling treatment programs. (Fridell and Hesse 2005).
Alternatives to prison for drug users No new information available.
Other interventions for prevention of drug related crime No new information available.
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10. Drug Markets
Overview / summary on drug market
The availability of illegal drugs is considered to be good. The number of seizures of cannabis, amphetamine, heroin and cocaine has doubled over the last 15 years. Over the same period, the prices are about halved for these drugs. Reports from local and regional experts as well as surveys support the picture of high availability as previously reported on. Sweden is mainly a consumer market and to some extent, a transit country for illegal drugs and almost all seizures of illegal drugs are of foreign origin. Exceptions are a limited manufacturing of GHB, some home growing of cannabis and some diversion of psychotropic pharmaceuticals from the legal drug handling.
Availability and supply
Availability of drugs On the issue of availability, the situation is generally as previously reported. Regarding problem drug users the police have reported on four seizures of fentanyl (one was fentanyl patches) in 2005 while there were no seizures during 2004. One of the 2005 seizures was 27 grams of fentanyl with a purity of 3%. Previous seizures have been significantly smaller and the purity has varied between 4 and 12 percent. Fatal accidents with fentanyl during 2005 are not known so far. The annual report on the drug situation in Sweden from the police and customs (Rikskriminalpolisen and Tullverket 2005) report on a new benzodiazepine analogue, alprazolam, as frequently occurring on the illegal market. The sized tablets are clandestine manufactured although the substance per se is part of several medicines on the Swedish market. According to the report diazepam (usually smuggled from Thailand) is the dominating medicine classified as narcotic drug on the illegal market followed by the clandestine manufactured flunitrazepam and alprazolam preparations.
Internet as a source of supply In 2004, the National Drug Policy Coordinator (NDPCo) initiated a project to combat the sales of illegal drugs via Internet. The project was carried out in collaboration between the National Criminal Investigation Department, the Customs and the Office of the Public Prosecutor. The project was reported in September 2005 and had by then resulted in the apprehending of about 50 persons and the seizures of approximately 6000 ecstasy pills, 1 hg of cannabis, 1 hg of amphetamine and a larger amount of medicine classified as narcotics. Eight cases of suspicion of severe drugs crime were initiated. Five of those resulted in prosecution and verdict of guilty (Nilvall 2005). The main purposes of the project where to: - Increase the risk of being discovered by the police when using Internet for promoting production, trade and use of illegal drugs. - Develop efficient methods and technical aids in order to increase the possibilities to discover the promoting of production, trade and use of illegal drug at the Internet. - Develop the possibilities to collect and analyze information available at the Internet, for the purpose to use it as basic data for decision on primarily investigation against persons involved with drug offences. In order to achieve these goals the project was divided into four operative unities: 1) education, 2) operational work and development of techniques, 3) information retrieval, 4) strategic and informative activity.
New research projects –Trafficking patterns The National Council for Crime Prevention (NCCP) has published a report where the organizational patterns of drug crime in Sweden are examined (Korsell et al. 2005). The
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authors seek to map the organized drug crimes in Sweden by reviewing all court judgments and pre-trial investigations of serious drug smuggling offences carried out in 2002 and interviewing relevant persons (inmates, customs officers, police and prosecutors). The report is the first scientific attempt at describing and analyzing this form of drug crime in Sweden.
127 persons, convicted with serious drug offences or serious drug smuggling charges in 2003, where examined in the study. This showed that the 127 persons had together been in contact, directly or indirectly, with at least 7000 persons who had been suspected of committing a crime. These contacts constitute a criminal network, which is mainly concentrated to the metropolitan districts of Stockholm, Gothenburg and Malmö. It is stated that international contacts or contacts in the county of Skåne (which is a strategic location for smuggling activities), are advantageous, since most of the drugs in Sweden are bought in the Baltic States, Poland, Denmark, Holland, Africa and South America. A majority of the drugs brought in to Sweden (among the examined cases) were purchased in Holland.
One of the general conclusions in the report is that the criminal organizations in Sweden are less hierarchical and consist largely of instable networks than outside of Sweden, where the groupings seem to be more stable and organized. People recruited to these networks are mostly young people already familiar with criminal activities, adults with a criminal record and people from other countries with contacts abroad. This is confirmed by a study made by the NDPCo in which criminal networks in the cities of Stockholm, Uppsala and Malmö are mapped (Puhakka 2005) The study reveals groupings of individuals (mostly men between 15-30 years old) engaged in crimes such as drug offences, thefts, violence, vandalism and robbery. These groupings are concentrated to areas that are socio-economically underprivileged. In the report from NCCP, it is stated that improving the possibilities for integration into society for people living in these areas would be a way to decrease the recruitment to criminal networks. NCCP also claims that since these networks involve many persons and therefore are flexible, arresting single players on the drug market will not prevent this sort of organized crime. One of the strategies to knock out the networks would be to undermine the trust that binds the networks together. According to NCCP, this can be done by intensifying the contacts with informers and offering better advantages to defectors.
Seizures
Quantities and numbers of drug seizures The total number of seizures of illegal drugs was 22 018 in 2004. This includes medicines used illegally, mainly benzodiazepines but also pain killers (CAN 2005b). The figure emanates from the police seizure and analysis register. The police accounted for 19 932 of the seizures and the customs for the remaining 2086. The figure for 2004 is lower than 2003 and according to the report the statistics for seizures of certain drugs is missing compared to previous years. Also, the statistics for the customs is not collected in the same way in 2004 as previously, which could have affected the comparability.
The trend for seizures of the six major illegal drugs is shown in figure 4 (full-scale figures in appendix 1). Due to methodological changes as discussed above the comparability of the 2004 figures to previous years could be limited. The figures are from the report “Drogutvecklingen i Sverige 2005” (CAN 2005b) and emanates from the police seizure and analysis register. Please note that the Y-scales are different for the different substances.
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Figure 4. Number of seizures and sized quantity as a function of time (1988 – 2004) for cannabis, amphetamine, heroin, cocaine and (1996 – 2004) for ecstasy and LSD. Ecstasy includes MDMA & MDA and from 2001 also MDE.(CAN 2005b)
Regarding the origin and production of the drugs reported on above the following is presented in the 2004 annual report from the Police and Customs on the illegal drug situation in Sweden (Rikskriminalpolisen and Tullverket 2005).
‹ Cannabis. For cannabis, more than 80 percent of the seizures of the resin originate from Morocco. The figure is based on intelligence agency information. ‹ Amphetamine. The major sources of supply are said to be Belgium/Netherlands, Poland, Lithuania and Estonia in line with previous years. The country of origin of the approximately 70 seizures of 0.5 kg or above during 2004 were Poland (63%), Lithuania (19%), and Belgium/Netherlands (11%). Unknown were 7%. The high figure for Poland is explained by a major seizure in Malmö in 2004 according to the report. ‹ Heroin. The brown heroin coming via the Balkan route dominates the Swedish heroin market. No seizures of heroin with South America as origin were made in 2004. The region of Stockholm is said to have its own scenario where white heroin is dominating. ‹ Cocaine. Sources of origin are not reported on. Although the number of seizures is about the same as previous year the report claims that the availability is significantly increased, occurs at street level and in youth circles and that the street level trade is dominated by immigrants from West Africa selling at low prices. The report also informs on 25 seizures of cocaine (30 kg in total) made abroad where the couriers were citizens (or place of residence) of Sweden and the goods was intended for the Swedish market. ‹ Ecstasy. The report states that the major country of manufacturing for ecstasy found at the Swedish market is the Netherlands. No information on country of origin in cases of smuggling is presented but it is stated that Sweden in five cases during 2004 also functioned as transit country for ecstasy aimed for Norway, Finland and Lithuania. In smaller parts ecstasy are brought in as parcels via the Stockholm airport (Arlanda) while larger lots are said to come in cars via the Öresund bridge. ‹ LSD. No information on manufacturing and smuggling of LSD is presented in the report.
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‹ Others. Medicines classified as narcotic drugs are frequently available according to the report. The dominating substance 2004 was diazepam (major country of origin Thailand) followed by the previously dominating substance flunitrazepam. Alprazolam, a new benzodiazepine rapidly entered the illegal market in the latter part of 2004. Country of origin so far unknown. Both the flunitrazepam and the alprazolam preparations sized in 2004 were judged as illegally manufactured in the majority of cases. ‹ Precursors. No handling of precursors for manufacturing of illegal drugs is accounted for in the report for 2004.
Price/Purity
Price of drugs at street level The development of street level price (median) for heroin, amphetamine, cocaine and cannabis is shown in figure 5.
Figure 5. Development of street level price (median) for heroin, amphetamine, cocaine and cannabis, 1988-2004 (CAN 2005e).
The price at street level (adjusted to the 2004 monetary value) is about halved for hashish and cocaine since the end of the eighties. In 2004 one gram of hashish was reported to cost between 6.8 and 10.5 € and one gram of cocaine between 63 and 105.3 €. For amphetamine and brown heroin, prices are about 60 per cent lower today than 15 years ago. Prices in 2004 per gram of amphetamine had an interval of 15.8 – 52.6 €, brown heroin 63 – 263.2 € and white heroin 84.2 – 315.8. All figures are from the CAN report Narkotikaprisutvecklingen i Sverige (The development of drug prices in Sweden) 1988-2004 (CAN 2005e).
The report also presents the price development for ecstasy (per tablet), LSD (per trip), GHB (per capsule - 20 ml) and khat (per bundle) for the period 2000 – 2004 and adjusted to the 2004 monetary value. In 2004 the median price for ecstasy was 12.8 €, for LSD 9.5 €, for GHB 3.2 € and for kat 26.3 €. Only ecstasy shows a continuous price drop over the period, starting at a median price of 16.9 € in 2000. The other drugs had small changes in the
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median price for the period. The factor used for the conversion SEK to € was 9.5/€. The methods used to map the price situation were presented in 2004 NR.
Purity at street level and composition of drugs/tablets The purity (and composition) of street level seizures is not monitored systematically in Sweden. On larger seizures made by the police or customs, purity is determined. For cocaine the Swedish Forensic Laboratory (SKL) report that the level of cocaine hydrochloride varies between 14 and 96 % in the different seizures 2005. In seizures larger than 1 kg the purity is commonly 75 - 85 % but in 2004 it never exceeded 45 % suggesting that the goods was all ready diluted upon arrival. Most frequently used diluters were fenacetine, lidocaine and caffeine (Rikskriminalpolisen and Tullverket 2005)
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Part B – Selected Issues
11. Gender Differences
Summary The report shows that studies of gender differences as regards substance-abusing, socially vulnerable young people and adult addicts deal mainly with young girls and adult women. There are few studies dealing with young boys and adult men from a gender perspective. With the exception of the National Board of Institutional Care’s documentation systems ADAD and DOK, there is a lack of systematic knowledge at group level about boys/men and girls/women where gender differences are taken into account. The existing studies are mostly small and have been carried out using qualitative methods, which means that they rarely show how common or prevalent a given phenomenon is even if they do prove the existence of certain phenomena and contribute towards a deeper understanding of them (Socialstyrelsen 2004b). Among substance-abusing, socially vulnerable young people and adults, girls/women form a minority. Studies of prevention and treatment, which do not take account of gender aspects, therefore tend to be based on knowledge about the majority of boys/men and thus reflect a hegemonic masculinity. Because of this, girls/women as well as men who do not fit traditional male patterns tend to be overlooked. Examples of this can be found in a research survey of social youth services, where most studies included deal with young people generally, not boys and girls specifically since girls make up a small share of the total population of juvenile delinquents in these studies (Andreassen and Nordli 2003), and a research survey of the treatment of adult addicts (SBU 2001). The latter report, which sums up and discusses information from a large number of studies in the alcohol and drug fields, deals with addiction treatment without paying much attention to the specific needs of men and women. According to Helmersson Bergmark (Helmersson Bergmark 2001), most of the studies surveyed where reports of gender structures are given have respondent groups consisting of men only or a large majority of men. Her conclusion is that women still form a minority in addict collectives. Thus, treatment systems are designed to meet the needs of men. Women seem to be less interesting to evaluators. The components of women’s abuse and the best responses for female addicts tend to be overlooked. Fridell (Fridell 2002) also underlines these problems in the context of his contribution to the SBU report. Having surveyed about 130 articles on randomised and controlled studies of drug-abuse treatment, he finds that very few of them made even post-hoc comparisons concerning gender differences. There may thus be serious consequences if society tends to build its responses to alcohol and drug abuse mainly on evidence-based research surveys that deal with large populations while neglecting qualitative research and research taking account of the gender perspective. This would risk hampering development opportunities and undermining optimal interventions as regards prevention and treatment for male and female addicts.
Situation
To understand the differences between men and women’s drug abuse and their respective needs for prevention and treatment, it is necessary to apply a theoretical perspective, which makes gender issues visible. Yvonne Hirdman (Hirdman 1988) talks about the “gender system” – the network of processes, phenomena, conceptions and expectations which creates patterns and a gender order. She sheds light on the logic of “keeping apart” – masculine and feminine should not be mixed –, which implies that in any society and at any point in time, there is a contract regulating the interaction between the genders. These
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“gender contracts”, which encompass ideal images of men and women, the division of labour between the genders and their respective socialisation, involve considerable gender differences. Throughout history, such contracts have determined how men and women should relate to each other. Women’s responsibilities include the “domestic sphere”, caring for the home and children. Men are in charge of the “public sphere” and life outside the home. Hirdman (Hirdman 2001) also describes how gender contracts have been losing influence over the past century in Sweden and other Western societies. The “modern project” has reshuffled the cards when it comes to the relationship between the genders. The early- 20th-century feminine ideal of the housewife whose place is in the home has been superseded by that of a woman who is on an equal footing with men, sharing responsibility for the home and children with her male partner and with a public sector which assumes some of the burden of domestic work. In parallel, examples are given of how gender stereotypes tend to come up short in the lives of “real” men and women.
A review of Scandinavian interdisciplinary studies as regards men’s and women’s drug abuse (Trulsson, K. 2003b) sheds light on addicts’ self-constructions in narratives about their lives. It shows some commonalities between male and female abuse, but above all it clearly shows the differences between men and women against the background of society’s ideals, which in their turn have an impact both on the division of labour between the genders and on their respective socialisation. A striking finding is the similarity between the addicts studied on the one hand and men and women in general as portrayed by research on the other.
In relation to the societal ideal of a sober woman who is in control of herself and keeps her home running smoothly, the female drug addict can almost be seen as the direct opposite; women’s abuse is also associated with the epithets of “sexually loose” and “bad mother”. This contributes towards weak self-esteem as well as shame and guilt in these women. Men’s use and abuse of drugs, however, is tolerated to a greater extent, which can be seen as reflecting the traditional place of alcohol in everyday life, where men’s drinking is seen as manly. A study (Trulsson, K. 1999) of psychosocially vulnerable addict families shows a traditional division of labour between the genders. According to the women’s narratives, mothers assume principal responsibility for the home and the children until their abuse gets out of hand; only then do drug-free fathers break out of their traditional role to take over responsibility for the children. Women’s abuse as a manifestation of their aspirations for freedom as well as men’s taking over responsibility for home and children can be seen as reflecting the “modern project” (Hirdman 2001).
A study of a therapeutic community for women (Trulsson, K. 2003b) shows that female addicts undergoing treatment can make up for shortcomings in socialisation (their teenage years, which often have been lost owing to early onset of abuse). This takes place through close interaction with female treatment staff and with the addicts’ female friends in the collective. In this way, female addicts – as found by Ravndal (Ravndal 1994) – may obtain access to tools for handling their addiction as well as their relationship with men. Spak (Spak, F. 1999) calls for a gender perspective to be applied to men’s family relationships as well. The paths out of drug abuse followed by female and male addicts are described by Blomqvist’s study (Blomqvist 2002), which is based on interviews with 42 men and 33 women. Many of the women described their decision to give up drugs as the result of a long, internal process of maturing. The men, and some of the women, mention a clear turning point as a result of a critical event or a strong deterioration in living conditions. Pregnancy and responsibility for one’s own children play a significant part in women’s paths out of abuse, while the men tend to bring up a variety of “external” reasons.
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Consumption in the general population and young people
General population The latest national survey focused on drug use in the adult general population was carried out in 2000. Data on the lifetime prevalence of having used an illegal drug from the four surveys performed between 1994 and 2000 are presented in figure 6. In 1994, the gender difference was rather small (lifetime prevalence was 8% for men, and 7% for women). In the years following 1994, the lifetime prevalence for men increased, peaking at 18% in 1998, while the lifetime prevalence for women peaked at 10% in 1998.
Figure 6. Lifetime prevalence of having used an illegal drug among men and women aged 16-64 years, 1994-2000 (CAN 1994, 1996, 2000b, a).
The surveys carried out between 1994 and 2000 showed that cannabis is by far the most common illegal drug used. The only recent national data on drug use in the adult general population, come from two postal public health surveys, containing one question regarding cannabis use, carried out in 2004 and 2005 (Statens folkhälsoinstitut 2004c, 2005b). Table 3 shows cannabis prevalence data for persons aged 18-64 years between 1994 and 2005 (in order to compare the results between different survey years, the 16-17-year-olds have been excluded in table 1). The prevalence pattern is similar to the lifetime prevalence of any illegal drug, with a similar prevalence for men and women in 1994, followed by a marked increase for men, but only a slight increase for women. The latest public health survey, performed in 2005, showed a decrease in lifetime prevalence of cannabis use among men, compared to the survey performed the previous year, whereas the lifetime prevalence among women remained about the same.
Table 3. Cannabis prevalence (%) among men and women aged 18-64 years, 1994-2005. (CAN 1994, 1996, 2000b, a, Statens folkhälsoinstitut 2004c, 2005b) Lifetime Lifetime Last 12 Last 12 Last 30 Last 30 months months days days Year Men Women Men Women Men Women 1994 8 7 * * * * 1996 13 8 * * * * 1998 19 10 2 0 1 0 2000 16 9 1 0 0 0 2004 18 10 3 2 1 0 2005 15 9 3 1 1 1
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The estimated number of problem drug users was close to 26 000 in 2003 giving a central rate/100 000 of 4.5 in the 15 -64 interval. The figures are from a governmental report presented in October 2005 (SOU 2005:82). The estimated number of problem drug users in 2003 is about the same as in the latest case-finding study in 1998 (Olsson, B. et al. 2001). According to the report, the number of problem drug users has been rather constant over the years since 1998 with a peak in 2001 of close to 28 000-problem drug users. In the treated population used for estimating the hidden population of problem drug users the mean age varied between 37 and 38 years and the female ratio varied between 35% and 36% in the period studied. The true ratio as well as age distribution could be different in the estimated hidden population.
Youth population National surveys regarding drug use have been carried out annually since 1971 among pupils turning 16 during the year of survey. In this age group, the gender difference when it comes to the prevalence of illegal drug use is generally very small. In 2004, the lifetime prevalence and last month prevalence was identical for young men and women (7% and 3% respectively)(CAN 2004c). In 2004, a national study among pupils turning 18 during the year of survey was carried out as well. The lifetime prevalence of ever having used an illegal drug was 17% for the young men and 14% for the young women and the last month prevalence was 5% and 2% respectively (CAN 2005c). Thus, there is a pronounced difference in total prevalence as well as gender prevalence between the two age groups with the exception of last month prevalence for young women. Cannabis was by far the most common illegal drug showing no apparent gender differences in either of the studies.
A national youth survey carried out in 2003 in the age group 16-24 years (Table 4), showed that lifetime prevalence of having used an illegal drug was about 1.5 times higher among men than among women, and that last year and last month prevalence was twice as high among men(CAN 2004d).
Table 4. Lifetime, last year and last month prevalence of having used an illegal drug among men and women aged 16-24 years, 2003 (CAN 2004d) Lifetime prevalence Last year prevalence Last month (%) (%) prevalence (%) Men 20 9 2 Women 14 5 1
Among young people at risk who had been placed outside their home by social child-welfare services, substance abuse was as common in boys as in girls. Asocial behaviour such as crime and violence was twice as common in boys. Sexual acting-out or prostitution was the only behaviour found to be more common in girls than in boys (Socialstyrelsen 2004).
As regards abuse patterns, Andersson’s study (Andersson, C. 1993, 1996) of young addicts at Maria Ungdom, a special treatment unit for young patients in Stockholm, shows that conflicts with parents as well as running away from or being rejected by one’s family were more common among the girls. Andersson’s interpretation is that the girls were rejected by their families if they broke the norm of female behaviour too flagrantly. They were placed in foster homes or institutions more often than the boys, whose deviant behaviour seemed to be treated in a less judgmental and more indulgent manner by their parents.
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Mortality and drug related deaths There are no recent studies on mortality among drug users in Sweden. The number of drug related deaths 1990-2002 for men and women are presented in figure B. The number of drug related deaths increased during the 1990:s, and peaked at 191 deaths in 2000. The percentage of women varies between 11% and 20%, with no clear time trend.
Figure 7. Number of drug related deaths among men and women 1990-2002 (definition of drug related death: selection B according to EMCDDA DRD-Standard, version 3.0, with the exception of ICD 10 code T40.4) (Statens folkhälsoinstitut 2004a).
Treatment demand data The number of occasions of persons being treated in inpatient care for illegal drug abuse has increased steadily, from approximately 8,000 occasions in 1987 to 15,000 in 2002. The share of women has been stable throughout this time period, making up approximately one third of the treatment occasions (CAN 2004a).
An information system on treatment demand, KIM (“Clients in treatment”, corresponding to TDI), containing information on all kinds of drug treatment, not only inpatient care, is under development. It is presently too early to look at the evolution of the absolute numbers of persons being treated since more treatment centres are added to the system each year.
Among the patients registered in KIM in 2004, mean age was about the same for men and women (32 and 33 years respectively). The main illegal drug of abuse registered for each patient is presented in table 5. Amphetamine type substances are the main drug for both men and women, followed by heroin. Cannabis is the third most common drug for men. Compared to women, men are twice as likely to have cannabis as a main drug. For women, benzodiazepines are the third most common drug. “Other opiates” are more than twice as common as main drug for women, consisting mainly of painkillers containing opiates. Thus, the abuse of pharmaceutical drugs is more common among women, whereas cannabis abuse appears to be more common among men.
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Table 5. Main illegal drug (%) for men and women treated for abuse reported in the KIM system 2004.
Men Women Heroin 25 21.5 Methadone 0.3 0.5 Other opiates 5 11.8 Cocaine 2.4 1.2 Amphetamines 33.7 38.1 Benzodiazepines 6.9 13.5 Hallucinogens 0.1 0 LSD 0.2 0.3 Cannabis 23.6 10.4
Infectious diseases The number of new Hepatitis C cases per year, has decreased steadily since the mid 90: s: from almost 2,900 cases in 1995, to approximately 1,900 in 2004. Intravenous drug users make up more than 80% of the cases with a known transmission route. The share of female cases among intravenous drug users is approximately 25 to 30%.
In 2004, 52% of cases with a known transmission route of Hepatitis B were among intravenous drug users, which is slightly lower than pervious years. In the last five years, women make up 22-29% of the cases.
In 2002-2004, approximately 30 cases of HIV among intravenous drug users were notified annually (which was 6-12% of the total number of notified HIV cases). The proportion of women varied between 11 and 31 percent. The low absolute number of cases makes it hard to distinguish any trends when it comes to gender.
Crimes and arrests The figures presented on crimes and arrests are from the report on drug statistics (BRÅ 2004b). The number of persons assented to summary fines imposed by prosecutor or sentenced by court for drug offences per year, has almost doubled between the years 1994 and 2003. The share of women among the total number of drug offenders was about the same during this time, approximately 14%.
The share of drug offences related to drug use is more common among women than among men. In 2003, 50% of the drug offences among women were related to drug use, compared to 39% among men. Drug offences related to possession are slightly more common among men (32% men vs. 28% women in 2003). Other than that, the gender differences are small regarding offence type. When it comes to consequences of drug offences, women are more likely than men to be fined, and less likely to be sentenced to jail. Women are also sentenced to shorter prison sentences. Regarding substances, cannabis is more common among men, while amphetamines are more common among women. Looking at other substances, there are no substantial gender differences. The age distribution of the drug offenders is similar for the two genders.
The aetiology of drug problems In her dissertation, which investigates two population-based samples of women in “WAG” (Women and Alcohol in Gothenburg), Spak (Spak, Lena 2001) studies risk factors for alcohol abuse. She shows that there is a link between sexual abuse in childhood and alcohol
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addiction later in life, and that this link is strengthened by the occurrence of violence or threats. Depression and substance abuse are concurrent. In another dissertation (Trulsson, Karin 2003a) about the family life and treatment experiences of female addicts, the subjects describe childhood turning points involving mainly separations and sexual abuse. A report from the Swedish National Board of Health and Welfare (Socialstyrelsen 2004b) finds that it is important, in prevention and treatment contexts, to take account of the fact that the development which may lead to substance abuse starts early in life.
Peer-group strategies Studies of the socialisation of young substance abusers make it easier to understand the importance of peer-group strategies during the early teenage years. Ramström (Ramström 1983) sheds light on their progressive socialisation. As regards the first step – experiences in early childhood –, it turns out that boys and girls alike exhibit shortcomings in their socialisation owing to early experiences of separations, substance abuse and other types of socially precarious conditions in the home. This affects the second step – the teenage crisis. Both boys and girls have often experienced destructive dialogue in their family of origin, and they are badly prepared for their teenage crisis. Both genders solve this dilemma by finding a community and a place for themselves in drug-abuser gangs, where those who had felt left out find a culture, which they can become, part of. Research on treatment of substance-abusing young people shows that society treats the acting-out behaviour of teenage boys and teenage girls differently: There is a tendency to overlook what the boys do – responsibility is located outside them. However, girls’ acting-out behaviour, especially the sexual part, is something the girls themselves are held responsible for, and they are made to leave their homes or change foster homes to a greater extent than boys (Sjöblom 2002, Andersson, G 2002). In their studies of the socialisation of boys and girls, Bjerrum Nielsen & Rudberg (Bjerrum-Nielsen and Rudberg 1991) have found a differentiation among girls who act out in their teens: a group of gang girls calm down after a few years, while another group of problem girls continue both to act out and to take drugs; a feature common to those in the latter group is problems with gender identity.
Hedonistic behaviour among young people In a study of drug use among backpackers and long-distance travellers, Svensson & Svensson (Svensson and Svensson 2005) find that this should be seen as a type of global and mobile drug-taking, which is temporally and spatially restricted. To the subjects, there was in fact one “space” back home in Sweden and another space abroad, where drugs were tied to travelling – the “spaced-out” space. This meant that the drug-taking of the travellers – all of whom were students – was restricted to certain times and certain situations. Because their drug-taking was limited in this way, it does not seem to lead on to recreational use or abuse. No differences were found between women’s and men’s attitudes towards the use of illegal drugs. For women to do the same things as men is seen as part and parcel of travelling. The backpacker lifestyle emphasises an ideal of equality, which is, however, based on a male norm. When the women return home, they seem to adjust to current norms of femininity. This could be seen in how the female travellers chose to reconstruct their narratives in retrospect: they questioned their actions and sometimes felt ashamed of them.
Forms of treatment for female addicts Research on men and women in therapeutic communities in nine European countries (De Wilde and Trulsson 2005, Segraeus 2005) shows that women have specific needs which have to be met in treatment and that they require gender-sensitive treatment. Women exhibit a specific psychiatric profile, which can be derived from the fact that they have more
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extensive experience than men of sexual abuse, physical violence, suicide attempts and medication for psychological problems. They often have relationship problems and need support as regards caring for children. It is also more common for women than for men to have mothers with addiction problems or psychological problems. Segraeus (Segraeus 2005) mentions two Scandinavian studies as examples of promising outcomes from gender-sensitive treatment. In one of these studies, Ravndal (Ravndal 1994) reports on treatment outcomes in the outpatient part of Phoenix House in Norway: among the successful clients were women who had in most cases been part of a women-only group, while the unsuccessful clients had all been part of a mixed group and initiated destructive relationships with male clients. In the other study (Trulsson, Karin 2003a) which investigated a therapeutic community for women, the Sofia treatment home, women who had spent a long time in treatment made positive statements about the focus of the treatment and emphasised closeness to and community with other women as an important opportunity for development. Central features of that treatment are identified by Segraeus (Segraeus 2005) as individual therapy, group support and activities focusing on women’s needs and everyday life. Similar findings were made in a study of a treatment unit for female addicts, the EWA unit within the health-care system (Dahlgren, L. and Williander 1989). Both Dahlgren (Dahlgren, Lena 1992) and De Wilde & Trulsson (De Wilde and Trulsson 2005) mention that individual sessions offering an opportunity to develop a close relationship and process traumas are a central feature of the treatment of women, as are group friendship among women and a focus on support in the role as parent and in the relationship with children. Symptom tolerance and a long-term perspective in treatment are the basic prerequisites for increasing self-esteem and confidence, according to the women themselves. An evaluation of the Sofia treatment home shows the outcome of gender-specific treatment to be good (Hedin 2003). A group of young women (about 20 years old) managed to stop abusing drugs and change their lives radically, with training, employment and a partially new social network; and a second group of slightly older women (about 30 years old) improved their situation in life by for example receiving a flat of their own, going back to school and re- establishing relationships with their children. A third group of women was unable to give up drug abuse, experiencing frequent relapses and continuing to suffer from precarious health and various social problems.7 The most important components of treatment were the long- term perspective, individual sessions with the woman’s contact persons for support and processing of traumas etc., a conversational group with other women, and the opportunity to develop relationships in their social networks through aftercare. The women-only character of treatment was an important prerequisite for the achievement of these results (Hedin 2003).
Parenthood and abuse In Sweden, maternity-care services carry out important preventive work offering support to women during their pregnancies; practically 100 per cent of all women are reached (Österling 2002). The overwhelming majority of women abstain from using alcohol while pregnant, but a remaining group continues to drink at a level entailing a risk of foetal damage. Göransson (Göransson 2004) has studied a group consisting of slightly less than half of 300 women who were going to have their first baby and who attended either of two maternity-care centres. These women underwent special screening as regards their alcohol habits before the pregnancy and during the first trimester. The other group of women received standard maternity care. This screening identified a group of 15 per cent of the women who had continued to drink at a level which can be considered damaging to the foetus according to internationally established guidelines. What gives cause for concern, according to Göransson, is that almost none of these women were identified by the maternity-care centres. This prompted further training of the midwives in screening alcohol consumption by means of AUDIT (Alcohol Use Disorders Identification) and TLFB (Timeline Follow-Back
7 Approximately one-third of addicts were in each group.
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Interviews), after which they performed at an adequate level in establishing alcohol use through screening. Almost all women were willing to discuss their alcohol consumption. On Göransson’s interpretation, this indicates that pregnancy is a period in life when women are prepared to change their habits. Pregnancy is a key situation for women exhibiting advanced alcohol and drug abuse as well, as shown by the life-story narratives of a number of addicted mothers. Most pregnant women break off or reduce their abuse, partly out of concern for the child and partly owing to greater openness to their relationship with their own mother and other women in the context of preparing for the birth of their own child (Trulsson, K. 1999, Trulsson, Karin 2003a). This may be part of the reason why many studies show particularly positive treatment outcomes for pregnant addicts and mothers of small children, but also part of the reason why the failure to make interventions, mainly repressive ones, may lead to negative consequences (Andersson, G. 1995, Eriksson 1997, Steneroth et al. 1996, Trulsson, K. and Nötesjö 2000)). Motherhood has proved to be an important driving force when it comes to approaching treatment services and completing treatment (Dahlgren, Lena 1992, Laanemets 2002, Trulsson, K. 2000a). Within compulsive institutional care, differences between men and women have become clearly visible. To women, forming a good relationship with their children and resuming responsibility for their fellow human beings are important objectives. Women often see being placed in compulsive care as help in an emergency, and they want individual conversational therapy. Men, however, see care as a coercive intervention against them and do not want any treatment (Kurube 2004)). Experience from the Ambulatory – an outreach activity targeting pregnant addicts as a joint effort by health and social services – shows positive effects of providing female addicts with support and treatment at an early stage of their pregnancies and continuing to provide follow- up support while the children are small (Björkhagen Turesson 2001, Österling 2002). The largest cities in Sweden have specialist clinics for pregnant addicts, which aim for drug-free pregnancies. Their objective is to initiate comprehensive support and treatment interventions, but this has become more difficult over the last decade as a consequence of financial cuts and a strong decrease in the availability of treatment resources in both inpatient and outpatient care. For opiate addicts, inpatient treatment during pregnancy is recommended to minimise the risks associated with a relapse into abuse. Sarman (Sarman 2000) discusses the increasing opiate abuse in Sweden, the problems in connection with health care of pregnant opiate addicts, and the consequences for the foetus in terms of neonatal abstinence syndrome (NAS). He shows the benefits of centralising the care of pregnant addicts to special units, which have access to comprehensive knowledge about the social and medical consequences of substance abuse. While motherhood has been the subject of a series of studies, only one Swedish study involving in-depth interviews has specifically studied the importance of fatherhood to addicted and socially marginalised men. Bangura Arvidsson (Bangura Arvidsson 2003) characterises substance-abusing fathers as “questioned fathers”. A great many of them want to take part in raising their children, but social authorities see them only as addicts, even though they consider themselves capable and important in their children’s lives. Social services focus on addicted mothers, both as regards various interventions and as regards responsibility for the children. The lack of a gender perspective entails that addiction treatment and research on substance abuse are managed on the basis of a hegemonic masculinity, whereas social child-care and research on children and young people tend to have motherhood and a hegemonic femininity as their starting-points. This situation risks causing a lack of holistic vision in addiction treatment, leading to neglect of the family perspective. For instance, there is limited knowledge about the consequences for those children, who are exposed during pregnancy, to the opiate-like medical drug Subutex, whose active substance is buprenorphine. Treatment with Subutex in connection with opiate abuse has become common in the past few years. Major studies have been initiated, including in Sweden and the other
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Scandinavian countries, as part of a major international effort. While findings from these studies have been delayed, however, according to the Stockholm drug services there has been a “baby boom”, fertility being higher with Subutex treatment than with for instance methadone treatment. In Norway, two dissertations (Slinning 2004, Moe 2003) have investigated 42 substance-exposed children and compared them with 50 non-substance- exposed ones. The study shows that there are large differences between the two groups and identifies specific problems affecting the substance-exposed children. Children manifesting neonatal abstinence syndrome (NAS), of which 78 per cent had been exposed to opiates, exhibited signs of over-active nervous system, sleep disruptions, feeding problems and problems in their relationship with their mother or other carer. The researchers point out the need for both preventive action and interventions in favour of the exposed children.
Prostitutes (women – and men) In Sweden, the notions of “sex trade” or “prostitution” are normally used to refer to the buying and selling of sexual services; the international notion of “sex worker” is rarely used, because selling sexual services is not conceived of as an occupation (cf. Hedin and Månsson 1998). Prostitution is a diffuse phenomenon whose manifestations are constantly changing. Some researchers have actually begun to talk about “prostitutions”, claiming that the sex trade consists of several sub-markets with their own individual distinguishing features (Pettersson and Tiby 2003). At present, four such prostitution sub-markets can be distinguished: - Street prostitution, above all in the three largest cities (Stockholm, Gothenburg and Malmö); - Hidden prostitution, including the Internet trade; - Trafficking of women and children (teenagers), mainly from Eastern Europe; - Homosexual prostitution.
Street prostitution decreased sharply when the law against the purchase of sexual services came into force in 1999, making it a criminal offence to buy (but not to sell) sex. The number of women “walking the streets” halved from about 730 in 1998 to 340 in 1999; since then there has been a slight increase. In 2003, according to the police, there were about 450 female street prostitutes in the three largest cities (Socialstyrelsen 2004c). Their average age is rather high: 30–40 years. In Malmö, but not in the other cities, there is a group of younger women: heroin users in their early 20s. To a large extent, the establishment of young female newcomers in street prostitution has been prevented, partly through active work by the police and prostitution task-forces, partly because older prostitutes contact the police to try to prevent the establishment of newcomers (Hedin and Månsson 1998).
The women who remain in street prostitution can be divided into three groups. The first one consists of problematic abusers of for instance heroin who must make large sums of money every day to pay for their drugs. These women are often very run down both physically and mentally, and they expose themselves to risks of violence and infection with sexually transmitted diseases, as they often have to perform sexual services without a condom. The other two groups are foreign-born women (from Asia and Latin America) and a small group of older women who have been active in prostitution for many years and have sustained social damage in terms of isolation and a poor social network (Socialstyrelsen 2004c).
There are long-established hidden forms of prostitution at massage parlours, hotels, restaurants and porn clubs. According to earlier estimates, twice as many women were active in hidden prostitution as in street prostitution – that is, slightly over 1 500 women (SOU 1995:15). At present, there are indications that some women have moved from the street to the Internet, hotels and so on. Superficially, hidden prostitution offers better conditions, but there is also a great deal of competition, fear of violence and psychological pressure (Hedin and Månsson 1998). Over the past few years, the Internet seems to have evolved into a new
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arena for contacts between prostitutes and customers, for pornography and for other activities which can be tied to sex, such as the buying of sex products (Månsson et al. 2004). The Internet offers anonymity and flexibility, which works in favour of sex customers. Estimates of the number of women active in Internet prostitution vary between sources: some researchers claim there to be about 80–100 women on various websites, while the police claim a much larger number: about 200–250 women (Socialstyrelsen 2004c). There is also information indicating that women in Internet prostitution take more risks; they are exposed to unsafe sex, “harder services” and risks of violence (op. cit.). An emerging risk group consists of teenagers who naively publish personal information and pictures on Internet chat sites, thereby exposing themselves to paedophiles and sex buyers with unusual preferences (Månsson et al. 2004).
While trafficking of women from the Baltic countries and Eastern Europe does take place, this trade has not increased to the extent previously feared. The law against the purchase of sexual services has made it difficult for traffickers to transport women, rent flats for them and establish contacts with potential customers. What is more, men/customers also fear becoming the subject of rumours and stigmatisation, as buying sex is condemned by public opinion. The Swedish National Criminal Investigation Department estimates that in any one year, about 400–600 women are active for some time in Sweden, above all in the suburbs of the largest cities and in the northern half of the country. They are taken to Sweden by fellow countrymen by means of organised transport, held captive in private flats in disgusting conditions involving a great deal of violence, and rented out to interested customers or major festive events. In northern Sweden, such trade with women from Murmansk and the rest of Russia is well established. Police in the largest cities carry out proactive investigation work against trafficking, both because the women in question are young and greatly exposed to violence and because trafficking involves an element of organised crime. The police often receive tip-offs from the public, which supports their work. However, in smaller towns and in the countryside, carrying out this kind of resource-intensive police work is more difficult (Socialstyrelsen 2004c, Craciunescu 2005).
Male prostitution is somewhat different; it should be described as “men selling sex to men”. In a survey made by the Swedish National Board of Health and Welfare in 2000, twelve local authorities said that they were aware of such activities going on in their municipality. In Stockholm, a small group of young men (aged 15–30 years) has been identified: they advertise for customers on the Internet, make appointments with them on the net and then meet in public places or in somebody’s home. Such activities are found in Gothenburg and Malmö as well. Prostitution task-forces report that the young men in question exhibit similar psychological and social problems as female prostitutes, for instance experience of sexual abuse and precarious mental health.8 However, selling sexual services may also be a way to search for a partner, to experiment with different identities or to search for a new lifestyle (cf. Tikkanen 2003).
Inmates in the criminal-justice system A particularly vulnerable group consists of women who commit crimes, are brought to justice and sentenced, and end up within the sanctions system of the Prison and Probation Administration.
According to an earlier report on women’s criminality, women accounted for 15.2 per cent of suspects for different crimes (BRÅ 1999). Theft is the most frequent female crime, followed by road-traffic offences, fraud and drug offences. Women’s criminality is thus restricted to certain types of crime, whereas male criminality is more differentiated. Women’s share of violent crime has historically been low, at 2–10 per cent, but a certain increase has been observed in recent years. Certain categories of crime have increased more than others;
8 Oral communication from ProCenter, Stockholm, 2002.
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these include assault and battery, violence against public servants and unlawful threat. Some explanations are given in the report, including changes to gender roles as well as societal changes such as unemployment and increased marginalisation of certain groups (BRÅ 1999).
Women’s criminality has increased since the turn of the century. In 2004, a total of 144 900 persons were brought to justice for different crimes in Sweden. Women accounted for 19 900 of these, or 17 per cent. This amounts to an increase by 1 200 persons, or 6 per cent, on the previous year. A particularly large increase can be seen for girls aged 15–17 years, where the number is up by 20 per cent (corresponding to 690 persons). It is above all prosecutions for shoplifting which have increased; the reason may be enhanced supervision in shops.
In 2003, the new intake of inmates at prisons and other penal institutions in Sweden was 10 700 persons. On a certain day, 4 500 persons were in prison. Of the entire 2003 new intake, 6.8 per cent were women. In the new intake of drug addicts, 8.1 per cent were women. In the entire new intake, 58 per cent of the women and 41 per cent of the men were problematic drug abusers.9 “No known abuse” was reported for 29 per cent of the women and 41 per cent of the men (Kriminalvårdsstyrelsen 2004). Further, on a certain day in 2003, 1 760 persons were in detention; 5 per cent of them were women. In non-institutional care within the prison and probation system, the share of women is slightly larger: of all clients under supervision in April 2003, 13 per cent were women. The share of problematic drug abusers was 26 per cent for women and 20 per cent for men. Those with no known abuse accounted for 55 per cent of women and 56 per cent of men (Kriminalvårdsstyrelsen 2004).
We know from earlier studies that prison inmates are in a precarious social situation (Ekbom et al. 1999). Of the 2003 new intake, 44 per cent had been unemployed and 25 per cent had been homeless during the period immediately before being deprived of liberty (this applies to both men and women) (Kriminalvårdsstyrelsen 2004). Approximately 50 per cent of the new intake had health problems as a consequence of injury and disease; 44 per cent claimed to have been abused psychologically and 50 per cent physically as children; and 8 per cent had been sexually abused. More women than men claimed to have been subjected to different forms of violence during childhood. As regards mental problems, 36 per cent claimed to have suicidal thoughts and 23 per cent to have made at least one suicide attempt; women claimed this more frequently than men did.10 These findings are well in line with previous studies, which have also found female inmates to be more exposed to violence and to have a poorer mental health than male ones (Somander 1993, Kolfjord 2003)
It is also known that addicts and women within the criminal-justice system often have a smaller and more damaged social network, having experienced departures and separations (Kristiansen 1999, Skårner 2002, 2001) Many female inmates have had their children taken away from them and placed in social care because of the parents’ substance abuse, and the children are now often in foster homes or relatives’ homes (Hedin 2000)These mothers often lack a working contact with their children who are in foster homes. Among male inmates, three groups can be identified: those who have previously been functional fathers and remain in contact with their partners and children, who visit them in prison; those who have previously separated from their partner but try to stay in touch with their children in spite of difficulties; and those who have entirely given up contact with their children.
9 The prison and probation services have been granted additional resources by the Government to counter drug abuse. All new inmates undergo ASI interviews intended to identify drug abusers. ‘Abuse’ is defined as regular use of illegal drugs during the 12 months prior to deprivation of liberty. There are two categories of abusers: abusers and problematic abusers, as well as a classification according to substance: amphetamines, polydrug use, cannabis and heroin (by falling group size). 10 The report contains no data on the respective prevalence in men and women.
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Studies of gender differences in drug situation and responses
1. Preventive work – children and young people (a) Universal (“primary”) prevention targeting children and young people has been initiated through the government’s national action plan for the prevention of alcohol damage (Regeringens proposition 2001). Priorities in the implementation of the action plan’s proposals include providing pregnant women at maternity-care centres with information, for instance through a leaflet on how alcohol may harm a foetus, entitled “One glass of wine couldn’t do any harm, could it?” Moreover, the Alcohol Committee in charge of implementing the plan is aware of the need for knowledge about how well alcohol- and drug-prevention efforts match the needs of girls and young women; this has resulted in a national survey of this issue (Kvinnoforum 2002), which shows that most municipalities in Sweden lack alcohol- and drug-prevention efforts targeting girls/young women. This is not to say that girls and young women are not reached by drug prevention, but it does mean that the interventions made do not take account of gender aspects, and this leads to a situation where girls’ and young women’s interests and needs become secondary to those of boys and young men. This has prompted further efforts in the fields of training and methodological development as well as a report on teenage girls’ way of life based on interviews with teenage girls, researchers and practitioners in the field of alcohol-related issues (Alkoholkommittén 2005). (b) When it comes to selective (“secondary”) prevention with a gender perspective, the form most commonly encountered in municipalities is group activities targeting young girls (Kvinnoforum 2002). Pupil- and family-oriented programmes for the prevention of alcohol and drug abuse have been implemented in some Swedish municipalities; one example is the STAD project in Stockholm. One study (El-Khouri and Sundell 2005) proposes a number of preventive actions based on the findings from a drug-habit survey, which concerned the drug-taking habits and norm-breaking behaviours of school pupils. However, like in other studies on prevention for young people, no emphasis is placed on the specific problems of girls and boys, or on their respective need for interventions. (c) Selective treatment interventions targeting socially vulnerable young boys and girls (“tertiary prevention”) have been the subject of only a few in-depth studies where the gender perspective is taken into account. Andersson (Andersson, C. 1993, 1996) has studied a treatment unit in Stockholm (Maria Ungdom) for young addicts. Andersson (Andersson, Berit 1998) has studied the situation and treatment of young girls at a special home for compulsory care of young people. Hallén Hemb & Olsson (Hallén Hemb and Olsson 2002) have, based on a few in-depth interviews, shed light from a gender perspective on the specific needs of boys and girls in treatment at an outpatient centre, “Minimaria” in Gothenburg. Andersson (Andersson, G. 1995, Andersson, G 2002) and Vinnerljung et al. (Vinnerljung et al. 2002) show, in qualitative and quantitative studies, differences between boys’ and girls’ problems in foster homes: biological and foster mothers tend to form closer ties to boys, and girls are at greater risk than boys of being rejected by their foster parents. Robertsson (Robertsson 2005) describes successful interventions at an institution (Lunden) for compulsory care of socially vulnerable substance-abusing girls and women, involving sexual counselling and support in connection with pregnancies, with the participation of midwives. Swedish studies have found that 7–12 per cent of the girls/women in normal populations investigated have been victims of sexual abuse (Svedin 1999). Such abuse constitutes an important causal factor in social problems such as substance abuse and in mental and physical ill health in adulthood. It is now known that sexual abuse can lead to long-term effects of an emotional, cognitive and social nature, and that it can increase the risk of health problems (Finkelhor and Browne 1986). Since sexual abuse in childhood is a trauma causing such wide-ranging consequences in adolescence and adulthood, preventive work is now being carried out at schools under the aegis of a special women’s refuge service, targeting teachers, parents and the children themselves. The project is called “Break the
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Silence” and aims to inform adults in the children’s immediate environment, make them pay attention to risks and teach them how to recognise and interpret the children’s signals. A pilot project being implemented at schools in the Gothenburg area involves direct work with school children in order to teach them to listen to their feelings and enable them to set their own limits against adults who act in a way that violates their integrity or who make demands on them (Nyman 2003).
2. Responses to intravenous drug use, the spread of infection and health problems (Responses to problem drug use and gender; gender-specific harm reduction responses) (a) Both addiction services and psychiatric care are implementing programmes whose objective is to reduce substance abuse and make abusers change their life patterns in the direction of a drug-free life. In this context, there is a need for gender-specific programmes focusing on the specific life situation and needs of women (see the above section on treatment). Existing research involving comparisons between different forms of treatment (mixed-gender and gender-specific) shows that outcomes for women are considerably better in gender-specific treatment (Fridell 2002). As regards other respects, please refer to Point 3 below.
(b)–(c) Three public organisations are involved in countering the sex trade: police, social services and health-care services.
– The police focus mainly on street prostitution and trafficking, attempting to track down and arrest sex buyers, pimps and transporters. In their investigations, the police also encounter women who are victims of the sex trade; they are questioned, given protection and counselling, and later handed over to the social services. In the largest cities, the police carry out highly competent and proactive work in this field. However, this competence needs to be spread to other parts of Sweden, especially to the northern region, where transporters from the Baltic countries and Russia are active (Craciunescu 2005). The police also carry out investigations on the Internet in order to identify websites linking to pornography and prostitution.11
– Prostitution task-forces within the social services of the largest cities carry out extensive psychosocial work with female prostitutes in their respective regions, trying to make these women leave the sex trade and providing them with rehabilitation support (Hedin and Månsson 1998). When foreign prostitutes are encountered, they are placed at certain youth homes where they stay while the investigation lasts, receiving material and psychosocial help. After the trial, however, they are sent back home to Eastern Europe. Methods used by prostitution task-forces include social support and counselling, therapeutic sessions one-on- one and in groups, and preventive work, for instance at schools (cf. SOU 1995:16). Social services in smaller towns do not have the competence necessary for this at their disposal; there is a need for competence-building efforts involving co-operation within counties (Socialstyrelsen 2004c).
In the health-care system, contacts with female prostitutes take place within addiction care, at gynaecological outpatient centres and youth counselling centres, and within psychiatric services. The main objective within gynaecology is to prevent the spread of sexually transmitted diseases from the Baltic countries, Russia and the rest of Eastern Europe. In addition, many women who wish to leave prostitution need psychiatric assistance during the rehabilitation phase (Hedin and Månsson 1998). The “Spiral” project in Stockholm and the needle-exchange project in Malmö work specifically with medical assistance and social support to drug addicts and female prostitutes (Socialstyrelsen 2004c).
11 In recent years, several paedophile networks have been uncovered and broken up as a result of investigations involving international police co-operation (Information published in Dagens Nyheter in the spring of 2005).
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(d) See the above descriptions regarding substance abuse during pregnancy and treatment interventions, under the heading “Parenthood and abuse”. (e) Women’s life-story narratives Trulsson (Trulsson, K. 1999) show that to women exhibiting advanced abuse of alcohol or drugs who live apart from their children because of their abuse, the ideal is that of a “normal family”. Motherhood offers a chance to acquire social value, and most women interrupt or strongly reduce their consumption while they are pregnant but usually resume their habit when the child is 3–4 months old. Reasons for resuming include the pressures of having responsibility for children, the attraction of the drugs and insufficient social support. Being forced to part with their children is experienced as social degradation, often associated with shame, guilt and a feeling of worthlessness – and, to some women, depression and suicidal thoughts as well. This separation helps some women decide to try breaking off their abuse through treatment, so that they can take care of their children; for others, it signals the beginning of accelerating abuse, sometimes coupled with extreme social deprivation. The problems associated with everyday life in an addict family are clear from the women’s narratives, which also show the women’s fear of losing custody of their children because of their abuse – they are afraid to ask for help, and they develop a “choreography of agencies” to make sure that the authorities do not know too much about their everyday life or interfere with it. This amounts to a good argument in favour of making interventions in addict families early on – already during pregnancy, when the women are open to support and treatment.
3. Gender-specific treatment (Gender-specific treatment data and approaches – differences in treatment organisation) (a) Since the mid-1980s, attention has been paid in Sweden to the vulnerable situation of women in therapeutic communities for both genders (Björling 1986). This has led to the emergence in the past two decades of a variety of women-only treatments; mainly different kinds of voluntary institutional treatment oriented towards milieu therapy, Minnesota treatment and religiously oriented treatment. These different treatment forms have been the subject of several studies (e.g.Fridell 2002, Hilte 2002, Hedin 2003, Holmberg 2002, Laanemets 2002, Trulsson, K. and Nötesjö 2000, Trulsson, K. 2000b, Trulsson, Karin 2003a). There are no corresponding men-only treatments, and nor are there any studies on the specific needs of men in addiction treatment. Within compulsory-care services, the National Board of Institutional Care, which is the authority in charge, has made efforts to enhance knowledge and develop activities. Research from a gender perspective is described by Segraeus (Segraeus 2005). Documentation systems have been developed for both youth care (“ADAD”) and adult care (“DOK”), and all data are reported by gender. Jansson & Fridell (Jansson and Fridell 2003) have studied problems and treatment interventions in connection with the care of women and young girls at the Lunden compulsory-care institution. All compulsory treatment for adult men and women is single-gender, and the objective is that all care of young people should be carried out at single-gender wards as well. (b) See the above descriptions under “Forms of treatment for female addicts” and “Parenthood and abuse”. (c) No research available. However, Byqvist’s (Byqvist 1997) follow-up of treatment at addiction-treatment institutions within the SWEDATE project (Bergmark et al. 1989) contains interesting findings as regards positive and negative treatment outcomes, in terms of substance abuse and social conditions, in a group of mainly male clients. Features common in traditional, gender-neutral addiction treatment, such as group sessions and practical work, were appreciated the most by those clients whose outcome was positive. Clients with negative outcomes expressed a wish above all for individual sessions as well as help in their
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contacts with their children and parents. As has been indicated above (Dahlgren, Lena 1992, Trulsson, K. 2000b), the features of treatment which the negative-outcome group wished for are in fact very important in the treatment of women. It may be that the findings from Byqvist’s study show that the group of men who no longer follow traditional patterns are in fact the losers in gender-neutral treatment. Parenthood and relationships with the people closest to them may be something that these men, like women, want to pursue even when they are undergoing addiction treatment. Men might also prefer to discuss various traumas as well as feelings of shame and guilt in individual sessions rather than in group treatment, which is a traditional feature of therapeutic communities. There is a need to pay attention to the fact that masculinity and femininity are in a state of flux (Trulsson, K. 2003b).
4. Social reintegration: training, employment and debt counselling (Gender-specific social reintegration approaches)
(a) See the above description under “Parenthood and abuse”. (b) The most difficult task is to integrate former addicts and criminals in the open labour market; they often become marginalised and excluded, ending up in the social-welfare system on sickness benefit or a retirement pension.12 In recent years, there have emerged social work co-operatives where former addicts and criminals engage in the production of goods or services. Such co-operatives are often founded with support from EQUAL or other EU programmes as well as public support from the local authority in question (cf.Hansson, J- H. and Wijkström 2001). Two examples of successful social work co-operatives are Basta Arbetskooperativ in the suburbs of Stockholm and Vägen ut (“The Way Out”) in the Gothenburg region; they both achieve changes in life patterns, rehabilitation and recovery (Meuvisse 2001). At Basta, which is gender-mixed, about 70 per cent of participants are men and 30 per cent are women; relations between the genders are characterised as “trusting” (op. cit.). Vägen ut is made up of three single-gender co-operatives and one mixed-gender co-operative; women account for about two-thirds of participants. The women-only co- operatives use somewhat different methods, which involve long-term development, a supportive spirit of community and empowerment (see Hedin 2005). (c) Former addicts and criminals who wish to educate themselves and fill knowledge gaps remaining from their school days have several options. The most common ones are municipal adult education and the government-owned company Lernia, which focuses on adult students. There are also various labour-market courses arranged by the National Labour Market Board as well as advanced vocational-training courses at universities and university colleges. Independent adult-education colleges also offer some basic education for people with social disabilities. In addition, there is a special organisation (KRAMI) whose task is to educate and train juvenile delinquents for working life; however, evaluations of KRAMI’s work show varying results (Nyström and Soydan 1999). These evaluations lack a gender perspective, which makes it hard to interpret the experience from that viewpoint. (d) In the field of household indebtedness and municipalities’ financial and debt counselling for their inhabitants, single parents with children account for a large share of applicants: about 20–25 per cent (Dellgran 2001, Konsumentverket 2002), Single persons without children make up the majority of applicants: 60–70 per cent. Debt problems seem largely to be the result of low income because of illness and unemployment. However, these problems are not analysed from a gender perspective but by reference to occupations, income levels and consumption patterns (Dellgran 2001).
5. Gender-specific interventions in the criminal-justice system
12 Swedish labour-market and employment policy includes a variety of forms of protected employment for people with “socio- medical work incapacity”, such as posts in the public sector and wage allowances paid to employers.
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(Gender-specific aspects in the criminal justice system)
(b) Prison institutions in Sweden are nowadays differentiated by target group and gender. Women are placed at a major national institution (Hinseberg) and four local institutions, one in each correctional-care region. At all prisons, there are daytime works and other activities, which are compulsory for inmates, as well as voluntary education and training organised through municipal adult-education services. In addition, all prisons run a number of programmes for various target groups intended to influence inmates’ behaviour. There are specific such programmes against violent crime and sexual crime, in which men who have committed such crimes participate (Månsson et al. 2002) . Further, there are three different such programmes against drug abuse: “Våga välja” (“Dare to choose”) and BSF (shorter version) as well as the 12-step programme, in which many inmates participate after being referred to treatment institutions for the final part of their sentence under Section 34 of the Act on Correctional Treatment in Institutions (Kriminalvårdsstyrelsen 2004). The results of these programmes, however, are not reported with a gender breakdown. In 1999, parental training in study circles was started on an experimental basis at prisons in order to support inmates in their role as parents and in their contacts with their children. Such training is led by two specially trained warders and consists of study and discussion of various themes based on a study material. The results were so good that this training was made permanent and is now implemented at most prisons in Sweden. Participants at men’s prisons learned a great deal about children and appreciated the opportunity to talk about relationships, and their contact with their children increased (Hedin 2000). Female participants above all needed to talk about their feelings of guilt and shame in relation to their children and to build a parental role as a “distance mum”. The mothers were usually in touch with their children, even if they were living in foster homes, but these study circles helped relieve the mothers of some of their mental burden, which facilitated treatment (Hedin 2000). Similar experiences have been reported in research from the United States (cf. Gabel and Johnston 1995). At the turn of the millennium in 2000, several inquiries found that the prison and probation service lacked knowledge about the psychology of women, women’s needs and feminist perspectives. Women constituted a marginal group whose experience and needs were not taken into account. In recent years, attempts have been made at some women’s prisons to improve conditions and create behavioural programmes oriented towards relationships and designed to suit women’s needs, but unfortunately there are as yet no evaluations of these experimental activities (Oral communication from employees).
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12. European Drug policies: extended beyond illicit drugs
Official endorsement by the National Drug Strategy
Summary
The Swedish National Drug Strategy only refers to what is considered as illegal drugs.
A preventive public health perspective
The national strategy on drugs is only one part of the wider Public Health Strategy. In 2003 the Swedish Parliament adopted a plan for a global national public health goal consisting of eleven public health objective domains (Regeringens proposition 2002a). The overall aim of the policy is to improve public health and reduce inequalities in health among different groups of the population. One of the objective domains cover several of the more important determinants of Swedish public health under the heading “ Reduced use of tobacco and alcohol, a society free from illicit drugs and doping and a reduction in the harmful effects of excessive gambling”.
Strategy on illegal drugs The goal and main message in the National Drug Strategy (Regeringens proposition 2002b) is the vision of a drug-free society. The efforts in that work can be summarised in the following way: more people are to become involved in work against drugs; more people are to say no to drugs; more people are to know about the medical and social consequences of drugs; fewer people should start using drugs; more abusers are to obtain help to a life free of drugs and criminality; and the availability of drugs is to be reduced. Particular priorities in the present strategy are directed to the prison and probation area and the treatment and care sector.
The strategy is a downright drug strategy in terms of focusing on what is considered as illegal drugs. The only exception from that is a passage saying that leakage of narcotic pharmaceuticals into the illegal market should be narrowed. It is also a downright drug strategy in the meaning that substances are never mentioned. The aim is on political prioritising, demand and supply reduction, treatment and rehabilitation improvement and with no distinction between different illegal drugs.
The National Drug Strategy is valid since May 2002 and expires in December 2005. A new strategy will be presented for the Parliament late in 2005 and in function from January 2006. The current strategy is coordinated at the national level by a National Drug Policy Coordinator (NDPCo). The NDPCo has formed a committee, “Mobilisering mot narkotika”, within the Ministry Health and Social Affaires and developed an action plan to mobilise and coordinate the implementation of the national drug policy (http://www.mobilisera.nu/). A number of Government Offices and agencies are also part in the implementation of the strategy.
In practice “drugs” is about all illegal drugs (pharmaceuticals, doping substances, narcotic plants, food supplements and other substances) that can be used as mind-altering drugs. This is how the issue is handled in school education and most other circumstances in the local community. The national drug strategy constitutes a source of inspiration and guidelines for those responsible in local communities to set up their own strategy. Such strategies in terms of policy documents exists in 80% of the 290 Swedish municipalities (see SQ 25), while preventive efforts exist in all municipalities.
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Doping Doping substances are regulated in a certain act and not mentioned in the drug strategy. A doping strategy has been discussed but is not yet formulated. Food supplements, pharmaceuticals, narcotic plants or tobacco is neither mentioned explicitly in the drug strategy, but since 1999 Sweden has a Law about certain goods dangerous to health that can put a substance under control in spite it cannot be declared as a narcotic drug in the sense that the Penal Law on Narcotics does. Gambling addiction has only recently been visibly on the national agenda and a strategy document has not yet been developed.
Strategy on Alcohol and tobacco The Swedish Alcohol Strategy (Regeringens proposition 2001) is coordinated in a way similar to the National Drug Strategy by the office of the National Alcohol Commission (http://www.alkoholkommitten.se/). This strategy will also be renewed in 2005 and running from 2006. While the policy on illegal drugs has been more or less unchanged for many years, the alcohol policy has changed as a result of the harmonisation of Swedish regulations to that of the EU. It has been showed that the consumption of alcohol has risen about 30 % since Sweden joined the EU. Alteration in policy and practice has been inflicted several times since that.
Also for the tobacco preventive work, Sweden has developed a specific strategy where legislation in combination with particular efforts at the national and local level is the main instruments. (http://www.tobaksfakta.org/Default.asp?bhcd=16&bhsh=768&bhsw=1024&bhrf=http%3A%2 F%2Fwww%2Efhi%2Ese%2Ftemplates%2FPage%5F%5F%5F%5F344%2Easpx) An action plan is running to the end of 2005 and for many years the SNIPH has been the leading actor in this task (see 12.3)
Genesis and rationale
Summary
There are separated national strategies/action plans for alcohol, illegal drugs and tobacco. The fight against tobacco has been given priority in the public health efforts for at least 20 years in policy as well as in the work of the agencies responsible for public health issues at national, regional and local levels. An informal action plan on tobacco was implemented by the SNIPH in 1999. The first action plan on alcohol came in 1995 and the second in 2001. The first action plan on illegal drugs was adopted by the parliament in 2002 (Statens folkhälsoinstitut 2003a). As indicated in 12.1 the available information suggests that the government also in the future will have separate action plans for alcohol and illegal drugs. Both strategies are to be renewed from 2006 for a three-year period. On the issue of tobacco, no action plan is announced by the government.
Separate to the action plans for alcohol, illegal drugs (and tobacco) the global national public health goal has one domain covering drugs under the heading “Reduced use of tobacco and alcohol, a society free from illicit drugs and doping and a reduction in the harmful effects of excessive gambling” as presented in 12.1.
National programme and everyday practice
The fact that the drug strategy does not refer to a number of different mind-altering drugs is not the same as these drugs are neglected in practical work in prevention, treatment and control measures. On the contrary, the public awareness of new drugs is high as media coverage of new drugs and ways of using drugs is intensive. Professionals all over the field
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are fully aware of multiple drug abuse and take actions according to that, and have done so for many years. The awareness of multiple drug abuse and double diagnosis of drug abuse together with psychiatric disturbances runs back to the second part of the 1970s. At that time treatment units specialised in “the doubly troubled”, benzodiazepine dependence, multiple drug abuse, etc, were established. Already in 1966, Methadone maintenance treatment was separated from the traditional settings, and still is. Specialised out-patient units were common until the early 1990s, when economic recession saw a cutback in economic resources that resulted in withdrawal of that sort of operations.
The National Drug Strategy has little to do with the shaping of the treatment sector, one of the main arenas for actions. The strategy has its impact by focusing on sectors in need of improvement and priority and by releasing resources to improve the situation. The strategy is presenting a scheme of actions that the state expects the municipalities to carry out. The means to do that is not foremost a written strategy but the money that follows with it. The strategy is also a reaction upon signals from the practical field and that of research of what is needed as was expressed in the report from the Swedish drug commission (SOU 2000:126).
Responsibility and competences (coordination)
Summary
From the public health perspective the responsibility for national strategies on legal and illegal drugs is a matter for the Ministry of Health and Social Affaires. The ministry is responsible for the bills introducing action and/or strategy plans and cooperates closely with its committees and agencies for the implementation and evaluation once the plans are adopted by the Parliament. The Ministry governs the actions of the committees and agencies by the instructions (ordinances) and the annual letters of intent. At the local and regional levels the municipalities and county councils initiate strategies and/or action plans adapted to their needs and the situation at hand. See also the role of the alcohol and drug committees in 12.1 and 12.3 (alcohol).
Funding and acting
Generally the social administration in the local municipality has the responsibility when it comes to substance abuse of any art. However, medical treatment is arranged by the counties but still, the responsibility stays with the social administration of the municipality. Funding from the government is offered only in special circumstances. With the present national drug strategy there has been a significant augmentation of economic resources for the municipalities, in particular in the care and treatment sector. This also happened in the middle 1980s under the danger of an HIV/AIDS epidemic among IDUs. The funding is presented in section 1 of the report.
Illegal drugs
When the drug problem appeared in the late 1960s and early 1970s Sweden reacted relatively quickly with the same sort of actions that alcohol was handled with restrictions and information. But the restrictive drug policy, as it soon was called, did not come alone. A massive staking on treatment and prevention followed and preventive actions as wells as treatment resources were extensive until the 1990s began. Incidence figures for drug use followed this the other way around with high figures in the beginning of the period, with ever lower figures during the period. The lowest incidence figures for grade nine pupils occurred in 1989. However, this could not prevent that the number of problematic abusers increased. The national strategy (Regeringens proposition 2002b, pp10-11) point out that the Swedish restrictive drug policy has been successful, but at the same time it is declared that the results
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must be better as the drugs problem has not been reduced. The recommendations from the committee, the Drugs Commission, who analysed the development from the middle 1980s, were to strengthen existing efforts (SOU 2000:126). Already in the instructions for the committee it was stated that restrictive policy should be a prerequisite.
Misuse of pharmaceuticals is recognised as a problem, but this has not resulted in a national programme of the same sort as for illegal drugs, alcohol and tobacco.
Doping Doping in sports is an internal affair for the sports movement, The Swedish Sports Confederation (“Riksidrottsförbundet”, www.rf.se). Sweden is, since 1990, associated to a convention on doping established by The Council of Europe, and associated to the International Anti-Doping Arrangement, IADA, since 1998. Sweden is also member of the Association of National Anti-Doping Organisation, ANADO (since 2003). The World Anti- Doping Code, WADC, issued by the World Anti-Doping Agency, WADA, is standard within Swedish sports.
However, use of doping substances in terms of AAS, GH, and testosterone is judged to be more common outside sports. A law against doping was issued in 1991 and by an amendment in 1999, also the use of doping substances was prohibited. The act is valid for synthetic anabolic steroids, testosterone and its derivatives, growth hormone and substances that increase the production and release of testosterone and its derivatives or growth hormone. No specific action plan or strategy is proposed for the doping issue.
A resource-centre for doping is situated at the Karolinska Institute (a hospital) in Stockholm. At that centre is a national and toll-free hot-line established in 1992 (for information see www.dopingjouren.se ), and a laboratory that is affiliated with the Swedish Sports Confederation, the International Olympic Committee, IOC (1985) and the World Anti-Doping Agency, WADA (2004). The laboratory runs tests not only as part of the anti-doping efforts in sports, but also for medical services, social administrations, the prison system, the police and others. The centre is working together with a clinic for alcohol- and drug dependence in Stockholm, and also has a research programme. The centre is financed by state funding since 2003. A management board with representatives from several national agencies has been established. Except that board, there is no national agency responsible for doping affairs. In that respect, doping is different from drugs, alcohol and tobacco.
Alcohol Sweden has had a restrictive alcohol policy since about 1850. Between 1919 and 1955 only those who were allowed to have a ration book (“Motbok”) could buy liquor in the only place that alcohol is for sale, the State liquor shops (“Systembolaget”). Between 1919 and 1941 the monthly ration for men was 4 litres, and after that 3 litres. Married women was not supposed to need a ration book and unmarried women could only get a much lower quantity. Wine was normally not regulated as it was uncommon that people asked for it. However, all purchases were entered in the ration book. Today, the State liquor shops are still the only place you can buy alcohol, and that includes beer (except beer with low alcohol content, which is for sale in grocery shops for those 18 years of age or older).
Sweden was able to get a few years exemption from the common alcohol policy within the EU, but successively these exceptions has been removed. This has led to an “alcohol rally” where people buy great amounts of alcohol abroad at a much lower price. Most common is to go by car (sometimes even with a trailer) and buy alcohol in Denmark or even northern Germany. Others do the same. Danes buy cheaper alcohol in Germany, Finns buy in Estonia and Norwegians (which has the highest taxes of all) in Sweden.
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The national alcohol action plan has this condition to live with, which is a dramatic difference from the earlier period. In one period, the early 1990s, when massive resources would have been needed to counteract what was expected to be a backlash for the restrictive Swedish alcohol policy because of the membership in the EU, Sweden went into a recession that resulted in cutbacks not least in the prevention and treatment sector.
Alcohol has its own national strategy (Regeringens proposition 2001). The goal is to reduce the harmful effects of alcohol. A number of defined sub-goals are mentioned: Alcohol should not be consumed in traffic situations, at workplaces or during pregnancy; Children should grow up in an alcohol-free environment; The age of onset of alcohol consumption should be postponed; Intoxication should be reduced; There should be more alcohol-free environments; Illegal dealing in alcohol should be eliminated. The action plan also calls for measures in the following areas: Special support for groups and individuals at risk; Care and treatment programmes; Building public opinion and providing information; Restricted access to alcoholic beverages; Restricted marketing of alcoholic beverages; Improved skills in professional groups; Monitoring patterns of consumption and damage to health; Alcohol research.
A committee within the Ministry of Health and Social Welfare, the National Alcohol Commission (“Alkoholkommittén”, www.alkoholkommitten.se ), coordinates the national efforts and is responsible for the implementation of the action plan. It also organises various conferences and seminars to promote new preventive methods. National campaigns are organised by this committee.
Another actor on the national arena is the SNIPH. The institute is responsible for the follow- up of the action plan and is also the national supervising agency in alcohol affairs.
Tobacco The SNIPH has the central controlling role regarding tobacco: The Tobacco law has put a stop for smoking in official buildings; Restaurants must be smoke-free; Tobacco packages must have warning signs; Tobacco can only be sold in stores under some restrictions; There is an age limit to buy tobacco; There are restrictions for tobacco in slot-machines; There is a product-control of tobacco. SNIPH was granted 9 million Euros to use in the period 2002- 2005 in an effort to counteract tobacco use. This has been done through three strategies: National strategic support (information, knowledge dissemination, documents, networks, media contacts); competence development for key groups; cooperation with counties and communities for development of new methods. The work has been successful. The number of smokers has been reduced continually in thirty years.
Gambling Gambling as a public health issue has been highlighted since the end of the 1990s. The SNIPH has got an assignment to put in measures to arrest excessive gambling. A hot-line has been established and an association for those with a gambling problem has received help to get started. Various other actions have been initiated, but it will still take a few years to get a complete picture of the problem. The government has over the last five years contributed with approximately 7 million € and has in the budget bill for 2006 granted about 2.5 million € for the gambling problem.
No specific action plan or strategy is proposed for the gambling issue.
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13. Developments in drug use within recreational settings
New findings about trends in drug use, patterns of consumption and availability within recreational settings
Results of research conducted within targeted settings, such as music/dance clubs and other recreational youth settings In 2004 and 2005, a large number of qualitative-research projects on experimental drug use were carried out (Bossius, Thomas and Sjö 2004b, Hansson, M. and Rödner 2005, Hellum 2004, Lalander and Carmona Santis 2004, Bossius, Thomas and Sjö 2004a, Skårner et al. 2005).13 A total of 129 qualitative interviews were made where young people aged 18–30 talked about their experience.14 Among these 129 young people, 112 had drug-taking experience; 87 are young men and 42 are young women.15 The studies were funded by the Swedish Government’s organisation for co-ordination in the drugs field – the National Drug Policy Coordinator – and were intended to fill knowledge gaps at a time when the country had seen a popularisation of drugs, particularly cannabis, in the 1990s and early 2000s. Before 2004, this type of research had been carried out only to a very limited extent in Sweden. The various studies dealt with subjects ranging from local low-status environments to global backpacker circles. In addition, two major surveys were carried out in 2004–2005: one on university students’ alcohol and drug habits (Röger 2005) and one on 16–24-year- olds’ relationship to alcohol and drugs (CAN 2004d) The findings from some of these studies are reported below.
Music festivals One study involved interviews with and observation of music-festival visitors at the major Swedish Hultsfred Festival and the even larger Danish Roskilde Festival (Bossius, Thomas and Sjö 2004b). The festivals were found to provide young people who otherwise lead relatively steady and future-oriented lives with an opportunity to live differently for the duration of the festival. Many of the young people interviewed said that they used cannabis a couple of times a year and that they saw the festival as an occasion to try it. Only a few had
13 All studies used qualitative interviews as the principal data-collection method. While interview guides could vary slightly across studies, they all focused on young people’s reflections and reasoning as regards drugs. For four of the projects – Bossius & Sjö (2004), Hellum (2004), Lalander & Carmona Santis (2004) and Sjö & Bossius (2004) –, a common methodological plan was drawn up under the direction of Associate Professor Philip Lalander. Three of the projects – Bossius & Sjö (2004), Hellum (2004) and Lalander & Carmona Santis (2004) – involve an element of participant observation. 14 The samples used in these studies were strategic in the sense that the projects focused mainly on young people who had drug-taking experience. One exception is Skårner (2005), where half of the 20 people interviewed had such experience and half did not. In the study of music festivals by Bossius & Sjö, 148 individuals were interviewed briefly; 58 per cent of them had tried drugs. The sampling method used to select these 148 was random choice: the interviewer stood at a strategic location, stopping young passers-by and asking them whether they had the time to answer a few questions about festivals and drugs. Then a group of 24 was recruited for longer, qualitative interviews from among those who had tried drugs and said that they were willing or had the time to be interviewed. Hansson & Rödner’s (2005) sample consisted of people who lived in Stockholm and had drug-taking experience. The authors’ friends and acquaintances put them in touch with a few informants, who provided additional contacts in their turn – i.e. a snowball sample, which consisted of 25 young people in all, with whom in-depth interviews were made. Hellum’s (2004) study of backpackers focused mainly on travellers with drug-taking experience. The researcher first tried to establish contacts by means of an advertisement in the widely-read free newspaper Metro, but this yielded only three informants. A further four were recruited on a Greek island, and the remaining six were found through the researcher’s personal network of contacts. Lalander & Carmona Santis’s study of 15 young second-generation Chilean immigrants living in Sweden also used a classic snowball sample. To begin with, the researchers were in contact with only one person, but by spending a great deal of time in the area they expanded their network of contacts so that it contained 15 young Swedish-Chileans, all of whom had extensive drug-taking experience. In Sjö & Bossius’s study of club culture in the largest cities, some of those interviewed were recruited through a ‘club tour’ financed by Mobilisation against Drugs. The researchers were also helped by a young person with drug-taking experience and a large network of contacts, which lead to a total of 17 in- depth interviews being made. Svensson & Svensson recruited 15 informants through their own acquaintances and through acquaintances of their acquaintances; all of the interviewees lived or studied in the Malmö region in southern Sweden. 15 The fact that young men are in the majority has several reasons, one of which is that the men were more eager to talk about their drug use. This is also in line with certain findings from the studies, where women felt more shame and ambivalence about their own drug-taking experience.
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developed more intensive drug habits, and the interviewees mostly came from well-ordered homes and had parents who are well integrated in Swedish society.
Foreign travel Hellum’s (Hellum 2004) and Svensson & Svensson’s (Svensson and Svensson 2005) studies focused on young people’s drug-taking experience during travels abroad. In the latter study, which dealt with young people’s travelling from a general perspective, it was found that distance had an impact on the likelihood of accepting an offer of drugs: the farther away they went, the more likely they were to accept. Hellum’s study dealt with the backpacker lifestyle – which developed from, and is not entirely unlike, the traveller style created through the hippie movement in the 1960s and 1970s – and the attempts made by backpackers to escape from the Western way of life so as to approach local cultures in for example India and Latin America. Another subject discussed is how Swedish restrictive values regarding drugs tend to become less and less important as the backpackers encounter a world where above all cannabis is common and (in some countries) more permitted than in Sweden. The interviewees generally stopped using drugs when they returned to Sweden to continue their education or to work. Both studies clearly show how experience of other cultures changes many young people’s attitudes towards drugs, most often in a more permissive direction.
Dance and music clubs Sjö & Bossius (Bossius, Thomas and Sjö 2004a) studied the club scene in large Swedish cities and arrived at findings similar to those of British studies (see Thornton 1996, Malbon 1999) a rather loosely connected culture where interest in dancing and music becomes a way of distinguishing oneself from mainstream young people. Two main settings could be identified: first, clubs of a more organised nature in inner cities, where police control is tighter and drugs are used more cautiously because of fear of being arrested by the police; and second, ‘underground’ parties, which may take place in a forest or at a secret location and where drugs are used to a greater extent, particularly psychedelic drugs such as mushrooms and LSD. The young people who attend the more organised kind of parties are most often relatively well established in terms of studies and plans for the future.
Drugs and social exclusion In Lalander & Carmona Santis’s (Lalander and Carmona Santis 2004) research on young second-generation immigrants in a Swedish low-status suburb, other drug-use patterns than those reported from the other studies were identified. On the one hand, drugs were found to offer a temporary escape from a difficult and marginalised position in Swedish society, and on the other hand they were part and parcel of a tough, masculine and criminal lifestyle. Many of the persons studied started to sell drugs and moved on to intensive drug use. Their childhood and adolescence had been characterised by social exclusion and failure at school.
The studies by Hansson & Rödner (Hansson, M. and Rödner 2005) and by Skårner et al. (Skårner et al. 2005) have not yet been presented, as they did not focus on specific settings. However, their findings are taken into account in the text under the heading ‘General findings’ below. It is important to emphasise that drugs occur in other settings as well, such as ordinary discos and restaurants. However, since these settings have not yet been the subject of research, they are left out of the present discussion.
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General findings This section describes some general findings where qualitative and quantitative findings have been woven together in order to achieve a certain degree of generality. For improved generalisability, the following quantitative studies based on representative samples are used: Guttormsson’s (CAN 2005d) on the drug habits of 18-year-old men undergoing compulsory military enrolment in 2004, Guttormsson et al.’s (CAN 2004d)on young people’s drug habits in 1994–2003, based on interviews with 16–24-year-olds (both of these studies were carried out by CAN, the Swedish Council for Information on Alcohol and other Drugs), and Bullock (Bullock 2004): Alcohol, Drugs and Student Lifestyle: A Study of the Attitudes, Beliefs and Use of Alcohol and Drugs among Swedish University Students (carried out by SoRAD at Stockholm University; see also Röger 2005).
Cannabis was found to be the clearly most prevalent and most accepted drug. Its popularity can be understood against the background of its strong position in various global youth cultures such as reggae, hip-hop and techno/rave. What is more, some young people were of the opinion that natural drugs such as cannabis and mushrooms are preferable to synthetic ones. Other researchers (e.g Bossius, Thomas 2003) have reported that within youth culture, there is a growing interest in psychedelic experiences, which squares well with drugs such as cannabis, mushrooms and LSD. In party settings, however, drugs such as ecstasy and amphetamines are relatively popular. The drug considered the most taboo was heroin, which only a very small share of the young people had tried.
In the questionnaire-based survey of the alcohol and drug habits of Swedish university students, the above findings are confirmed (see Bullock 2004, Röger 2005): 25.4 per cent of the respondents had tried cannabis at least once in their lives (27.1 per cent had tried any illegal drug), 8.9 per cent had used cannabis in the past year and 6.9 per cent had done so during the current semester. These data are also well in line with CAN’s study. Cannabis has been the predominant illegal drug in the 1990s and early 2000s, with amphetamines in second place (CAN 2004d). It should also be noted that having tried ecstasy has become almost three times as common since 1998.
Figure 8. Distribution across five drugs of those aged 16 – 24 who have tried illegal drugs at least once in their lives, 1994–2003. (Note that the time scale is broken between 1998 and 2003.) (CAN 2004d).
% Cannabis Amphetamines Ecstasy Cocaine 100 Heroin
80
60
40
20
0 1994 1996 1998 2003
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Awareness that drugs are dangerous The vast majority of Swedish young people do not use illegal drugs, and very few move on to more intensive drug-taking habits, as shown by figure 9.
Figure 9. Share of young people at different ages in the 2003 survey who have used illegal drugs (CAN 2004d)
% …at least once …past 12 months …past 30 days 25
20
15
10
5
0 16 17 18 19 20 21 22 23 24 Age
It can be seen from the qualitative studies that a large majority of those who have tried illegal drugs consider drug use as an exception, not as a central or normal part of their lives. Most of them are aware that drugs can have a negative impact on their future if they let their drug- taking become more frequent or long-term. For this reason, they develop risk-management strategies such as taking drugs only at music festivals, never using in their hometown or never buying drugs – only accepting when offered. Most young people have been influenced by society’s message that drugs are a bad thing, and this guides their decisions and actions to some extent so that they either do not try at all or, if they decide to do so, impose certain limits on their drug use. Taking drugs is not a normalised action, but rather an exception. However, it is clear from the studies that young people know a great deal about drugs, both in general and about specific preparations. They also often know many slang words for drugs. A probable explanation, as suggested by Skårner, Donning et al. (Skårner et al. 2005), is that information about drugs spreads over the Internet and through films. Knowledge about drugs is greater and more nuanced today than ever before.
Gender and drugs There are still differences between men’s and women’s drug consumption (see CAN 2004d). As regards ‘heavy’ drug use, recent Swedish research (Lalander and Carmona Santis 2004, Lander, Ingrid 2003) indicates that women are strongly subordinated in user circles. While men in these circles are seen as enterprising and competent, women are more easily stigmatised and become the victims of rumours. But what about the recreational settings described in the qualitative reports? Women generally have very little contact with sellers; it is almost always a male member of their group who obtains the drugs. Young women describing their consumption express much more ambivalence and shame than men do. Men often emphasise the cool and adventurous aspects of drug-taking, which is rare in women. This applies equally to backpackers, clubbers and festival-goers. In this sense, the settings for recreational drug use are rather conservative, although other aspects of these
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settings can be seen as reflecting a greater equality between the genders. It can also be seen from statistics (CAN 2004d) that men are much more likely than women to move on from recreational to more intensive use of drugs; a probable reason is that drug use is seen as more shameful in a woman than in a man.
Nuanced criticism of Swedish drug policy The qualitative studies show the existence of a critical attitude towards Swedish drug policy, but the criticism voiced is usually nuanced and oriented towards specific aspects. Purely neo-liberal attitudes are very rare. Many young people consider the government’s view on drugs to be overly categorical and authoritarian, thinking that cannabis should be distinguished from ‘heavier’ drugs. The vast majority of those interviewed also said that they thought the government specially favoured alcohol, and many of them were of the opinion that cannabis should be given similar treatment. In that sense, the government was criticised for applying a double standard. Moreover, many were critical of the punitive system which leads to young people being criminalised for their drug use instead of being given help and treatment. However, almost all interviewees – at festivals, at clubs and abroad – think that drugs such as amphetamines, ecstasy, LSD and heroin should remain illegal as regards both use and selling. CAN's study of 16-24-year-olds' alcohol and drug habits (CAN 2004d) shows that 35 per cent are of the opinion that the use of illegal drugs should be punished by prison, while an equally large share think that a fine is sufficient and 22 per cent say that use should not be punishable at all;. However, only 10 per cent agree with the statement 'The use of hashish or marijuana should be permitted'.
The socially excluded develop more severe habits An interesting finding from the qualitative reports is that the vast majority of those interviewed come from well-ordered homes and express faith in their future as regards studies and work16. They do not see themselves as losers or as living on the margins of society. An exception, however, can be seen in the report on young second-generation immigrants in a Swedish low-status suburb (Lalander and Carmona Santis 2004), where school failure, contacts with social services and the police as well as a dark view of one’s own future prospects were very prominent features. Drugs and crime became a remedy to feelings of marginalisation. The young people were influenced by reggae and gangsta rap in their efforts to create an alternative identity enabling them to feel self-respect. One reason why they continued and moved on to intensive drug use was their socio-economic position on the margins of Swedish society. American ((Bourgois 1995, Williams 1989) and British (Parker et al. 1998) 1998) studies provide similar explanations of how abuse may develop. This subject is also dealt with in the 2004 CAN report (CAN 2004d), which presents statistics showing that the two groups with the largest share of people who have tried illegal drugs are university students and the unemployed. However, the authors also conclude that ‘drug-taking experience is of a more serious nature among the “non-occupied” – they had clearly more experience of various drugs, and their age at first use was almost two years lower than that of the university students’ (ibid. 2004: 93).
These data indicate that the study of young second-generation immigrants may have a certain generality, but that their problems probably cannot be explained by reference to their ethnicity or their status as immigrants. Rather, these problems should most likely be seen as a consequence of the social problems which arise in segregated societies. The interview-
16 This is a recurrent theme of all reports except Lalander & Carmona Santis (2004) and, to some extent, Hansson & Rödner (2005). In the other studies, the vast majority of the young people were ‘heading somewhere’ through their studies or through work. Taken together, the young people in question (with the exceptions noted) did not constitute a socially excluded group. Most of them had well-functioning parents employed within various sectors of society.
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based study of the drug habits of the 18-year-old young men who were enrolled in the military in 2004 (CAN 2005d) includes an analysis of the subjects’ social backgrounds. Those claiming neither to study nor to work are almost three times as likely to have tried illegal drugs as those who claim to be students, ‘and the difference is five times as large when it comes to drug use in the past month’. Almost 15 per cent of the ‘non-occupied’ have used illegal drugs on more than 20 occasions, while the corresponding share of students is slightly more than 2 per cent (ibid. 2005: 64). These results clearly show how drug-taking experience and intensified use are associated with both studies and work.
The above reasoning indicates that the drug problem is actually a societal problem and that there is a need for fundamental efforts in order to close gaps between groups and enhance participation. It also points to the crucial role of schools. Many of those who become advanced criminals and drug users fail to meet the requirements for admittance to upper- secondary school, and those who do manage to enter often leave before graduating.
Types of recreational settings in which drug use is reported to be most prevalent (types of music, venue, clientele and lifestyle)
Abroad It is difficult to make any conclusive comments on the above, but the tendencies emerging from the reports presented here show that ‘abroad’ is a context in which 23 per cent of the young people tried illegal drugs for the first time. How is this to be understood? It is probably the case that when someone is outside Sweden, a feeling may arise that using drugs would not force him or her to assume a stigmatised identity, as the restrictive Swedish policy no longer seems to apply (Hellum 2004, Svensson and Svensson 2005). This creates an opportunity to try illegal substances without having to feel like a bad person or an addict. The young backpackers studied by Hellum (Hellum 2004) talked about how they used drugs to get to know other cultures, for instance in India or Central America.
At festivals or parties In the study of music festivals, many young people described how the festival became a scene of exception, that is, a place where they could do things which they did not want to do at home. Festivals enable participants to take drugs without having to feel like criminals or addicts. In this respect, festivals function much like ‘abroad’ in creating a space where the restrictive Swedish attitudes temporarily cease to apply. No particular musical styles or similar factors can be identified in this context; it is more correct to talk about a ‘festival style’ where alcohol is still the predominant drug, but with cannabis not so far behind in second place. It was found that young people at the Hultsfred Festival were more cautious than those at the Roskilde Festival, where it was felt by many that drug-taking, particularly cannabis use, took place more in the open.
In club settings Most of those interviewed said that there is some drug consumption at clubs, where the dominant musical style is techno. On the other hand, it is rare to see people who are drunk. Clubbing is largely about dancing until you reach a pleasant state of mind. While many people can dance themselves to such a state, some use drugs as well. Further, like in other countries, clubbing culture is surrounded by rumours that drugs are more or less freely available. Those interviewed say that there are in fact drugs, mainly ecstasy and
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amphetamines, but that most people do not use them. It is important to add here that the lack of statistics makes it difficult to make any well-founded statements about the prevalence of drugs in club settings.
In ‘outsider settings’ General statements are difficult to make here as well. However, statistics (CAN 2005d, 2004d) indicate that drug use is more intensive among young people who neither study nor work. The survey of upper-secondary pupils (16–17-year-olds) (CAN 2005c) showed that young people who play truant or who dislike school are more likely to have used drugs than those who claim never to have skipped a lesson and say that they like school.
The settings discussed above contain a great deal in addition to drugs – music, happiness, creativity, etc. – and drugs occur elsewhere as well: in regular discos, bars, homes, and so on. It is important to be aware of this to avoid contributing towards the stigmatisation of certain settings. These settings have been scientifically investigated and the others have not, and for this reason it is important to abstain from focusing only on them; future research should investigate more ‘ordinary’ settings as well.
Changes and developments in drug use, patterns of use and attitudes over the past 5 years
The study of 18–19-year-olds undergoing military enrolment (CAN 2005d) provides some data which may form the basis for such comments as are referred to in the above heading. As regards the share who had been offered to try drugs, a rising trend could be seen throughout the 1990s and up to 2002, when this share was almost 50 per cent, as compared with only slightly more than 20 per cent in 1992. It is interesting to note that while amphetamines used to be the second-most available drug (after cannabis), since 2000 a larger share claim to have been offered ecstasy (15 per cent for ecstasy and 8 per cent for amphetamines in 2004). As regards drug-taking experience, there is a similar trend: the entire 1990s have seen a steady increase in the share of young men who have tried drugs, but figures have been falling since 2002. There is also a falling trend from 2002 for the share having used drugs in the past 30 days. Since 2001, experience of ecstasy is more common than experience of amphetamines. The data presented in the enrolment study are supported by CAN’s survey of 16–24-year-olds’ alcohol and drug habits (CAN 2004d), even though amphetamines and ecstasy are at approximately the same level in that survey. Since 1998, ecstasy has been growing more popular. This is supported by the study of 16–17-year-old upper-secondary pupils (CAN 2005c) as well; this study found ecstasy to be the third-most common illegal preparation, after hashish and marijuana.
Geographical area in which specified drugs (or patterns of use) are reported to be most prevalent (specifying by name the city, town or rural area and any relevant features such as high club density, deprived inner city, tourist resort, etc.). And comment on any new developments such as shifts to, or away from, geographical areas
It is hard to make any specific comments on this matter. The enrolment study (CAN 2005d) does provide some regional details. There are large inter-regional differences in the share who have been offered to try drugs. In the large-city counties – Stockholm, Västra Götaland (Gothenburg) and Scania (Malmö) – upwards of 50 per cent claim to have had the opportunity to try drugs. In other counties, such as the northern ones of Norrbotten, Västerbotten and Västernorrland, only one-third make this claim. As regards drug-taking experience, there are similar patterns: higher percentages in the large cities. One exception
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is the northern county of Jämtland, which closely trails Stockholm County in drug-taking experience. It is also interesting to note that experience of sniffing (of glue, solvents etc.) is at or above the national average to the north of the river Dalälven in central Sweden. Guttormsson et al. (CAN 2004d) report similar patterns: 23 per cent of 16–24-year-olds living in large cities have tried drugs, while only 9 per cent of those living in sparsely populated areas have done so. Further comments on this matter are difficult to make without more in- depth analyses. As reported on in previous NRs the abuse of GHB and/or its analogues appears to be most frequent on the west cost of Sweden with Göteborg as regional centre.
Correlates and consequences of specified drug use (or patterns of use) that are generating concern (use of ambulance and hospital services, overdose, other physical and psychological health risks, public nuisance, etc)
One of the major Swedish newspapers reported in august 2005 on a new concept for arranging dance and music club events that causes concern due to suspicion of frequent drug availability and abuse (Dagens Nyheter 2005). The event is organized as a Party-Cruise on the Baltic See for approximately 24 hours on one of the cruisers normally operating the route Stockholm – Helsinki. The whole ship is chartered by the organiser of the music- and dance club event and according to the Police, about 30 persons were suspected of a drug crime. This was the second cruise on the same theme. The first was in February 2005 and according to the DN article, the Police considered that about 50% of the more than 1600 passengers at that journey were intoxicated by illegal drugs. The availability of illegal drugs at the August cruise was much less than in February concludes one police officer. Presently there is no available information on the outcome of the suspicions for drug crimes in February or August.
Regarding consequences of specified drug use there are no reports on particular risks or acute intoxications that has not been observed or known previously. The Stockholm Police have reported on a marked increase in seizures of ketamine over the last year and claims that the use could be connected to dance- and music Clubs. Stockholm appears to have been the major arena for ketamin but a diversion to other cities is observed lately. According to Stockholm newspapers, also the use of non-prescribed Viagra by young men has been observed lately in Club settings.
An overview of developments in responses17, national policies and legal aspects
Information about approaches for responses to recreational drug use
In a report to the Parliament (Regeringens skrivelse 2005) the government report on the following activities undertaken to reduce demand and supply in the recreational area.
A study investigating how a group of employees in the restaurant trade assessed the drug situation at some of Stockholm’s most fashionable nightclubs in 2001 found that over 80 per cent of those interviewed had seen guests who were under the influence of illegal drugs. Against this background, within its co-operation with Stockholm, Gothenburg and Malmö, the
17 Definition: Activities developed to influence people, environment and drug use in settings such as: Clubs/ Discotheques/ Bars/ Parties/Restaurants; Outdoor events (e.g. festivals) and temporary venues. This also includes the "run up and the fall out": surroundings.
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NDPCo makes a special effort to assess the situation, provide training for staff and support policy development.
To remedy the situation in terms of violence and illegal drugs that is found today in Stockholm nightclub settings, the local police have established a Nightclub Commission. Moreover, the Stockholm restaurant trade and the authorities affected are co-operating within the framework of a project called STAD (presented in previous NRs). With financial support from the NDPCo, this project has produced a training film about illegal drugs at nightclubs, called ‘The Well-Dressed Junkie’ (Den välklädde knarkaren), and a Stockholm club-owners’ federation has formed an association called Clubs against Drugs (Krogar mot knark).
In Gothenburg municipality, a development and co-operation project (RUS) between the restaurant trade and the police was started in 2002. Initially, its focus was on the responsible handling of alcohol, but within the three-city effort, it has been expanded to cover illegal-drug use at nightclubs as well.
Malmö municipality is carrying out drug prevention within the framework of its strategy ‘A Drug-Free Future’ (En drogfri framtid), which will be operative until 2010. Actions to counter drug use at nightclubs include training of restaurant staff and supervision.
In Jämtland County in north-central Sweden, a nightclub group including representatives of the police, the social-welfare board, club owners and other parties was established in 2000. Its purpose is to address the abuse of ecstasy.
In addition to the examples from the government report above, projects aiming at prevention of drug use in recreational settings are also running in the six pilot municipalities presented in section 3.
Recent or innovative interventions (not previously reported) of selective prevention, including web-sites
In the previously reported project on cooperation with and within the recreational area (e.g. krogar mot knark, NR 2003) an important issue is the training of staff and managers in recreational settings such as Clubs/ Discotheques/ Bars/ Pubs /Restaurants. A resent development for the training is a film about drugs in recreational settings – “The Well- Dressed Junkie”, also presented above.
National policies and related legal developments to address drug use within recreational settings
The national action plan on drugs addresses the need for demand and supply reduction in recreational settings (Regeringens proposition 2002b). Thus, the NDPCo and many municipalities and counties have initiated several activities as discussed above and as previously reported on. For prevention and control, the staff and management of recreational settings as well as the Police are important partners in the work. Present legislation appears to be sufficient for the actions and interventions undertaken.
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Part C- Bibliography, Annexes
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15. Annexes
Lists of tables and figures
Tables
1 - Cannabis prevalence among 18-64 year olds, for men and women separately, 1994 2005. 2 - Annually reported cases of drink driving. 3 - Cannabis prevalence (%) among men and women aged 18-64 years, 1994-2005. 4 - Lifetime, last year and last month prevalence of having used an illegal drug among men and women aged 16-24 years, 2003 5 - Main illegal drug (%) for men and women treated for abuse reported in the KIM system 2004.
Figures
1 - Lifetime and last month prevalence of having used an illegal drug among pupils turning 16 during the year of survey, for boys and girls separately, 1986-2004. 2 - Lifetime prevalence of having used an illegal drug among military conscripts, 1971-2004. 3 - Estimated number of problem drug users in Sweden 1998 – 2003. 4 - Number of seizures and sized quantity as a function of time (1988 – 2004) for cannabis, amphetamine, heroin, cocaine and (1996 – 2004) for ecstasy and LSD. Ecstasy includes MDMA & MDA and from 2001 also MDE. 5 - Development of street level price (median) for heroin, amphetamine, cocaine and cannabis, 1988-2004. 6 - Lifetime prevalence of having used an illegal drug among men and women aged 16-64 years, 1994-2000 7 - Number of drug related deaths among men and women 1990-2002 (definition of drug related death: selection B according to EMCDDA DRD-Standard, version 3.0, with the exception of ICD 10 code T40.4) 8 - Distribution across five drugs of those aged 16 – 24 who have tried illegal drugs at least once in their lives, 1994–2003. 9 - Share of young people at different ages in the 2003 survey who have used illegal drugs
Appendix 1
Number of seizures and sized quantity as a function of time (1988 – 2004) for cannabis, amphetamine, heroin, cocaine and (1996 – 2004) for ecstasy and LSD. Ecstasy includes MDMA & MDA and from 2001 also MDE.
Appendix 2
List of abbreviations used in the text
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List of abbreviations used in the text
CAN Swedish Council for Information on alcohol and Other Drugs MPA Medical Products Agency NAC National Alcohol Commission NBHW National Board of Health and Welfare (Socialstyrelsen) NCCP National Council for Crime Prevention (BRÅ) NDPC National Drug Policy Coordinator (Mobilisering mot narkotika) NR National report PPS Prison and probation service SKL Swedish Forensic Laboratory SMI Swedish Institute for Infectious Disease Control SNIPH Swedish National Institute of Public Health (Statens folkhälsoinstitut) SOU Swedish official government reports SRA Swedish Road Administration (Vägverket) KIM “Clients in treatment”
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