Harm reduction social work with people who use drugs: a qualitative interview study with social workers in harm reduction services in Sweden.

BACKGROUND: Social work with people who use drugs (PWUD) has traditionally focused on abstinence and rehabilitation. In recent years, harm reduction has gained an increasingly more important role in social work with PWUD, and social workers are key professionals in many harm reduction services. This study investigates how social workers in harm reduction services for PWUD in Sweden understand the concept of harm reduction and how it relates to goals of rehabilitation, and how they assess and deal with dilemmas and challenges in everyday work. METHODS: The study is based on interviews with 22 social workers in harm reduction services for PWUD in the Scania region of Sweden. A thematic analysis in three steps was used in coding and processing the data. RESULTS: The social workers pointed to similar values between social work and harm reduction and argued for combining the two fields to improve services for PWUD. Three overarching principles for Harm Reduction Social Work (HRSW) were developed based on the social workers accounts: (1) Harm reduction is a prerequisite for rather than a counterpoint to rehabilitation and recovery, (2) motivational work must be non-mandatory and based on the client's goals, (3) a holistic perspective is crucial for Harm Reduction Social Work. Challenges in doing HRSW concerned restrictive laws, policies, and guidelines, resistance from managers, difficulties in setting boundaries between client autonomy and life-saving interventions, and the risk of normalizing high-risk behaviors. CONCLUSIONS: We use the concept of Harm Reduction Social Work to show how social work with PWUD can have a primary focus on reducing harm and risks, while at the same time it involves a holistic perspective that facilitates motivation and change. The suggested principles of HRSW can provide guidance in practical social work with vulnerable PWUD. Social workers can have important roles in most harm reduction settings and may act to enable recovery.

Taking Care of Business in a Male - Dominated Drug Economy: Income Strategies, Risks, and Opportunities of Women Who Use Drugs.

Background: Street level drug economies are often described as hierarchical and gender-segregated arenas where men hold high positions and control the supply of drugs, and where women are confined to marginal and low-level positions. Few studies have explored income strategies, risks and opportunities of women who use drugs within drug economies in the Nordic countries. Objective: The aim of this study was to analyze women's stories about "taking care of business"-making money and securing drugs-in a local drug economy. The study focuses on the women's gender enactments, the strategies they use to achieve success, and the barriers and risks they face in their everyday endeavors. Methods: This article draws on informal conversations and in-depth qualitative interviews with 27 female drug users in Malmö, Sweden during periods of fieldwork between 2009 and 2012. Results: The interviewed women had established themselves as entrepreneurs in the local drug economy, working hard for their money. However, only a few held middle or high positions, and all women described encountering gendered obstacles and risks in their efforts to take care of business. The patriarchal and sexualized nature of the drug economy meant special prerequisites for the women's income strategies and gender enactments. Three main income strategies were distinguished in the women's stories: (1) using femininity and sexuality, (2) proving tough and dangerous by using street masculinity, and (3) establishing trust, being professional, and keeping a low profile. These strategies involved different advantages and disadvantages, as well as different types of risk. Conclusions: The results show that it is possible for women to achieve success in male-dominated drug economies, but that this is associated with major challenges. Gendered social hierarchies, structures and norms seem to influence the women's gender enactments, opportunities and risks. However, factors such as type of drug use, degree of drug dependence and social position, was also decisive for their possibility of taking care of business. This points to the importance of combining a focus on gender with a focus on other determants of power relations and vulnerabilities, when studying the everyday lives of people who use drugs.

Police officers' attitudes and practices toward harm reduction services in Sweden - a qualitative study.

BACKGROUND: Since the 1980s, Swedish drug policy has combined a restrictive zero tolerance approach with the vision of a "drug-free society". However, in recent years, access to harm reduction services has increased through local initiatives and new national guidelines. The possible success of these services may be affected in part by police drug law enforcement. The aim of this study was to explore how Swedish police officers act toward and view harm reduction services in a national drug policy setting of zero tolerance toward drug use. METHODS: Applying a qualitative research design, we conducted 19 in-depth interviews with police officers who worked with drug law enforcement in Malmö. We conducted a qualitative textual analysis of the data. RESULTS: Officers largely supported harm reduction services and refrained from overtly enforcing drug laws in their vicinity. Officers engaged in boundary work that assigned the responsibility of care of marginalized people who use drugs (PWUD) to the health care system, while including policing of drug market problems, young PWUD and dealers in their own jurisdiction. Opioid substitution treatment was seen as positive, although diversion of medicines was pointed out as a problem. Needle exchange programs were seen as offering important public health services and a no-go zone for the police. Several officers wanted to carry naloxone on duty but requested more information about its use. CONCLUSION: The general support among police officers for harm reduction services is an indication of a changing drug policy landscape in Sweden. Drug policy should take police officers' views into consideration and there is a need for collaboration between police and harm reduction services. Further research should focus on how the police conduct boundary work since police actions may impact on the success of harm reduction services.

Parents' experiences of abuse by their adult children with drug problems.

AIMS: To examine parents' experiences of abuse directed at them by their adult children with drug problems. MATERIAL AND METHOD: The material consists of 32 qualitative interviews on child-to-parent abuse with 24 mothers and eight fathers. The interviewees had experienced verbal abuse (insults), emotional abuse (threats), financial abuse (damage to property and possessions) and physical abuse (physical violence). FINDINGS: In the parents' narratives, the parent-child interaction is dominated by the child's destructive drug use, which the parents are trying to stop. This gives rise to conflicts and ambivalence. The parents' accounts seem to function as explaining and justifying their children's disruptive behavior in view of the drug use. The fact that an external factor - drugs - is blamed seems to make it easier to repair the parent-child bonds. The parents differentiate between the child who is sober and the child who is under the influence of drugs, that is, between the genuine child and the fake, unreal child. The sober child is a person that the parent likes and makes an effort for. The child who is on drugs is erratic, at times aggressive and self-destructive. CONCLUSIONS: The interviewed parents' well-being is perceived as directly related to how their children's lives turn out. The single most important factor in improving the parents' situation is to find a way for their adult child to live their lives without drug problems.

Mental health problems among young people in substance abuse treatment in Sweden.

BACKGROUND: Young people with substance use problems face a high risk of co-occurring mental health problems, something that may involve a more difficult life situation, social problems as well as worse treatment outcomes. The aim of this study is to analyse self-reported mental health problems among young people receiving outpatient treatment for substance use problems in Sweden. We explore what types of mental health problems are more or less predominant, and whether there are significant differences between boys and girls. In addition, we analyse how various mental health problems covary with indicators of substance abuse severity. METHODS: The study is based on structured interviews with 1970 young people enrolled at outpatient clinics in 11 Swedish cities. The data was analysed through frequency- and averages-calculations, Chi-square tests and multivariate logistic regression analyses. RESULTS: Self-reported mental health problems were common among the young people in the study. A relatively large percentage of the total group (34-54%) reported problems such as concentration difficulties, sleeping difficulties, anxiety and depression. At the same time, many of the young people did not report any symptoms and only a small group, about 20%, reported diagnosed mental health disorders. The results show substantial gender differences, with girls reporting significantly higher levels of mental health problems. Multivariate logistic regression analyses demonstrated significant associations between severity of drug use problems and anxiety, concentration difficulties, aggression, hallucinations and mental stress caused by experiences of trauma. CONCLUSIONS: Treatment needs are diverse within this group of young people who use drugs. Since girls report higher levels of all mental health problems, and a larger burden of psychosocial risk factors than boys, they are likely to require more comprehensive treatment interventions. The link between more severe drug problems and mental health problems points to the importance of exploring this relationship in treatment. A multidisciplinary approach, in which co-occurring problems can be addressed simultaneously, may be the best treatment form for many young people with drug problems.

Non-prescribed use of methadone and buprenorphine prior to opioid substitution treatment: lifetime prevalence, motives, and drug sources among people with opioid dependence in five Swedish cities.

BACKGROUND: Opioid substitution treatment (OST) with methadone or buprenorphine is the most effective means of treating opioid dependence. If these substances are used by people who are not undergoing OST, they can however carry serious risks. This article examines the lifetime prevalence, motives, and drug sources for such use, as well as geographical differences in these variables. METHODS: Structured interviews were conducted with 411 patients from 11 OST clinics in five Swedish cities. The researchers carried out 280 interviews on-site, while 131 interviews were conducted by specially trained patients through privileged access interviewing. Data were analyzed by frequency and average calculations, cross-tabulations, and χ2 tests. RESULTS: The lifetime prevalence of non-prescribed use was 87.8% for methadone, 80.5% for buprenorphine, and 50.6% for buprenorphine/naloxone. Pseudo-therapeutic motives-avoiding withdrawal symptoms, staying clean from heroin, detoxification, or taking care of one's own OST-were commonly cited as driving the use, while using the drugs for euphoric purposes was a less common motive. Most respondents had bought or received the substances from patients in OST, but dealers were also a significant source of non-prescribed methadone and buprenorphine. Geographical differences of use, motives, and sources suggest that prescription practices in OST have a great impact on which substances are used outside of the treatment. CONCLUSIONS: Experiences of non-prescribed use of methadone and buprenorphine are extremely common among those in OST in southern Sweden. As the use is typically driven by pseudo-therapeutic motives, increased access to OST might decrease the illicit demand for these substances. Buprenorphine/naloxone has a lower abuse potential than buprenorphine and should therefore be prioritized as the prescribed drug. Supervised dosage and other control measures are important provisions in the prevention of drug diversion and non-prescribed use among people not undergoing OST.

Long-term self-treatment with methadone or buprenorphine as a response to barriers to opioid substitution treatment: the case of Sweden.

BACKGROUND: It is well known that illicit use of methadone and buprenorphine is common among people with an opioid dependence. Less notice has been taken of the fact that these substances are also used for extended periods of self-treatment, as a way of handling barriers to OST. In this study, motives for self-treatment are investigated, as well as attitudes and perceived barriers to OST among drug users with an opioid dependence in Sweden. METHOD: The study is based on qualitative research interviews with 27 opioid users who have treated themselves with methadone or buprenorphine for a period of at least three months. RESULTS: The duration of self-treatment among the interviewees varied from 5 months to 7 years. Self-treatment often began as a result of a wish to change their life situation or to cut back on heroin, in conjunction with perceived barriers to OST. These barriers consisted of (1) difficulties in gaining access to OST due to strict inclusion criteria, limited access to treatment or a bureaucratic and arduous assessment process, (2) difficulties remaining in treatment, and (3) ambivalence toward or reluctance to seek OST, primarily due to a fear of stigmatization or disciplinary action. Self-treatment was described as an attractive alternative to OST, as a stepping stone to OST, and as a way of handling waiting lists, or as a saving resource in case of involuntary discharge. CONCLUSION: Illicit use of methadone and buprenorphine involve risks but may also have important roles to play for users who are unwilling or not given the opportunity to enter OST. A restrictive and strict rehabilitation-oriented treatment model may force many to manage their own treatment. More generous inclusion criteria, a less complex admission process, fewer involuntary discharges, and less paternalistic treatment may lead to increasing numbers seeking OST. Control measures are necessary to prevent diversion and harmful drug use but must be designed in such a way that they impose as few restrictions as possible on the daily life of patients.

Diversion of methadone and buprenorphine from opioid substitution treatment: the importance of patients' attitudes and norms.

AIMS: Methadone and buprenorphine diversion by patients in opioid substitution treatment (OST) is a poorly understood phenomenon. We study the norms and attitudes on diversion among OST patients, including the role these norms and attitudes play as diversion risk factors. We also study whether perceived quality of care, social bonds to treatment staff, and deterrence can be associated with diversion. METHODS: Structured interviews were conducted with 411 patients from eleven OST programs. In total, 280 interviews were done on site by the researchers, while 131 interviews were conducted through peer interviewing by specially trained patients. The data was analyzed through frequency- and averages-calculations, cross-tabulations, and logistic regression analysis. RESULTS: Most patients consider diversion as mostly positive (83.7%), morally right (76.8%), and without any significant risk of detection (66.9%). Individual differences in norms and risk perceptions may play a role in explaining variations in diversion; patients who consider it right to share medication with friends report higher treatment-episode diversion than other patients (OR 1.455, p = 0.016). Patients who perceive control measures as effective report lower diversion than other patients (OR = 0.655, p = 0.013). Furthermore, data indicate that patients who are satisfied with the care and service are less prone to engage in diversion. Social bonds with treatment staff seem to be less importance. CONCLUSIONS: The norm system described by patients resemble Bourgois' 'moral economy of sharing' concept-not sharing drugs with friends in withdrawal is considered unethical. Efforts to decrease diversion may focus on lifestyle-changing interventions, and reducing black market demand for illicit medications by expanding access to treatment.

Diversion of methadone and buprenorphine by patients in opioid substitution treatment in Sweden: prevalence estimates and risk factors.

BACKGROUND: Diversion--patients who sell or share their medication--is a hotly debated but relatively unresearched phenomenon. We have investigated the prevalence of self-reported diversion of methadone and buprenorphine at OST programs in Sweden. We have also examined if demographic, treatment, and social factors can be associated with an increased risk of diversion. METHODS: Structured interviews were conducted with 411 patients from eleven OST programs. A standardized questionnaire with 106 close- and five open-ended questions were used. 280 interviews were done on site, by the researchers, while 131 interviews were conducted by specially trained patients through privileged access interviewing. The data were analyzed through frequency- and averages-calculations, cross-tabulations, and logistic regression analysis. RESULTS: In total, 24.1% (n=99) of the patients reported diversion in the past month. 67.6% (n=277) stated that they had diverted at some point. The peer interviews showed significantly higher levels of diversion (37.4% past month) compared with the researcher interviews (17.2%). Neither demographic factors, dosages, nor collection routines were associated with diversion. The likelihood of diversion was higher for patients on mono-buprenorphine (OR=5.64) and buprenorphine-naloxone (OR=2.10), than among methadone patients. Other factors which increased the likelihood of diversion were current illicit drug use (OR=5.60), having had patients as a primary source of illicit methadone or buprenorphine prior to treatment (OR=3.39), and mainly socializing with active drug users (OR=2.12). CONCLUSION: Self-reported diversion was considerably higher than in previous studies. This is most likely due to the new methodological strategy we used, but may also partly be explained by low availability of OST in Sweden, leading to a high demand for the substances by heroin users outside treatment. Efforts to decrease diversion should primarily focus on psychosocial and lifestyle-changing interventions, and expanded access to treatment, rather than on control measures.

Diversion of methadone and buprenorphine from opioid substitution treatment: patients who regularly sell or share their medication.

Diversion-the practice of patients selling or sharing their medication-is a much debated problem of opioid substitution treatment. Regular diversion by patients was studied at 11 opioid substitution treatment programs in the south of Sweden. Using quantitative and qualitative data, it was investigated whether those patients differ from other patients, their motives for and means of diversion, and who the recipients are. Regular diverters are a small, yet heterogeneous group. Continued illicit drug use, however, stands out as a common risk factor. Pecuniary need and a desire to help friends are other important motives. The client base mainly consists of people from the regular diverters' own drug milieus.

Wasted, overdosed, or beyond saving--to act or not to act? Heroin users' views, assessments, and responses to witnessed overdoses in Malmö, Sweden.

BACKGROUND: Overdose is a significant cause of death among heroin users. Frequently, other heroin users are present when an overdose occurs, which means the victim's life could be saved. There is a lack of studies that, based on heroin users own stories, examine their views, assessments, and responses to witnessed overdoses. METHODS: The study is based on qualitative interviews with thirty-five heroin users who witnessed someone else's overdose. RESULTS: The heroin users generally had a positive attitude towards assisting peers who had overdosed. A number of factors and circumstances, however, contribute to witnesses often experiencing resistance to or ambivalence about responding. The witness's own high, the difficulty in assessing the seriousness of the situation, an unwillingness to disturb someone else's high, uncertainty about the motive behind the overdose and whether the victim does or does not want assistance as well as fear of police involvement, were common factors that acted as barriers to adequate responses in overdose situations. CONCLUSION: The fact that being high makes it difficult to respond to overdoses, using traditional methods, argues for simpler and more effective response techniques. This can include intranasal naloxone programs for heroin users. The findings regarding the uncertainty about the intention of the overdose victim and the sensitivity to the experience of a good high argue for more up-front communication and discussion amongst using peers so that they can make their intentions clear to each other. Issues like this can be addressed in overdose education interventions. Overdose prevention measures also need to address the fact that fear of the police acts as a barrier to call emergency services.

Diversion of methadone and buprenorphine from opioid substitution treatment: a staff perspective.

Opioid substitution treatment (OST) is still controversial, despite positive results. The issue of diversion to the illicit drug market is a cornerstone in the criticism typically voiced against the treatment. Little research is available concerning how professionals who work in OST view the issue of diversion. In this article, we discuss existing ideas and attitudes toward diversion of methadone and buprenorphine among OST staff in Sweden. The article is based on semi-structured interviews with 25 professionals working in eight OST-programs in southern Sweden. Diversion was seen as a deleterious phenomenon by the interviewees. Three problematic aspects were highlighted: medical risks in the form of overdose fatalities and the recruitment of new opiate/opioid users; negative consequences for the legitimacy of OST; and moral objections, since diversion means that the patients remain in a criminal environment. However, positive aspects were also highlighted. Illicit methadone or buprenorphine is perceived as safer than heroin. In this way, diversion can fulfill a positive function; for instance, if there is a shortage of access to regular treatment. Patients who share their medication with opioid-dependent friends are seen as less culpable than those who sell to anyone for money.

Illicit use of methadone and buprenorphine among adolescents and young adults in Sweden.

BACKGROUND: Illicit use of methadone and buprenorphine has been described as a growing problem in Sweden in recent years, and has been associated with an increased drug-related mortality. Critics claim that the substances have become popular among adolescents and that they function as a gateway to heroin use. The aim of this study is to investigate, firstly, the extent to which illicit use of methadone and buprenorphine occurs among adolescents and young adults in Sweden, and secondly, at what stage in a user's drug career these substances tend to appear. METHODS: The study is based on surveys and structured interviews on drug use among various populations of young people, in addition to qualitative interviews with 86 informants who, in their professional capacity, encounter adolescents or young adults who are using illicit drugs. RESULTS: Illicit use of methadone and buprenorphine is rare among young people in Sweden. According to high school surveys, less than 0.1% have tried these substances. Among young drug users in general, few have tried the substances, and there is nothing to indicate that they act as gateway drugs. Among adolescents and young adults with severe drug problems, however, the illicit use of methadone and buprenorphine is more common (54% in a compulsory care sample). These substances normally enter the drug career late, and few use them as their main drug of choice. Other prescription drugs, like benzodiazepines and tramadol, are used by adolescents to a far greater extent. Diversion and illicit use of methadone and buprenorphine is not seen as a serious problem by the professionals interviewed. A general view is that the substances are mainly used by people with a heroin or polydrug addiction, often for "self-medication" purposes. However, several informants express concern that methadone and buprenorphine may cause fatalities among young drug users without an opioid tolerance. CONCLUSIONS: Illicit use of methadone and buprenorphine among young drug users is not a widespread problem in Sweden. Harm-reduction measures should target drug users with more severe problems, among whom illicit use of methadone and buprenorphine is more common and pose a medical risk. Illicit use of other prescription drugs, which are less controlled and more widely used by young people, is an important issue for further research.