Could 30 years of political controversy on needle exchange programmes in Sweden contribute to scaling-up harm reduction services in the world?

Abstract

Aims: To end the hepatitis and AIDS epidemics in the world by 2030, countries are encouraged to scale-up harm reduction services and target people who inject drugs (PWID). Blood-borne viruses (BBV) among PWID spread via unsterile injection equipment sharing and to combat this, many countries have introduced needle and syringe exchange programmes (NEP), though not without controversy. Sweden’s long, complicated harm reduction policy transition has been deviant compared to the Nordic countries. After launch in 1986, no NEP were started in Sweden for 23 years, the reasons for which are analysed in this study. Methods: Policy documents, grey literature and research mainly published in 2000–2017 were collected and analysed using a hierarchical framework, to understand how continuous build-up of evidence, decisions and key events, over time influenced NEP development. Results: Sweden’s first NEP opened in a repressive-control drug policy era with a drug-free society goal. Despite high prevalence of BBV among PWID with recurring outbreaks, growing research and key-actor support including a NEP law, no NEP were launched. Political disagreements, fluctuating actor-coalitions, questioning of research, and a municipality veto against NEP, played critical roles. With an individual-centred perspective being brought into the drug policy domain, the manifestation of a dual drug and health policy track, a revised NEP law in 2017 and removal of the veto, Sweden would see fast expansion of new NEP. Conclusions: Lessons from the Swedish case could provide valuable insight for countries about to scale-up harm reduction services including how to circumvent costly time- and resource-intensive obstacles and processes involving ideological and individual moral dimensions.

Characteristics of and Experience Among People Who Use Take-Home Naloxone in Skåne County, Sweden

“…Access and availability of these services have traditionally been restricted. Even though a gradual expansion has occurred during the last decade ( 24 , 25 ), the process has been slow and naloxone distribution is still unequal and insufficient on a national level ( 26 ). Therefore, studying the feasibility of broad scale THN implementation and use in a country with an inherent history of zero-tolerance drug policies and control by repression, which may affect acceptability, access, and availability, is important for countries in similar situations.…”

The Implementation of Needle Syringe Exchange Program in Malaysia: A Short Communication

“…To date, NSEP plays a crucial role in containing blood-borne viral infections, mainly HIV, Hepatitis A, and Hepatitis B (Chandrasekaran et al, 2017;Low et al, 2010;Singh et al, 2016;Yusuff, & Mohamed, 2018). This program has been practiced in many countries around the world, with Western European countries and Sweden and Australia being among the leaders in the NSEP (Karlsson et al, 2020).…”

Healthcare seeking among Swedish patients in opioid substitution treatment – a mixed methods study on barriers and facilitators

“…While most of these fatalities involve opioids [ 30 ] access to OST is unequally distributed on a national level [ 31 , 32 ], even though policy changes during the last decade have led to increased availability. The “zero vision”, meaning a drug-free society, is applied in all Swedish narcotic policies [ 33 ] leading to continuously restrictive policies and a limited provision harm reduction services [ 34 ]. Even in Sweden, where primary healthcare is tax financed and covered by the universal health insurance, structural discrimination and socioeconomic disadvantage poses barriers to healthcare seeking [ 35 ], correlates with unmet healthcare needs [ 36 , 37 ] and incident and fatal opioid overdose [ 38 ].…”