Sweden

"Cannabis remains the illicit substance most commonly used in Sweden. However, lifetime prevalence of cannabis use among the general population remains low in comparison with other European countries. The data indicate that cannabis use is concentrated among young adults, in particular those aged 15-24 years. The long-term trend analysis shows a slight increase in last year cannabis use over the past decade among 16- to 34-years-olds. In general, cannabis use is more common among males than females.

"The prevalence of use of cannabis and other illicit drugs was measured in the survey ‘Vanor och Konsekvenser’, conducted in 2017 following the previous data collection in 2013. The survey was conducted by the Swedish Council for Information on Alcohol and Other Drugs (CAN). The results show that, in 2017, around 4 % of people aged 17-84 years reported using at least one substance classified as narcotics in the previous 12 months.

"Several Swedish cities have participated in the Europe-wide annual wastewater campaigns undertaken by the Sewage Analysis Core Group Europe (SCORE). This study provides data on drug use at a municipal level, based on the levels of illicit drugs and their metabolites found in wastewater. These data complement the results from population surveys; however, wastewater analysis reports on collective consumption of pure substances within a community, and the results are not directly comparable with prevalence estimates from population surveys. The most recent available data on stimulant drugs was collected in Stockholm in 2016 and indicate weekly consumption patterns. The loads of the main cocaine metabolite (benzoylecgonine) and MDMA/ecstasy found in wastewater in 2016 were higher at the weekends than on weekdays, whereas methamphetamine traces were found to be distributed more evenly throughout the week."

"In the 2016 survey, 4% of 16-year-olds and 13% of 18-year-olds responded that they had used drugs in the past 12 months (Tables 39–40). In a broader group of young adults (16–29 years), about 8% said they had used cannabis in the past year (Table 45). Viewed in a 45-year perspective, it is mainly the 1980s that stand out, with a lower percentage reporting personal experience of illicit drug use.

"Although the percentage of young people who use illicit drugs has remained relatively stable during the 2000s, there are signs of a slight increase in the frequency with which they use drugs (see Tables 41–42). Thus, even if the user group has not grown, consumption within the group appears to have increased.

"Among 18-year-old students who have used illicit drugs, almost two-thirds have used cannabis only; slightly under one-third have also used other drugs, and 5% have exclusively used other drugs. In recent years, synthetic cannabis smoking mixtures such as “spice” have risen to second place after traditional cannabis (cannabis resin and marijuana). Other illicit drugs, mentioned less frequently, include ecstasy, cocaine, amphetamines, and pharmaceutical drugs as tranquillisers and pain-killers, which are classified as narcotic drugs when used without prescription."

"Sweden’s national drug strategy, the Comprehensive Strategy for Alcohol, Narcotics, Doping and Tobacco (ANDT), adopted in 2016, covers the period 2016-20. Its overarching goal is to have a society free from narcotics and doping, reduced medical and social harm from alcohol and reduced tobacco use. In 2018, the Swedish Riksdag adopted eight new target areas for public health policy. The overall aim of the policy has been reformulated to have a clear focus on equity in health. Measures relating to illicit drugs and other substances are relevant for several of the target areas. The ANDT strategy takes, as its starting point, the right of every person to have the best possible physical and mental health. The ANDT strategy is structured around six objectives and each objective has defined fields of action.

"Sweden follows up on and evaluates its drug policy and strategy by monitoring indicators aimed at describing developments related to the ANDT strategy’s objectives. In 2015, two different multi-criterion evaluations of the Strategy for Alcohol, Narcotics, Doping and Tobacco for 2011-15 were completed. The Swedish Agency for Public Management carried out a process evaluation focused on the degree to which the stated objectives were met and their operational level and quality. The Public Health Agency of Sweden undertook an evaluation that considered the implementation of the strategy based on the indicators it included, its design and the development of the successor strategy for the period 2016-20."

"The Swedish Council for Information on Alcohol and Other Drugs (CAN) conducts annual national studies of the alcohol and drug use of school-age children. Since 1971, they have conducted school-based teacher-monitored surveys among a nationally representative sample of 9th grade elementary school students 15-16 years old. Since 2004, studies have also been carried out in the second year of upper-secondary school (11th grade) among students aged 17-18. In these annual surveys of adolescents, questions are asked about their use of a wide range of different substances and illicit drugs.

"In the latest published measurement from the surveys conducted in 2013, the lifetime prevalence of use of any type of illicit drug among 15- and 16-year-old boys and girls was 7.3% and 5.7% respectively (Centralförbundet för alkohol och narkotikaupplysning, 2014c). Cannabis was by far the most common drug, and the change over time in the proportion of boys and girls reporting use of drugs is presented in Figure 2.7. The prevalence reached a low level in the mid- to late 1980s and early 1990ts, and have had a somewhat higher and varying level during the past 20 years.

"In the older age group i.e. 17- and 18-year-old students, the lifetime prevalence of ever having used an illicit drug was 19.4% for boys and 13.8% for girls (Centralförbundet för alkohol och narkotikaupplysning, 2014c) . Among those who had used an illicit drug, the most common drug was cannabis, although some level of use of benzodiazepines, cocaine and amphetamines was also reported. Very few students reported use of drugs before the age of 14, 2% of the boys and 1% of the girls, and these results have remained the same over the past 20 years."

"According to CAN’s 2012 school population survey (Centralförbundet för alkohol- och narkotikaupplysning, 2013), very few students used drugs before the age of 14; 2% of the boys and 1% of the girls. The percentage of students who reported drug use before the age of 14 has been stable over the last 20 years.
"The percentage of students (15-16 years of age) who had had an opportunity to try drugs (for the first time) increased at the end of the 1990s and the increase continued until 2000 when 27% reported in the survey that they had had the opportunity to try drugs. From then on, the percentage decreased again and in 2012 it was 18%. The percentage of older students (17-18 years of age) who had had an opportunity to try drugs is somewhat larger, approximately 32 % (Centralförbundet för alkohol- och narkotikaupplysning, 2013."

"Among students aged 15-16, approximately 40% of those who had used drugs also reported a large consumption of alcohol and this was a much higher proportion than among students with no reported drug use (8%). Further, among students aged 17-18, there was a large difference between students with and without experience of drug use with regard to extensive alcohol consumption, although the difference was not as large as for students aged 15-16 (Centralförbundet för alkohol och narkotikaupplysning, 2014c). There was also an association between reported drug use and binge drinking. Among students who reported drug use, almost 57% of 15- and 16-year-olds and 74% of 17- and 18-year-olds reported monthly binge drinking. This is a considerably higher percentage than could be found among students with no drug experience. Use of tobacco was also more common among students with experience of drug use, compared with students with no drug experience (Centralförbundet för alkohol och narkotikaupplysning, 2014c)."

"The National Board of Health and Welfare and the Public Health Agency of Sweden defines the procedures that county councils should follow when setting up NSPs [Needle and Syringe Exchange Programs], which include a justification of need (e.g. an estimate of the number of potential service users), an assessment of available resources, a provision plan for complementary and additional care services (e.g. detoxification, drug treatment and aftercare), and service quality requirements. The offer of low-threshold services includes medical and social care and support, free testing for infectious diseases and vaccination for hepatitis B virus infection and referral.

"In 2017, there were 13 NSPs operating across Sweden, and available data document a steep increase in syringe provision, starting from about 200 000 in 2014 and reaching more than half a million in 2017. Pharmacies in Sweden may sell needles or syringes only to people with a prescription for medical use.

"During 2018, several regulatory changes came into force to increase the availability of naloxone. These included allowing (i) emergency services staff to give naloxone before an ambulance arrives, (ii) nurses to prescribe naloxone and (iii) the medication to be handed out directly to the patient. National guidance on naloxone use and the risks of overdose has recently been published."

"Studies reporting estimates of high-risk drug use can help to identify the extent of the more entrenched drug use problems, while data on first-time entrants to specialised drug treatment centres, when considered alongside other indicators, can inform an understanding of the nature of and trends in high-risk drug use.
"A 2011 study estimated that there were 8 000 people who inject drugs in Sweden, the majority of whom used opioids and/or amphetamine. There is no national estimate on the prevalence of high-risk drug use by substance.

"Data from drug treatment providers indicate that opioids, cannabis and stimulants remained important among first-time clients entering treatment in 2017. Approximately 3 out of 10 treatment clients in Sweden are female; however, the proportion of females in treatment varies by type of primary drug and programme. In the last decade, the treatment demand registration system in Sweden has undergone changes, which need to be considered when interpreting the data."

"In 2013, an additional cross-sectional study of drug use was conducted in a nationally representative sample of the population in Sweden (Ramstedt, 2014). A total of 15,576 individuals (59.3% of the total sample) participated in the study and 10.5% reported that they had used an illicit drug or used some prescription medication in a non-prescribed way during the past 12 months. In this study, cocaine and amphetamines were the most common illicit substance reported after cannabis. Among men and women aged 17-64, 3.3% reported having used cocaine and 3.0% reported having used amphetamine at some time in their lives, followed by ecstasy (2.4%), opioids (2.2%), and hallucinogens (2.1%). Use of prescription medication was much more common and 6.5% reported having used painkillers in a non-prescribed way and 2.8% reported having used sedatives/tranquilizers in a non-prescribed way during the past 12 months."

"Two per cent of the men and 0.9 per cent of the women reported some type of illicit drug use in the past 30 days, corresponding to approximately 53,000 men and 24,000 women or a total of 77,000 people. Adding to this the 50,000 people who in the past 30 days had used prescription medicine without a doctor’s prescription, the total figure increases to 127,000 people. The population study indicates that the highest proportion of regular drug use is found among young men between the ages of 15 to 24, while the highest proportion among women is observed in the ages of 25 to 34. Regular drug use then decreases with increasing age for both genders. The results from the student survey do not indicate that students use illicit drugs more than others of the same age in the population. For prescription medicines, patterns opposite to illicit drugs are seen in terms of age and gender. Approximately twice as many women as men have used narcotics-classed or addictive medicines without or in excess of a doctor’s prescription."

"The use of APEDS was common among young males in the current study, and it was more related to the drive for muscularity and sexual orientation than symptoms of EDs. In a large national sample (N = 7401) of college and university students, including both sexes in the US (ages 18–30 years), the lifetime prevalence of the use of protein supplements and creatine was 23.8% and 7.7%, respectively [30]. The corresponding lifetime figures (Table 1) in our study of young males were 31.9% and 16.5%. Male sex was related to a greater likelihood of lifetime protein and creatin supplement use in the US study [30], which might partly explain larger prevalence figures in our study of young males. Focusing on male college students (18–26 years) from the top-10 National Collegiate Athletic Association Division I universities in the US, the rate of current use of appearance- or performance-enhancing supplements was 38.9% [31]. This is a highly selected sample in which athletic performance is assumably a top priority, and a very high current rate is expected. If “current rate” in our study is defined in terms of at least monthly use of these supplements, then it will amount to 23.1%. The anonymous nature of the study might increase the truthful report of use of such substances. It has been shown that computerized surveys leads to significantly more reporting of sensitive issues (e.g., socially undesirable behaviors) [32]. In a study on the role of anonymity and privacy in survey methodology, participants reported significantly higher mean comfort levels with anonymous surveys compared to non-anonymous [33]. Given the difficulties inherent in unknown representativity of Internet-based surveys, further replications using the same methodology are warranted to arrive at a robust estimate in use of appearance- and performance enhancing supplements among young males."

Click here for complete datatable of Lifetime, last year and last month prevalence (per cent) of cannabis use in Sweden by Age and Gender, 2004-2012

"The most common sanction issued to those convicted of drug offences is a fine, in the form of either a summary fine issued by the prosecutor or a court sentence. Those issued fines accounted for 58% of all those convicted of drug offences in 2012. In 2012, 29% of those convicted of drug offences took the form of waivers of prosecution, whereas 5% involved prison sentences.

"The increase in the total number of persons being convicted of drug offences is also mirrored as an increase in virtually all of the different sanctions. The number of fines has more than doubled over the period examined, from 4,580 persons in 2002 to more than 13,100 in 2012. The number of persons sentenced to a prison term has on the other hand decreased from 1,580 in 2002 to 1,140 in 2012. The average length of the prison term issued in 2012 was 13 months."

"The average number of drug addicts in prison has been fairly stable over an extended period of time. On 1 October 2012, 56% of the women and 62% of the men in prison were drug dependent, alcohol included."

"Seizures of pharmaceuticals classified as narcotics (mainly benzodiazepines) show an increasing trend. This increase may be due to an increase of medicines sold illegally over the Internet. The large number of seizures is partially due to the fact that these drugs are often used in combination with other drugs.
"The number of cannabis seizures shows an increase, indicating a substantial supply of cannabis on the drug market. Amphetamine seizures on the other hand, show a slight decrease since 2006, whereas methamphetamine has increased over the last 10 years. Yet, methamphetamine seems to have stabilised somewhat since 2008/2009.
"The increased seizures of cocaine indicate an increased availability. Seizures of ecstasy decreased dramatically in the beginning of the 2000s until 2009, however, the last three years the number of seizures has increased dramatically.
"The seizures of heroin show a decrease since the beginning of 2000s."

"In total, the number of problematic drug users in Sweden was estimated at a rounded of figure of 29,500. This number is not directly comparable to the figures previously derived in Sweden due to differences in both the data sources and the methods used. The national estimate relating to population was 3.2 with the 'all ages' denominator and 4.9 with the 15-64 years of age denominator (see Standard table 7 and 8 for details)."

"Based on register data from the patient register and from the Prison and Probation Services, it was estimated that there were 29,500 problematic drug users. This corresponds to 38 per cent of the 77,000 people who confirm regular use of illicit drugs in the population survey, or 23 per cent of the 127,000 people who regularly use some type of illicit drug or presomption medicine without a doctors prescriptive [sic]. This means that there is a large group of people whose regular drug use does not lead them in to the health or corrections systems."

"Individuals with drug use that could be categorised as problematic are generally a hard-to-reach population, making it difficult to obtain a picture of population size and development. Sweden also lacks a well-established definition of problematic or harmful drug use. In order to reach a more accurate picture of the Problem Drug Use (PDU) population size, as well as their living conditions, three nationwide studies were conducted in 1979, 1992 and 1998. In these case-finding studies, data was collected from professionals who met drug users in their daily work in e.g. the social services, healthcare, the police, the correctional system, customs and various treatment centres, including NGOs. Within a given period of time, the professionals reported clients or patients that either injected drugs at some point in the past 12 months or used illicit drugs daily or on an almost daily basis in the past four weeks. Those meeting these criteria where classified as problematic drug users. Estimates were obtained through capture-recapture calculations (Olsson et al., 2001).
"The population of problematic drug users in Sweden was estimated at approximately 15,000 in 1979, approximately 19,000 in 1992 and around 26,000 in 1998. This means an increase in nominal figures. However, a per capita figure would be more accurate since the general population increased during the same time period. In 1979, there were 1.8 PDUs per 1,000 inhabitants according to the above estimates. In 1998, this figure increased to 2.9 per 1000. Please note that the above figures refer to all ages."

"From an infectious disease perspective, there is a significant difference between a PDU and an IDU with regard to risk-taking and disease outcome. In 2013, the National Board of Health and Welfare used a new method to estimate the number of IDUs in Sweden. The method uses patient registries and applies a condition based on ICD-10 codes which distinguishes between those who receive a diagnosis of abuse and those who receive any diagnosis related to injecting drug use. The method estimates the number of IDUs at about 8,000 for the whole of Sweden in 2011. 57 per cent of these live in any of the three metropolitan cities: Stockholm, Gothenburg, and Malmö (National Board of Health and Welfare, 2013 (Unpublished)).

"The above estimate also includes the hidden population, i.e. IDUs who maintain a functioning life style and who does not seek help for drug use or any health consequence directly linked to drug use. The estimate is further believed to contribute to prevention efforts being tailored according to needs. The method is to be seen as an attempt to methodologically approach an alternative way with regards to previous PDU estimates, where information was self-reported by a non-randomised number of key information providers, from a non-randomised selection of Swedish regions."

"According to Sweden’s official criminal statistics for 2013, about 96,200 offences against the Act on Penal Law on Narcotics were reported in 2013, an increase of almost 2% compared to 2012. The number of convictions with drug violations as the main crime decreased by 8% (about 1,910 convictions) compared to 2012. Of the 20,800 convictions in 2013 with a drug offence as the main crime, 13% involved women and 28% adolescents between the ages of 15 and 20. The offences were considered minor in 87% of cases (18,103), not minor in 12% (2,456) and serious in 1% (206), as reported in the 2013 Swedish Official Crime Statistics from the NCCP."

"Sexually transmitted infections, such as HIV, are not reported by full identity to the authorities in Sweden. This limits the possibility of following individuals over time and duplicates of notifications concerning the same individual may occur in the surveillance data.
"Fewer cases of HIV were reported among injecting drug users (IDU) in 2010-2011 compared to 2008-2009, with 22 cases in 2012. By the end of 2012, IDUs accounted for 5% of all people living with a known HIV infection in Sweden, equivalent to about 400 IDUs (or former IDUs). In May 2012, an outbreak of HIV was detected among IDUs in Kalmar comprising 5 cases. The new needle-syringe exchange programme in Kalmar can hopefully prevent new cases.
"Data from non-representative studies based on IDUs tested in remand prisons in Gothenburg and Stockholm in 2009 and 2010 shows an HIV prevalence of 5-9%. The needle-syringe exchange programmes in Skåne appear to have had a positive impact on preventing new HIV cases in the region. No new HIV cases were found among the participants in 2010-2011."

"In Sweden, the prevalence of hepatitis C among injecting drug users is very high. In various studies conducted during the last 15 years, the prevalence has been reported to be between 60% and 92%.
"Altogether, 1981 cases of hepatitis C were reported in 2012. Intravenous drug use is the dominant transmission route and most cases are domestic. Viewed in a longer perspective, the total number of reported cases is decreasing. However, when viewed by age group, no falling trend can be seen in 15-29 year-olds over the last 10 years. In 2012, 693 cases were reported in this age group and 48 cases were reported among those under the age of 20. This indicates that there is on-going recruitment to injecting drug use among young people and an on-going transmission of the disease among young intravenous drug users in Sweden. Hepatitis C among IDUs remains a challenge and future intervention efforts are prioritized. The trend analysis is aggravated by the fact that it is not possible to differentiate between acute cases and chronic cases of hepatitis C in the surveillance data (Smittskyddsinstitutet, 2013)."

"Between 100 and 200 cases of acute hepatitis B are reported in Sweden annually. However, fewer cases of acute hepatitis B (82) were reported in 2012 due to fewer cases being reported among injecting drug users. Of all acute hepatitis B cases, 18 were among IDUs (compared with 51 cases in 2010), 17 of whom were infected in Sweden. The median age of IDUs diagnosed with acute hepatitis B in 2012 was 36 (range 19-52) (Smittskyddsinstitutet, 2013).
"The number of acute hepatitis B cases among IDUs varies depending on local outbreaks and immunity in the group following vaccination or previous infection. Other relevant factors are frequency in testing, injection behaviour and access to sterile equipment."

"The number of deaths with presence of methadone in the blood has tripled in Sweden during the period 2006-2008. In the same period, there has been a rapid expansion of methadone treatment. In 2005, the regulations on medically assisted substitution treatment were changed in Sweden. The previous restrictions on the number of people who were allowed to participate in treatment at the same time were removed. The number of new treatment units increased tenfold when a number of new programmes started throughout the country (Fugelstad et al., 2010). In autumn 2010 there were 64 units that provided pharmaceutically assisted maintenance treatment in Sweden (Swedish National Institute of Public Health, 2010).
"A forensic medical examination of the methadone related deaths shows that the majority involved mixed intoxication where the methadone played an important role. As the Swedish prescription register shows that 80 per cent of the deceased persons had not obtained their methadone from any legal sources, methadone programmes or pain relief treatment, leakage from methadone treatment appears to be a possible but minor source (Fugelstad et al., 2010)."

"The Swedish unemployment rates were rather low during the 1970s and the 1980s. During the first half of the 1990s unemployment rates reached relatively high levels, especially among youths (16- 24 years). In the late half of the 1990s the figures have decreased, but the unemployment rates 1998 was still four-folded compared to 1989. One possible reason for increases in drug use among younger people, apart from an increased supply, is problems connected to social exclusion and high levels of youth unemployment. Negative future prospects, at least for certain groups of youths, might be a reason for not giving up experimentation with drugs, which in turn might lead to long lasting severe drug use.
"During the 1990s there has been financial cut downs within the general welfare systems as well as in special forms of treatment (walk in clinics, therapeutic communities, etc). This might have had impact both on recruitment of new drug users who fall through the welfare net but also on the possibilities to offer drug users appropriate treatment. Statements from social workers, policemen, hospital staff and others sometimes indicates that the group of severe drug users are worse off nowadays, regarding economic and health aspects."

"Drug users, both men and women, are often unemployed, homeless and frequently at the margins of society. Moreover, female drug users most often have less social support and a worse mental health compare to male regular drug users. Most research does not differentiate between genders in their analyses and focus is usually on the male subjects. Women normally make up 20 - 35 % of the subjects in most published studies; however, women often have a more serious addiction. It was assumed that men and women have similar patterns in terms of abuse and experiences. The similarities are evident in terms of unemployment, homelessness and social exclusion. However, men more often than women earn their livelihood illegally (Byqvist, 2006).
"The use of drugs does not necessarily lead to criminal activity, although, there is a link between drugs and criminality. It can result from the direct production and distribution activities in the drug trade, or criminality committed under the influence of drugs. However, female criminals have a dual problem with drug abuse; the hardship associated with imprisonment and the difficulties associated with drug abuse in connection with motherhood. Furthermore, many women in addiction live in abusive relationships. In a recent study, which mapped the social situation among Swedish drug addicts it is indicated that there are several hardships in the everyday lives of drug abusing women. More so, compared with earlier research, the social circumstances of drug users seem to have worsened (Byqvist, 2006).
"A study of women injecting heroin (Richert, Månsson, & Laanemets, 2011) shows that they have a worse situation compared with amphetamine users, e.g. when it comes to housing and lack of legal/formal source of incomes. This implies that heroin addicts, in general, are more socially excluded. To a higher extent heroin addicts also have experiences of all types of treatment (op.cit.). Several factors were significantly related to a request for help, whereas heroin as principal drug was the single factor showing a significant positive relation to request for help in statistical analyse. This could be explained by differences in treatment available for the two groups. To this day there is no evidence-based treatment for amphetamine abuse. Treatment options for heroin abuse, on the other hand, are well documented and recognized (op.cit.)."

"A national mapping of homelessness⁹ in Sweden, which was conducted in April 2011 shows an increase in the number of homeless people – from approximately 18,000 in 2005 to 34,000 in 2011(Socialstyrelsen, 2011a). The large increase in reported homeless people mainly concerns people who live in relatively long-term housing solutions, such as training flats and apartments with social contracts.
"About 13% of the reported homeless persons were judged to be in acute homelessness, where several individuals slept outside or in public places. About 16% received institutional care or lived in different forms of category housing. About 40% lived in long-term housing solutions and another 20% lived in short-term housing solutions organized by themselves (Socialstyrelsen, 2011a).
"The National Board of Health and Welfare has made an attempt to identify substance abuse among homeless people. Of all participants in the mapping 40% were judged to have drug and alcohol issues, of these subjects 21% were women and 79% men. Most common was alcohol abuse l [sic], 65 %, with psychostimulants
such as the amphetamines, cocaine being the second most used group of substances. About one third used mainly cannabinoids. Approximately one fifth also used opioids. Mental ill-health among substance abusers is also common, about half of those with mental ill-health issues also abuse various forms of substances. The biggest proportion of homeless people with substance abuse can geographically be found in the Gothenburg region (Socialstyrelsen, 2011a)."

Treatment

"Data on treatment for problematic (or heavy) drug use at a national level is reported in TDI until 2010. In 2009 the reporting system covered 51% of all inpatient and 31% of all outpatient treatment centres. In 2010 the distribution should be similar even if the exact figures are not known.
"One third (1,597 patients) out of the total of 5,155 clients who were reported had entered treatment for the first time. The main drugs of choice by new clients are cannabis and amphetamine, closely followed by the summary category 'other opioids'.
"Most Injecting drug users (IDUs) in the population of new clients use amphetamine. For all clients undergoing treatment, the use of amphetamine is most prevalent, followed by heroin. The prevalence of amphetamine IDUs is higher than the prevalence of heroin IDUs."

"The distribution of drugs changed somewhat in 2008, with cannabis becoming more frequent than heroin. This trend has continued in data for the clients reported from treatment units in 2009: cannabis is now much more frequent than heroin.
"Amphetamine is still the most commonly used drug (29%) among the reported drug clients in treatment outside prisons, followed by cannabis (23%), heroin (17%), other opioids – analgesics and buprenorphine (11%) and benzodiazepines (11%).
"Cocaine use is still rare as a drug being the reason for seeking treatment (1%), and crack cocaine is almost non-existent in this population, as are methadone, ecstasy and hallucinogens."

"A vast number of controlled studies show that medication assisted treatment for opioid dependence (e.g. with methadone and buprenorphine) are efficacious in order to 1) prevent drug related deaths⁶; 2) reduce drug consumption; 3) increase quality of life for injecting drug users (Connock M, 2007). According to National Board of Health and Welfare (Socialstyrelsen, 2012), medication assisted treatment is available at 114 treatment units in Sweden. It is also estimated that the availability of such treatment is satisfactory in about half of the 21 counties.
"In 2011, approximately 5200 individuals was estimated to have been participating in opioid maintenance treatment (Socialstyrelsen, 2012), and the total number of individuals with opiate dependence diagnosis was estimated to about 7200⁷, which gives an estimated coverage of about 73%.
"There is no precise estimation of the number of individuals taking part in drug-free treatments, although it is reasonable to assume that the frequency of this type of treatment has decreased over the last 10 years due to the expansion of maintenance treatment programmes."

"Some Swedish maintenance treatment programmes have 'zero tolerance' against lateral use, which means that a patient can be discharged from treatment after a single positive urine test (Heilig & Gunne, 2008). In the study 'Involuntary discharge from medication-assisted treatment for people with a heroin addiction – patient’s experiences and interpretations' (Svensson B, 2011) the effects for involuntary discharged participants in a maintenance treatment programme in Malmö were studied by qualitative methodology. A deteriorating physical and mental health status were described by the participants generally. The serious medical risks of discharge were confirmed in a study by Fugelstad (2007) in which mortality in a group of patients expelled from a programme was 20 times higher than in treated patients.
"Recent Swedish research has shown good results in clinical trials with highly structured treatment based on positive reinforcement of desired behaviours (Kakko, 2011). In an evaluation of a drug-assisted programme for female prostitutes in Malmö, two success factors are mentioned: effective liaison with social services and mental health care and a reasonable programme size. Small-scale programmes create an organizational vulnerability while large-scale programmes increase the risk of neighbourhood problems and therapeutically unfavourable patient compositions (Laanemets, 2007)."

Harm Reduction

"In 2006, the Act on Exchange of Syringes and Needles entered into effect (SFS 2006:323). The purpose of the Act is to prevent the spread of HIV and other blood-borne infections through the exchange of syringes and needles in needle and syringe programmes. Such intervention is to be carried out in connection with interventions aimed at motivating the individual to accept care and treatment. Needle and syringe programmes may not be set up without the permission of the National Board of Health and Welfare."

"Last year syringe sharing has occurred in a total of 37 per cent of SEP-users and during the last month in 19 per cent. IDUs [Injection Drug Users] integrated into mainstream society, but not in the subculture, have significantly lower numbers than the rest, 29 per cent and 8 per cent respectively. Most IDUs had previously received some form of drug treatment, a total of 75 per cent.
"The average visitor participates in the programme for four years, does 50 visits and collects 200 syringes and 400 needles. The variations are however large. About half of the visitors have visited the clinic at any time without changing needles and syringes or using any other regular service. These visits seem to be of an informal social nature.
"Syringe and needle coverage was based on interview data on injection patterns during the last year. From the register the number of distributed needles and syringes was then obtained. Ratios of total syringes coverage was estimated at 15 per cent and 30 per cent for needles. Frequent users (> 100 visits) has a ratio for syringes of 21 per cent and for needles 44 per cent. Those who in the last year had not shared injecting equipment with others had a ratio of syringes of 17 per cent and for needles 34 per cent. The corresponding figures for those who had shared equipment with other were 11 per cent and 22 per cent.
"Nearly 60 per cent of SEP-users had some form of treatment experience before they joined the exchange programme. More than 40 per cent had received some form of treatment while in the programme, but of those, only 8 per cent had no previous treatment experience. Just over a third had never received treatment for their drug
use (Stenström, 2008)."

"In Sweden, a county council wishing to open a Needle Exchange Programme (NSP) must seek authorization from the National Board of Health and Welfare. One condition is that the programme be carried out in cooperation with a municipality. A well-functioning drug treatment unit must be present as a partner and the NSP should be run in close cooperation with either the county council ?s department for infectious diseases or the drug dependence department.
"Today (October 2013), there are five operational needle/syringe exchange programmes in Sweden (Malmö, Lund, Helsingborg, Kalmar and Stockholm).
"As is often the case in other countries, NSPs in Sweden were started mainly with the intention of reducing the spread of HIV, but also of HBV and HCV. Another important aspect of syringe exchange in Sweden has been to reach IDUs without contact with health care or social services and connecting them with regular drug services. The NSPs in Sweden have gradually developed to also include efforts to reduce risky sexual behaviour and somatic, psychological and social interventions (SOU 2011:6)."

"Low-threshold health care centres (LTHC) offer health services (e.g. needle exchange, medical services) without attempting to control intake of drugs, and provide counselling only if requested. LTHCs may be contrasted with regular treatment programmes (“high-threshold" programmes), in which the user is required to accept a certain level of control. In Sweden, drug-treatment programmes as well as harm reduction interventions (NSPs, maintenance-treatment) are required to apply a high degree of control over participants (e.g. identification, age above 20 etc.). No LTHCs are provided within the regular health care in Sweden. Only a few non-governmental organisations (user organisations) provide basic health care, e.g. prevention measures for infectious diseases, without requiring identification."

"Alanko-Blomé and colleagues (Alanko-Blomé et al., 2011) have done a follow-up covering the years 1997-2005 of 831 IDUs at the NSP in Malmö. In view of the low HIV prevalence among IDUs in Malmö the study focuses on the incidence of surrogate markers of HIV - particularly hepatitis C, because the risk of HBV infection is affected by the introduction of hepatitis B vaccination. HIV incidence remained very low. However, the corresponding incidence rates for HCV was 38.3 / 100 person-years at risk and for HBV 3.4 / 100 person-years at risk. RNA testing (Ribonucleic acid) showed that 12% already when entering the NSP was affected with hepatitis C virus, but antibodies had not yet developed. This subgroup was therefore already hepatitis C infected before they had access to clean syringes and needles through the NSP. If one corrects for those already infected, the HCV incidence rate decreases to approximately 30 per 100 / person-years at risk, which is still a high level of blood contamination. When the study period was divided into three periods, there was no trend of improvement in recent years. Risk factors for anti-HCV seroconversion were injection of both amphetamine and heroin and imprisonment. The strong improvement for hepatitis B may be entirely attributed to the introduction of hepatitis B vaccination11 (SOU 2011:6).

"The aim of a Swedish study from 2011 was to analyze the burden of HCV-associated inpatient care in Sweden, to demonstrate the changes over time and to compare the findings with a non-infected population. The authors conclude that drug-related care was common in the HCV-infected cohort, the demand for liver-related care was very high, and SLC increased notably in the 2000s, indicating that the burden of inpatient care from serious liver disease in HCV-infected individuals in Sweden is an increasing problem (Duberg et al., 2011)."

"Safe injecting practices aim at teaching injecting drug users to inject in a safe way (e.g. not sharing needles or syringes). Such practices are included in NSPs in Sweden. However, since the NSPs in Sweden are unevenly spread, a majority of injecting drug users in Sweden still lack the opportunity to reduce major health risks associated with using unsterile or contaminated injecting equipment. County councils in Sweden have developed strategies for reducing risk-behaviours by other efforts, including teaching-programmes for safe injection and motivational interviewing (Norden et al., 2009)."

Economics

"Care and treatment for drug users are considered by many to be costly and resources are often not enough. But the real waste is to refrain from treatment claim Swedish economists Ingvar Nilsson and Anders Wadeskog, who in particular have made analyses of the methadone programme in Stockholm (Nilsson and Wadeskog, 2008). With the help of experts and clients they carved out a number of courses that can be described as typical careers in addiction. They identified and priced around 150 different consequences that a life in alienation brings. Many of these effects are more or less invisible and difficult to detect. Their analysis indicates that an active heroin user on average costs society 2.1 to 2.3 million SEK per year. A large portion of these costs ceases or is reduced when the person stops or reduce their drug use.
"The cost of a place in the methadone programme is about SEK 100,000. The analysis shows that each invested krona gives 17 times the money back, which according to the researchers is equivalent to an annual return of 1778%.
"Drug users who are long-term drug-free without relapses give a return of between 50 and 150 times the money. But even those who have not been as successful generate a financial gain. One of the most important lessons according to Nilsson and Wadeskog is that everyone involved in the maintenance treatment - except those who very quickly leave treatment and return to drug use - contributes to the socio-economic gain. So it is important to nuance the view of what counts as success in treatment.
"The study identified a number of mechanisms that contribute to and reinforce marginalization. One of these is short-termism in decision making, where the financial year controls decisions. Another is the so-called 'downpipes effect', meaning that all instances only see their small part of the problem and no one tends to see and take responsibility for the big picture. It also means that most of the economic effects of marginalization are invisible to the individual decision-maker since they affect mainly budgets and sectors other than their own (Nilsson and Wadeskog, 2008)."

"The availability of cannabis resin is judged to have increased over the past 20 years. Both economic availability and physical supply have increased. This assessment is based on the fact that seizures and court cases involving cannabis have increased sharply, at the same time as prices have fallen. However, data for 2010 indicates that this trend may have been broken in that the prices for cannabis resin rose and seizures decreased somewhat.
"This does not mean that availability of cannabis has decreased in general since demand for marijuana has increased. Seizures of marijuana have also increased and virtually all regions in Sweden currently report marijuana prices, which was unusual in the 1990s. However, marijuana prices have risen over the past five years, perhaps because demand is keeping prices up, despite a larger supply. This could also be due to an effect on prices by increases in quality. Although marijuana has become relatively more common, cannabis resin is still the dominant form of cannabis on the Swedish market.
"Central stimulants such as amphetamines and cocaine are judged to be more available now compared with the end of the 1980s; prices have fallen sharply at the same time as seizures have increased. As with marijuana, relatively few cocaine prices were reported at the beginning of the period but in recent years most regions in Sweden report cocaine prices. However, amphetamines are still the most common central stimulants in Sweden, although cocaine has become relatively more common compared with 20 years ago. Amphetamine prices have decreased more than other drug prices and today the price is a third of the price in 1988.
"Ecstasy, LSD, khat and GHB prices have been monitored since 2000 but these drugs are all less common in Sweden compared with the other kinds of illicit drugs (with regard to the number of price reports, seizures and court cases). Consequently, the availability trend for these drugs is more difficult to assess. However, data indicates that ecstasy, LSD and GHB are now less common than ten years ago, while khat appears to have become somewhat more common.
"Accordingly, the conclusion is that there was an increase in illicit drugs since the 1980?s, both in terms of economic availability and physical supply. However, information from recent years indicates a decrease for cannabis resin, heroin and cocaine, but not for cannabis in general, because marijuana has increased."

"Throughout the 1990s the seizures of several drugs have increased. Particularly seizures of amphetamines and heroin have gone up significantly during the period, in numbers but also in kilos. Increase in seizures holds true also for LSD, ecstasy and cocaine, but at much lower and more fluctuating levels.
"Heroin and amphetamine prices have decreased significantly during the decade. Ecstasy and LSD prices fluctuate and the price intervals reported are considerable, probably due to limited availability. Cocaine and cannabis prices remain relatively unchanged and also the cannabis seizures have more or less hovered during the 1990s, both in numbers and size (apart from the very high figures of 1999).
"To sum up: availability of particularly heroin and amphetamines seem to have increased during the 1990s and there are no signs of this these trends to taper off."

"During the 1990s there has been reduced funding in this field [drugs] and at the same time there has been an increase in the availability of drugs with a corresponding increase in lifetime prevalence of drug use among young people. However, the annual school survey in grade 9 made during the spring showed a decrease in use of alcohol, drugs and tobacco. This decrease was the first in more than a decade.
"There are indications that the number of problematic abusers has increased in this period and also that the social services are less informed about their whereabouts and conditions than they used to be. There are also fewer specialised agencies involved."

"Indicators such as seizures (amounts as well as number of seizures), prices on the street and anecdotal data from users unanimous tell the same story: supply is more generous and prices lower than ever. The variety of drugs has also expanded during the 90s and now follows what happens in the rest of the EU."

"The results of this investigation provide further support to the possibility of using exhaled breath as a readily available specimen for drugs of abuse testing. There is a possibility that exhaled breath will develop into a new matrix for routine drug testing and present an alternative to already used matrices like urine, blood, oral fluid, sweat and hair. Each matrix may have its specific advantages and disadvantages. Since exhaled breath may be as easy to collect as in alcohol breath testing, it may present a new, more accessible matrix than blood at the roadside and elsewhere when the sampling procedure is an obstacle. We previously observed that exhaled breath methadone increases after intake [2]. If a correlation to blood concentration can be shown for exhaled breath levels, it may become a substitute matrix for monitoring impairment. One advantage of exhaled breath may be the detection of 6-AM, which is problematic in blood."

Laws and Policies

"In March 2011, the Swedish Parliament decided on a cohesive strategy for alcohol, narcotics¹, doping and tobacco (ANDT) policy. The overall objective of Swedish ANDT policy is a society free from illicit drugs and doping, less alcohol-related medical and social harm, and reduced tobacco use. The aim of the strategy is to set forth the objectives and emphasis of how societal efforts will be carried out, coordinated and followed up over the period 2011-2015. Every year, an action programme is issued with the aim of implementing the strategy.
"ANDT work in Sweden is cross-sectorial and comprises several authorities' areas of responsibility, regulations and legislation. At the political level, work is coordinated by the ANDT secretariat (Ministry of Health and Social Affairs) which is supported by an ANDT council, whereas the implementation of the monitoring system and the implementation of ANDT strategy’s goals is the responsibility of the Swedish National Institute of Public Health. The Swedish Prison and Probation Service, the Swedish Police, the Swedish Institute for Infectious Disease Control, the Swedish National Board of Health and Welfare and the Swedish Customs are other main authorities that have a central role in the narcotics field."

"SNIPH was given the task of evaluating the strategy for the period 2006-2010 and a final report was published in autumn 2010 (Statens folkhälsoinstitut, 2010b). In summary, a more negative development was observed for narcotics than for alcohol, with increasing harm in the form of ill-health, mortality and crime. While efforts to attain the goals in the area of alcohol have intensified, efforts in the area of narcotics have stagnated.
"As stated in the evaluation report, the organisation of preventive work at the national, regional and local level is crucial to the development of national objectives in the action plans. At the regional level, impressions of the county drug coordinators' activities are all consistently positive. National support for coordination, as well as the support from the county drug coordinators at the local level, has had a positive impact. The number of coordinators funded by the municipalities has increased during the action plan period, but many municipalities cannot or will not prioritise this function.
"The ultimate objective of the narcotics policy – a drug-free society – has not been achieved. However, it should be emphasised that the restrictive narcotics policy long pursued in Sweden has radically reduced the use of narcotics and its harmful effects. Nevertheless, the overall assessment is that the trend during the period up until 2009 went in the wrong direction, with an increase in harmful effects in the form of morbidity, mortality and crime. The evaluation report further states that the narcotics trend is difficult to interpret due to lack of reliable data.
"The spread of effective prevention methods to regional and local levels was stated by the evaluator to have worked well, although it was more effective in the area of alcohol than narcotics."

"In Sweden, narcotic drugs are defined as drugs or goods dangerous to health, with addictive properties or that create a state of euphoria, or goods that can easily be converted to products with such properties or effects, and that, on such basis, are objects for control according to international agreements that Sweden has supported, or have been declared by the Government to be considered illicit drugs according to the law (SFS 1968:64).
"The aim of the legislation is to regulate drugs and other products that, due to their intrinsic properties, entail harm to people's lives or health and that are, or can be assumed to be, used for the purpose of inducing intoxication or other effects. Narcotics may only be used for medical, scientific or other purposes useful to society that are particularly important (SFS 1968:64; SFS 1992:860). All other possession or use is punishable.
"If the offence concerning the handling or use of narcotics, with regard to the nature and quantity of narcotics and other circumstances, is considered to be:
"• minor, the penalty is a fine or imprisonment for a maximum of six months
"• serious, the penalty for a serious narcotics offence shall be imprisonment for a minimum of two and a maximum of ten years.
"In judging whether an offence is serious, particular consideration shall be given to whether or not it has been part of large-scale or professional activities, has involved especially large quantities of narcotics or has in any other way been of a particularly dangerous or unscrupulous nature. The judgment shall be based on a joint consideration of the circumstances in the particular case."

"Since drug use is prohibited with a maximum of six months imprisonment, the police are allowed to conduct drug tests (blood or urine) if there is reasonable cause to believe that a person is under the influence of drugs, however not on persons younger than 15 years old. The conservatives have however suggested a change in the legislation so that also these persons could be tested, in order to detect and stop drug use among young teenagers at an early stage. Not only the conservative former Minister of Justice and the present Social Welfare City Commissioner of Stockholm are advocating this for example, but also representatives from other parties as well. A response to criticism on the proposal is that the health of the children is more important than their integrity."

"In January 2010, a preliminary commission report concluded that Swedish health care and social services were of insufficiently quality and not diversified enough in the area of drug use. In the commission?s final report in June 2011, a number of proposals were submitted including increased financial resources, implementation of national guidelines, increased availability to drug treatment including a statutory enhanced health care guarantee, needle exchange and other evidence-based interventions. The report also suggests new laws and a new organization where the county council is given overall responsibility for treatment and municipalities overall responsibility for social support. The commission?s proposals are suggested for adoption in January 2013 (SOU 2011:35)."

"Between 1917 and 1955 Sweden had an alcohol rationing system, and even today embraces a comparatively restrictive alcohol policy. This tradition makes a restrictive drug policy a logical option. The current alcohol policy is based on the “total consumption” model, which holds that the more people use alcohol, the more they will abuse it and the greater the total harm caused by alcohol will be. The implication for policy, then, is to limit alcohol use through the instruments of price and availability."