4th NordAN drug network meeting, November 20, 2023

Anneli Uusküla, University of Tartu

Anneli Uusküla, a scientist from Tartu University, delved into the findings of a study conducted a few years earlier. She focused on interventions to prevent the initiation into injecting drug use and emphasized her academic and research-oriented role at the university, distinct from fieldwork or policy work.

Her presentation centred on an intervention aimed at preventing the initiation into injecting drug use, highlighting the significant increase in individual and societal adverse consequences associated with the transition from non-injecting to injecting drug use. She referenced a poster from AIDS 2014 to underscore the stigmatization and challenges faced by people who inject drugs.

Uusküla delved into the transition process from non-injecting to injecting drug use, emphasizing the associated high risks. She outlined various tested interventions, including social marketing, peer-based behaviour modification, treatment, and drug law enforcement. The most effective were identified as peer-based behaviour modification and addiction treatment interventions.

She also discussed the study's focus on factors influencing individuals to initiate injecting drugs, categorized into individual, familial, and social-environmental factors. The intervention targeted both non-injectors and current injectors, incorporating social cognitive theory, highlighting peer modelling, outcome expectancies, and self-efficacy about injection.

In Estonia, Uusküla and her team conducted two studies on this intervention, which included motivational interviewing and role-playing to address various aspects of drug use and prevention. The studies, conducted in collaboration with the harm reduction centre Convictus, involved more than 200 participants and yielded insightful findings on drug use patterns, sharing behaviours, and network dynamics.

Takeaway points:

• The transition from non-injecting to injecting drug use significantly heightens the risk of adverse individual and societal consequences, underscoring the need for effective interventions.

• Peer-based behaviour modification and addiction treatment interventions emerged as the most effective strategies in preventing the initiation into injecting drug use.

• The comprehensive intervention Uusküla and her team developed combined motivational interviewing, role-playing, and a focus on social cognitive theory. It showed promising results in changing behaviours and perceptions among drug users in Estonia.

Arni Einarsson, FRÆ-Fræðsla og forvarnir

Arni Einarsson shared insights into the country's alcohol and drug policy, emphasizing their approach to addressing alcohol and drugs together. The official policy, adopted in 2014, focuses on limiting access, protecting vulnerable groups, preventing initiation, reducing harmful use, providing quality services for those with problems, and reducing deaths related to substance use. Einarsson stressed the importance of a public health perspective in policy decisions.

He highlighted that Iceland maintains a monopoly on alcohol sales, a practice that had been consistent until 2022, when it changed to allow direct sales from producers. This shift also saw the emergence of unregulated online alcohol sales. The legal age for purchasing alcohol is set at 20 years, and 18 for tobacco. Iceland also enforces high alcohol taxes, bans on alcohol and tobacco advertising, and strict limits on legal blood alcohol concentration.

Einarsson presented data indicating no significant changes in drug use among Icelandic youth, with some slight increase in the use of tranquillizers or sedatives without prescriptions, mirroring trends in other European countries. Concerns have been raised about a potential increase in alcohol and drug use among young people based on observations from schools and those working with youth.

For older age groups, there has been an observable increase in cannabis use, particularly among younger adults. After a decline during COVID, drinking has begun to rise again. In terms of nicotine use, there has been a notable shift from smoking to nicotine patches, especially among younger demographics.

The discussion also covered the increase in prescribed drug use, though the total quantity of drugs has not increased proportionally. An opioid pandemic was identified, with a steady rise in opioid addiction cases since 2012.

Public opinion in Iceland on drug use has evolved significantly. There is growing support for legalizing cannabis and possession of drugs for personal use. More people now view regular cannabis use and heavy drinking as low-risk behaviours. Despite these changes, there is still considerable resistance to dismantling the alcohol monopoly. Repeated legislative attempts to legalize possession of drugs for personal use have not progressed in parliament.

Einarsson concluded by reflecting on these trends, noting a recent shift towards treatment over prevention. This shift potentially indicates a move away from the traditional Icelandic model. However, he also observed an increasing number of influential individuals joining the conversation, raising critical questions about the side effects and potential risks of these changing trends.

Takeaway points:

• Shift in public opinion and policy: There has been a significant change in public opinion in Iceland regarding drug use, particularly towards the legalization of cannabis and possession of drugs for personal use. This shift is also reflected in policy changes, such as the allowance of direct alcohol sales from producers and the unregulated online sale of alcohol.

• Changing trends in substance use: Einarsson highlighted notable changes in substance use patterns in Iceland. Among younger adults, there is an increase in cannabis use, and a shift from smoking to nicotine patches is evident, particularly among the youth. Additionally, there's a concerning rise in risk drinking post-COVID, reversing the trend observed during the pandemic.

• Focus on treatment over prevention: The current trend in Iceland shows a growing emphasis on treatment rather than prevention in addressing drug and alcohol issues. This approach marks a potential shift away from the traditional Icelandic model, which has historically focused more on prevention strategies. This change raises questions about the long-term effectiveness and impacts of such a shift in strategy.

Peter Moilanen, Narkotikapolitiskt Center

In his presentation, Peter Moilanen from the Swedish Narkotikapolitiskt Center provided an in-depth analysis of Sweden's drug policy, current challenges, and potential future changes. Moilanen began by discussing the criticisms of Sweden's drug policy, especially its reduced harm reduction contribution compared to other European countries. He pointed out that while the UN praised the policy in 2006, it now views it less favourably.

Moilanen highlighted the concerning trend of Sweden's increased drug-related deaths compared to two decades ago despite the stable rates of illegal drug consumption. This stability contrasts with the decreased use of alcohol and tobacco. He raised questions about why illicit drug consumption hasn't been reduced and how this issue is intricately linked with organized crime and gang violence in Sweden.

The presentation delved into the outcomes of recent investigations, revealing proposals focusing on prevention, early detection, and evidence-based treatment. Moilanen mentioned the introduction of a minister of social law in the new government, signalling a potential shift in the approach to drug policy.

He further discussed the complexities surrounding the treatment of comorbidity involving drug dependence and psychiatric disorders. The new proposals suggest mandatory combined treatment for such cases, addressing the current challenge where patients often receive fragmented care. Moilanen also touched upon the divided responsibility for drug treatment in Sweden, split between regional and local levels, and the inefficiencies this causes.

The presentation also covered the difficulties in comparing drug policies and outcomes across countries and the need for a more unified and less stigmatized approach to treatment.

Takeaway points:

• Concern over drug-related deaths and stable drug consumption: The increasing drug-related death rate in Sweden, despite stable illegal drug consumption rates, is a significant concern. This trend demands attention and action, particularly in light of decreasing alcohol and tobacco use.

• Criticism and need for reform in drug policy: Sweden's drug policy, once hailed as a success, now faces criticism, particularly regarding its harm reduction strategies. The recent investigations suggest a need for reforms focusing on prevention, early detection, and evidence-based approaches.

• Challenges in comorbidity and treatment responsibility: Addressing comorbidity in drug dependence and psychiatric disorders is a critical area of focus, with new proposals advocating for mandatory combined treatment. Additionally, the divided responsibility for treatment between regional and local levels in Sweden presents challenges, highlighting the need for a more centralized and effective approach.